I.

Introduction
Cerebrovascular accident (CVA), ischemic stroke, cerebral infarction, or brain attack is a sudden loss of function resulting from disruption of the blood supply to a part of the brain (Smeltzer et al., 2008). A cerebrovascular accident often results in permanent serious complications and disability and is a common cause of death. CVAs are the second leading cause of death worldwide. The brain requires a steady supply of oxygen in order to pump blood effectively to all of the body. Oxygen is supplied to the brain in the blood that flows through arteries. In a cerebrovascular accident, one or more of these arteries becomes blocked or ruptures or begins to leak. This deprives a portion of the brain of vital oxygen-rich blood. This damage can become permanent within minutes and result in the death of the affected brain tissue. This is called cerebral necrosis. A cerebrovascular accident caused by a cerebral thrombosis is the result of a build-up of plaque and inflammation in the arteries, called atherosclerosis. This process narrows the brain arteries and lowers the amount of oxygen-rich blood that reaches the brain tissue. Arteries narrowed by atherosclerosis are more likely to develop a blood clot that completely blocks blood flow to an area of the brain. Risk factors for atherosclerosis include having high cholesterol, diabetes, and hypertension. The extent of the damage done to the brain and resulting symptoms of a cerebrovascular accident vary depending on the type, the area or areas of the brain affected, and how much time passes before the cerebrovascular accident is treated. Complications of cerebrovascular accident include permanent neurological damage, disability and death. Patient E.D.G. experienced right-sided weakness with slurring of speech which convinced the family to bring her to the hospital. The symptoms of stroke depend on what part of the brain is damaged. In some cases, a person may not even be aware that he or she has had a stroke. Symptoms usually develop suddenly and without warning, or they may occur on and off for the first day or two. Symptoms are usually most severe when the stroke first happens, but they may slowly get worse. Symptoms may include: muscle weakness in the face, arm, or leg (usually just one side), numbness or tingling on one side of the body, trouble speaking or understanding others who are speaking, problems with eyesight, including decreased vision, double vision, or total loss of vision, sensation changes that affect touch and the ability to feel pain, pressure, different temperatures, or other stimuli, changes in hearing, change in alertness (including sleepiness, unconsciousness, and coma), personality, mood, or emotional changes, confusion or loss of memory, difficulty swallowing, changes in taste, difficulty writing or reading, loss of coordination, loss of balance, clumsiness, trouble walking, dizziness or abnormal sensation of movement (vertigo), lack of control over the bladder or bowels. Risk factors for a cerebrovascular accident include a having hypertension, heart disease, diabetes, high cholesterol and obesity. Other risk factors include being of African-American ancestry, being male, drinking excessive amounts of alcohol, smoking and having a family history of heart disease or cerebrovascular accident.

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II.Objectives
Specific Objectives Patient and Significant Other Centered To establish a good working relationship with the nurse To give patient and significant other a welcoming atmosphere for her to express their needs To give the watcher health teachings about her condition to raise their level of awareness To motivate the family to care for the patient conscientiously To assist patient with activities of daily living To promote self esteem and independence of the patient To promote positive outlook of the patient towards healing To alleviate patients suffering To meet developmental needs of the patient To provide patients oral needs to maintain consistency of care Student-centered To establish rapport with patient and significant others To increase knowledge regarding the case of the patient To understand the principles underlying cerebrovascular accident To broaden understanding on the disease process To familiarize with the tests done in diagnosing the disease To give the appropriate interventions To identify factors that could worsen the condition To know the different surgical and medical management and as well as the diseases nursing management To work professionally and set limitations To identify appropriate nursing interventions To apply the concepts learned in the school To become a better nurse who is fair and just to her patients To respect the patients decisions regarding the care she wants To work with the health care team and maintain good working relationships with them To learn new ways to care for the patient To maintain consistency of care to the patient To develop self-awareness and professionalism To gain experiences and apply them in the future

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III. Personal Data

Name: Patient E.D.G. Address: Quirino, Santa, Ilocos Sur Age: 62 years old Birth date: April 14, 1949 Sex: Female Civil status: Married Religion: Roman Catholic Nationality: Filipino Occupation: Housewife Medical Profile: Institution: Metro Vigan Cooperative Hospital Room: 214 Date and Time of Admission: November 19, 2012 at 8:35 AM Attending Physician: Dr. Elton Ong/ Dr. Velasco Chief complaints: Right-sided weakness and slurring of speech Admitting diagnosis: Stroke with residual right hemiplegia Final Diagnosis: Cerebrovascular Accident

IV.Nursing History of Past and Present Illness

A. Past According to her significant others, Patient EDG was hospitalized at Metro Vigan Cooperative Hospital last 2010 with the same diagnosis. The first stroke was believed to be caused by the patient being obese and having a persistent high blood pressure. There was no affectation like paralysis and impaired mobility on her first stroke. According to her son, though low cholesterol diet was recommended by the physician, she was still fond of eating shrimp, crab, bagnet, and pork which predisposed her to obesity, hypertension and stroke. Both of her parents have a history of hypertension which largely affects her to have hypertension. There are no known allergies to food or any drugs and her vaccinations are incomplete due to financial constraints when she was still a child. B. Present There was a sudden onset of right sided weakness as of November 19, 2012 associated with slurring of speech. The first time I handled the patient, her initial vital signs were: BP 140/100 mmHg, temperature 36.3 C, respiratory rate 24 cpm, and pulse rate 81 bpm.

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V. PEARSON Assessment
Assessment Physical, Psychological, and Psychosocial Confinement She has a dark coarse hair with minimal gray hair Fair complexion. Afebrile No lesions and scars noted. No headache and enlarged lymph nodes. With clear vision and hearing. Unable to assume sitting and standing position. Unable to walk. With edema on upper and lower extremities. With right sided paralysis. Her body built is fat. With no IVF. Appears weak but conscious and coherent. Speech is clear, moderately paced and culturally appropriate. Dress is appropriate for the weather. During my first contact with the patient, I observed that she can already smile, laugh and mingle with her significant others. Slightly anxious because of her condition. Patient didnt talk about her condition and still thought to live a normal life after her discharge. Psychosocial theory---Integrity. Though the patient has impaired mobility due to the right sided paralysis, according to her, she does not have any regrets since all her children are now settled and in good condition. She wants to continue a normal life. Elimination The patient can normally urinate, no pain during urination. She constantly wears a diaper since she is incapable of moving the right part of her body. Home Visit (December 29, 2012) During my home visit at Quirino, Santa, Ilocos Sur, I found out that patient EDG passed away last December 11. According to her husband, two days after her discharge (December 3) at Metro Vigan Cooperative Hospital, she complained difficulty of breathing and they observed generalized edema. They brought her back to MVCH wherein she was confined to the ICU. She stayed there for six days, then, unfortunately, she did not make it. Her husband said that her liver was already affected and suddenly had

different complications.

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 Activity/Rest Safety Oxygenation

She has a regular bowel movement and not suffering from constipation. The urine appears yellowish and the stool is yellowish and watery. She consumes three diapers during a whole shift. No sweating was observed because of the air-conditioned room. Oral mucosa is not dry. The patient stays in the room for the whole day. She is confined in her bed, usually assumes a semi-fowlers and a high-fowlers position. She often mingles her significant others and communicates with them. She is often seated in the bed and watches television for a few minutes then sleeps again. After eating her meals and taking her medications, she would take a nap until her vital signs are to be taken. The patient verbalizes that she has no sleep disturbances. She sleeps almost all the time even during the day. The side rails are always raised, the patients significant others, maintain her position at the center of the bed to avoid f alling. Her husband, niece, and children stay with her in the hospital. The medications were checked three times before administering to the patient. The room is well ventilated and lighted. Fire precaution was observed in the hospital. The patient has no known allergies to medications and food. The room is well ventilated. The room has air conditioner. The patient breathes room air and supplemental oxygen is readily available. With difficulty of breathing when positioned flat on bed is noted. No nasal flaring and no nasal discharges. The patient wears loose hospital gown. Hematologic results: HGB- 153 g/L HCT- 46%

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 Nutrition Afebrile

WBC- 12.7 X 10^9/L

The patient weighs 73 kilograms. She has no IVF. On soft, low salt, low fat diet, with poor appetite. Eats three times daily. Usually eats Lugaw with milk. No difficulty of swallowing. The patient cannot eat alone, her son usually feeds her. After eating, she takes her medications such as Ampicillin, Piracetam, Pantomazole, Rosuvastatin and etc. Drinks a glass of water after eating.

VI. Diagnostic Procedures A. Ideal Procedure 1. Computerized Tomography (CT) Scan Definition and Purpose A CT scanner sends a series of X-rays through the head that are analyzed by a computer to create a detailed picture of a "slice" of the area being studied. Each X-ray lasts a fraction of a second. During a CT scan of the head, the head is positioned inside a CT scanner's cylinder. The entire scanner can tilt, and the X-ray scanning cylinder within it can rotate to obtain the views needed. For a head scan, 10 to 30 slices are usually taken. The results are highly-detailed images of the head, including the brain, eyes, bones of the skull and sinuses within the bones around the nose. This is often one of the first tests given to patients who may have had a stroke. These scans provide important information about the cause of the stroke and the location and extent of brain injury. CT scans are clearer pictures of the brain than regular X-rays. Sometimes a special dye (contrast material) that contains iodine is injected into the blood during a CT scan of the head. The dye makes blood vessels and certain structures inside the head more visible on the CT scan images. This is known as CT angiography.

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2. Magnetic Resonance Imaging (MRI)

An MRI produces a picture of the brain using a large magnetic field. It also can show the location and extent of brain injury, but the image is sharper and more detailed. An MRI can distinguish between the blockage of blood flow due to a clot, which causes transient ischemic attack and ischemic stroke, and bleeding, which causes hemorrhagic stroke. This type of diagnostic technique is often used to diagnose small, deep injuries. After the first 24 hours, MRI can identify the exact size and location of the area affected by a stroke. This information may help the doctor determine how well the person may recover from a stroke. An MRI is more sensitive than a CT scan in identifying changes caused by lack of oxygen to brain cells during the first 72 hours after a stroke. An MRI is more accurate than a CT scan of the head in identifying multiple small strokes within the brain. An MRI is also better for detecting strokes in the lower, back part of the brain (cerebellum) and the part of the brain that connects with the spinal cord (brain stem). An MRI seems to be more accurate in detecting strokes caused by clots (ischemic strokes) during the first 3 days after a stroke, but the test is less accurate if it is done in the first 24 hours after symptoms first begin.

3.

Magnetic Resonance Angiography (MRA)

Magnetic resonance angiography (MRA) is a form of MRI that can measure blood flow through blood vessels. The test uses a strong magnetic field and radio signals to create pictures of the blood flow through blood vessels. With an MRA, both the blood flow inside of the vessel and the condition of the blood vessel walls can be seen. An MRA takes pictures quickly that can be seen individually or together as a three-dimensional picture. An MRA is often used to determine if narrowing of blood vessels (especially the carotid arteries), abnormally formed blood vessels or an aneurysm is present. MRAs are relatively safe and easy to perform, and they cost less than some other tests. People with pacemakers or certain metal implants cannot have an MRA done. Pregnant women should not have an MRA done. The pictures of the carotid arteries that are produced by an MRA are not as clear as those produced using carotid arteriography. MRA is no more sensitive than carotid ultrasonography/duplex scanning, but it is more expensive. MRAs do not produce clear pictures when the blood flow through the vessel is very rapid or when the vessel has severe narrowing. Holes (ulcerations) within plaque may not always be seen with an MRA.

4. Electroencephalogram (EEG)

In an EEG, electrodes are put on a person's scalp to pick up electrical impulses, which are printed out as brain waves. An evoked response test measures how the brain handles different sensory information, using electrodes that record electrical impulses related to hearing, body sensation or vision.

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5.

Carotid Angiogram

Carotid angiography is the best test available to identify and measure the blockage in the carotid arteries of the neck. It is usually done after a carotid ultrasound has shown that there probably is a blockage in the artery and if surgery (endarterectomy) is being considered to remove the blockage and reopen the artery. In this test, a tiny tube (catheter) is inserted into an artery (often in the arm) and threaded through other blood vessels to reach the carotid artery. A dye is then injected through the tube and into the artery. The dye outlines the blood vessel and X-rays are taken to evaluate the degree of narrowing and the condition of a plaque. If a plaque is rough, clots are more likely to form in the blood vessel. When the dye is injected, some people feel a burning sensation in the face and head, a brief headache, flushed on one side of the face or nauseous. The test usually takes from one to three hours. The patient may be given a drug to help relax during the test.

6.

Echocardiogram (ECHO)

Echocardiography (ECHO) is a sophisticated type of blood flow test that uses high-pitched sound waves to produce an image of the heart. The sound waves are sent through a device called a transducer and are reflected off the various structures of the heart. These echoes are converted into pictures of the heart that can be viewed on a monitor similar to a TV screen. An echocardiogram is used to evaluate how well the heart chambers fill with blood and pump blood to the rest of the body. ECHO can also be used to estimate the amount of blood pumped out of the left ventricle with each heartbeat (called the ejection fraction). An ECHO can help evaluate heart size and heart valve function, identifying areas of poor blood flow in the heart, areas of heart muscle that are not contracting normally, previous injury to the heart muscle caused by impaired blood flow or evidence of congestive heart failure, especially in people with chest pain or a possible heart attack. In addition, ECHO can identify some heart defects that have been present since birth (congenital heart defects).

7.

Spinal Tap

A needle is inserted into the spinal canal to collect samples of the clear, fluid that surrounds the brain and spinal cord. The pressure of this fluid is measured, and the samples are analyzed for color, blood cell counts, protein, glucose and other substances. Some of the fluid may be placed under conditions that promote the growth of infectious organisms (cultured), such as bacteria or fungi, to check for infection.

8.

Cerebral Angiogram

Cerebral angiography uses the same technique to study the arteries of the brain. It is usually done at the same time as carotid arteriography to evaluate blood flow through the brain. The results will help decide whether surgery to reopen a blocked artery (carotid endarterectomy) is appropriate. Angiography carries the risk that the procedure itself may cause a piece of plaque to break away and travel through the blood to the brain, causing a stroke during the procedure.

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 B. Actual

Name and Indication 1. Blood Urea Nitrogen and Creatinine

Normal Values BUN= 2.5-6.5 MMOL/L Crea= 53-97 umol/L

Results

Interpretation

Nursing Responsibilities Explain the procedure to the

This test is performed to evaluate a person's total kidney function. It is a measure of how well both kidneys clear creatinine and urea from the urine. It does not measure the function of one kidney compared to the other.

3.1 MMOL/L

Normal

patient. Assist patient during specimen

69.7 umol/L

Normal

collection, if needed. Check puncture site for bleeding. Send specimen to the laboratory.

2. Blood Chemistry Blood chemistry tests are often ordered prior to surgery or a procedure to examine the general health of a patient.

Sodium= 135-148 mmol/L Potassium= 3.5-5.3 mmol/L 3.60 mmol/L Normal 140.9 mmol/L Normal

Note any procedures that may interfere with test results. Inform the patient about the

procedure. Refer result to the physician

3.

Urinalysis

Colorpale to yellow amber Characteristicclear to slightly hazy Specific gravity1.016- 1.022

Coloryellow CharacteristicClear Specific gravity1.010 Purulent matter makes it turbid Slightly low but not significant Normal

Provide specimen bottle to the patient Instruct the patient to do the following: First, wash your hands thoroughly, and then wash the vulva and surrounding area four times with

Urinalysis is actually a large number of tests that are performed on the urine. A great deal of information can be obtained by testing for various chemicals and cells in the urine. Urinalysis is one of the most helpful, simple, and cost-effective of all medical tests. It can provide information about the

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urinary system and other organs in the body.

RBCnegative

RBC2-4 hpf This may indicate glumerular damage or UTI

downward strokes, using a new soapy sponge each time. Begin urinating into the toilet and stop after an ounce or two. Position the container to catch the Normal middle portion of the urine stream. Excrete the remainder into the Normal toilet. Tighten the cap on the container Normal securely, being careful not to touch the inside of the rim. Normal Label the specimen appropriately. Send specimen to the lab. Normal Refer the result to the Physician.

Glucosenegative Proteinnegative Bacterianegative Pus cells5-10 hpf Amorphous uratesfew Mucus threadsnegative

Glucosenegative Proteinnegative Bacterianegative Pus cells0-2 hpf Amorphous uratesfew Mucus threadsfew Can be due to the bacteria and vaginal discharges

4. Hematology To check any abnormal changes in blood components that can also determine the severity of the disease. This test gives a

WBC= 4.5-11 X 10^9/L RBC= 4.2-5.4 X 10^12/L

WBC= Indicates infection

CBC does not require fasting or any special preparation but the

12.7 X 10^9/L RBC=

procedure should be explained to Normal the patient as well as its purpose.

X 10^12/L

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doctor a great deal of information about the general health of a patient. Important measurements include: hemoglobin, white blood cell count, and platelet count. The CBC is the simplest test to diagnose anemia (low red blood cells). 5. Cranial CT Scan

HGB= 120-160 g/L PLT= 150-400 X 10^9/L HCT= 39-47%

HGB= Normal

Apply pressure to the puncture site until bleeding stops. Promote rest. Normal Refer the result to the physician.

153 g/L PLT=

285 X 10^9/L 46% Impression: HCT=

Normal o Assist the patient during the procedure. o Encourage increase oral

A CT scan is done to study the skull, brain, jaw, sinuses, and facial bones. The scan will look for signs of injuries, tumors, or other disease.

Minimal acute evolving hematoma in the right cerebellum is considered. Left maxillary sinusitis.

fluid intake to excrete the dye.

6.

FBS

S.I.3.89-5.83 mmol/L

S.I. 6.3 mmol/L

Increased: may be associated with Diabetes Mellitus

Instruct the patient for NPO 6-8 hours before the procedure.

Fasting blood glucose (FBG) is a blood test done to measure the amount of glucose present in the blood after an eight-hour fast. It is thus not affected by recent food intake. 7. HBA1c

4.3-6.4%

5.1%

Normal

No special preparation is needed.

HbA1c is a lab test that shows the average level of blood sugar (glucose) over the previous 3 months. It shows how well you are controlling your diabetes.

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8.

Cholesterol and triglyceride tests

Total Cholesterol= <5.20 mmol/L Triglycerides= 0.70-1.70 mmol/L HDL= >1.56 mmol/L LDL= <2.6 mmol/L

4.3 mmol/L

Normal

Ensure that food has been restricted for at least 6 to 12 hr prior to the

Blood tests that measure the total amount of fatty substances (cholesterol and triglycerides) in the blood.

0.76 mmol/L

Normal

procedure if triglycerides are to be measured.

1.2 mmol/L

Normal

2.71 mmol/L

Increased: may indicate risk for heart disease

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VII. Anatomy and Physiology of Organ Involved

In Cerebrovascular accident, the brain is being affected. The human brain serves many important functions ranging from imagination, memory, speech, and limb movements to secretion hormones and control of various organs within the body. These functions are controlled by many distinct parts that serve specific and important tasks.

Brain Cells: The brain is made up of

two types of cells: neurons and glial cells. Neurons are responsible for all of the functions that are attributed to the brain while the glial cells are non-neuronal cells that provide support for neurons. In an adult brain, the predominant cell type is glial cells, which outnumber neurons by about 50 to 1. Neurons communicate with one another through connections called synapses.

Meninges: The bony covering around the brain is called the

cranium, which combines with the facial bones to create the skull. The brain and spinal cord are covered by a tissue known as the meninges, which are made up of three layers: dura mater, arachnoid layer, and pia mater. The dura mater is a whitish and nonelastic membrane which, on its outer surface, is attached to the inside of the cranium. This layer completely covers the brain and the spinal cord and has two major folds in the brain, which are called the falx and the tentorium. The falx separates the right and left halves of the brain while the tentorium separates the upper and lower parts of the brain. The arachnoid layer is a thin membrane that covers the entire brain and is positioned between the dura mater and the pia mater, and for the most part does not follow the folds of the brain. The pia mater, which is attached to the surface of the entire brain, follows the folds of the brain and has many blood vessels that reach deep into the brain. The space between the arachnoid layer and the pia mater is called the subarachnoid space and it contains the cerebrospinal fluid.

Cerebrospinal Fluid (CSF): CSF is a clear fluid that surrounds the brain and spinal cord, and helps to cushion these
structures from injury. This fluid is constantly made by structures deep within the brain called the choroid plexus which is housed inside spaces within the brain calledventricles, after which it circulates through channels around the spinal cord and brain where is it finally reabsorbed. If the delicate balance between production and absorption of CSF is disrupted, then backup of this fluid within the system of ventricles can cause hydrocephalus.

Ventricles: Brain ventricles are a system of four cavities, which are connected by a series of tubes and holes and
direct the flow of CSF within the brain. These cavities are the lateral ventricles (right and left), which communicate with the third ventricle in the center of the brain through an opening called the interventricular

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foramen. This ventricle is connected to the fourth ventricle through a long tube called the Cerebral Aqueduct.CSF then exits the ventricular system through several holes in the wall of the fourth ventricle (median and lateral apertures) after which it flow around the brain and spinal cord.

Brainstem: The brainstem is the lower extension of the brain which connects the brain to the spinal cord, and acts
mainly as a relay station between the body and the brain. It also controls various other functions, such as wakefulness, sleep patterns, and attention; and is the source for ten of the twelve cranial nerves. It is made up of three structures: the midbrain, pons and medulla oblongata. The midbrain is inovolved in eye motion while the pons coordinates eye and facial movements, facial sensation, hearing, and balance. The medulla oblongata controls vegetative functions such as breathing, blood pressure, and heart rate as well as swallowing.

Thalamus: The thalamus is a structure that is located above the brainstem and it serves as a relay station for nearly
all messages that travel from the cerebral cortex to the rest of the body/brain and vice versa. As such, problems within the thalamus can cause significant symptoms with regard to a variety of functions, including movement, sensation, and coordination. The thalamus also functions as an important component of the pathways within the brain that control pain sensation, attention, and wakefulness.

Cerebellum: The cerebellum is located at the lower back of the brain beneath the occipital lobes and is separated
from them by the tentorium. This part of the brain is responsible for maintaining balance and coordinating movements. Abnormalities in either side of the cerebellum produce symptoms on the same side of the body.

Cerebrum: The cerebrum forms the major portion of the brain, and is divided into the right and left cerebral
hemispheres. These hemispheres are separated by a groove called the great longitudinal fissure and are joined at the bottom of this fissure by a struture called the corpus callosum which allows communication between the two sides of the brain. The surface of the cerebrum contains billions of neurons and glia that together form the cerebral cortex (brain surface), also known as "gray matter." The surface of the cerebral cortex appears wrinkled with small grooves that are called sulci and bulges between the grooves that are called gyri. Beneath the cerebral cortex are connecting fibers that interconnect the neurons and form a white-colored area called the "white matter."

Lobes: Several large grooves (fissures) separate each side of the brain into four distinct regions called lobes:
frontal, temporal, parietal, and occipital. Each hemisphere has one of each of these lobes, which generally control function on the opposite side of the body. The different portions of each lobe and the four different lobes communicate and function together through very complex relationships, but each one also has its own unique characteristics. The frontal lobes are responsible for voluntary movement, speech, intellectual and behavioral functions, memory, intelligence, concentration, temper and personality. The parietal lobe processes signals received from other areas of the brain (such as vision, hearing, motor, sensory and memory) and uses it to give meaning to objects. The occipital lobe is responsible for processing visual information. The temporal lobe is involved in visual memory and allows for recognition of objects and peoples' faces, as well as verbal memory which allows for remembering and understanding language.

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Hypothalamus: The hypothalamus is a structure that communicates with the pituitary gland in order to manage
hormone secretions as well as controlling functions such as eating, drinking, sexual behavior, sleep, body temperature, and emotions.

Pituitary Gland: The pituitary gland is a small structure that is attached to the base of the brain in an area called
the sella turcica. This gland controls the secretion of several hormones which regulate growth and development, function of various organs (kidneys, breasts, and uterus), and the function of other glands (thyroid gland, gonads, and the adrenal glands).

Basal Ganglia: The basal ganglia are clusters of nerve cells around the thalamus which are heavily connected to the
cells of the cerebral cortex. The basal ganglia are associated with a variety of functions, including voluntary movement, procedural learning, eye movements, and cognitive/emotional functions. The various components of the basal ganglia include caudate nucleus, putamen, globus pallidus, substantia nigra, and subthalamic nucleus. Diseases affecting these parts can cause a number of neurological conditions, including Parkinson's disease and Huntington's disease.

Cranial Nerves: There are 12 pairs of nerves that originate from the brain itself, as compared to spinal nerves that
initiate in the spinal cord. These nerves are responsible for specific activities and are named and numbered as follows: Cranial nerve I (Olfactory nerve): Smell Cranial nerve II (Optic nerve): Vision Cranial nerve III (Oculomotor nerve): Eye movements and opening of the eyelid Cranial nerve IV (Trochlear nerve): Eye movements Cranial nerve V (Trigeminal nerve): Facial sensation and jaw movement Cranial nerve VI (Abducens nerve): Eye movements Cranial nerve VII (Facial nerve): Eyelid closing, facial expression and taste sensation Cranial nerve VIII (Vestibulocochlear nerve): Hearing and sense of balance Cranial nerve IX (Glossopharyngeal nerve): Taste sensation and swallowing Cranial nerve X (Vagus nerve): Heart rate, swallowing, and taste sensation Cranial nerve XI (Spinal accessory nerve): Control of neck and shoulder muscles Cranial nerve XII (Hypoglossal nerve): Tongue movement

Pineal Gland: The pineal gland is an outgrowth from the back portion of the third ventricle, and has some role in
sexual maturation, although the exact function of the pineal gland in humans is unclear.

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VIII. Pathophysiology
Algorithm Etiology: Unknown Risk factors: Age Hypertension Diet Obesity Previous stroke Decreased blood supply in the brain

Energy failure

Acidosis

Ion imbalance

Increased glutamate

Depolarization

Intracellular calcium increased

Cell membranes and protein break down Formation of radicals Protein production decreased

Cell injury and death

Signs and Symptoms: muscle weakness in the face, arm, or leg (usually just one side), numbness or tingling on one side of the body, trouble speaking or understanding others who are speaking, problems with eyesight, sensation changes that affect touch and the ability to feel pain, pressure, different temperatures, or other stimuli, changes in hearing, change in alertness, personality, mood, or emotional changes, confusion or loss of memory, difficulty swallowing, changes in taste, difficulty writing or reading, loss of coordination, loss of balance, clumsiness, trouble walking, dizziness or abnormal sensation of movement (vertigo),

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 Explanation In ischemic brain attack, there is disruption of the cerebral blood flow due to obstruction of a blood vessel. This disruption in blood flow initiates a complex series of cellular metabolic events referred to as the ischemic cascade. The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL per 100 g per minute. At this point, neurons are no longer able to maintain aerobic respiration. The mitochondria must then switch to anaerobic respiration, which generates large amounts of lactic acid, causing a change in pH level. This switch to the less efficient anaerobic respiration also renders the neuron incapable of producing sufficient quantities of adenosine triphosphate (ATP) to fuel the depolarization processes. The membrane pumps that maintain electrolyte balances begin to fail, and the cells cease to function. Early in the cascade, an area of low cerebral blood flow, referred to as the penumbra region, exists around the area of infarction. The penumbra region is ischemic brain tissue that may be salvaged with timely intervention. The ischemic cascade threatens cells in the penumbra because membrane depolarization of the cell wall leads to an increase in intracellular calcium and the release of glutamate. The influx of calcium and release of glutamate, if continued, activate a number of damaging pathways that result in the destruction of the cell membrane, the release of more calcium and glutamate, vasoconstriction and the generation of free radicals. These processes enlarge the area of infarction into the penumbra extending the stroke. After cell injury or death, signs and symptoms will manifest which include: muscle weakness in the face, arm, or leg (usually just one side), numbness or tingling on one side of the body, trouble speaking or understanding others who are speaking, problems with eyesight, including decreased vision, double vision, or total loss of vision, sensation changes that affect touch and the ability to feel pain, pressure, different temperatures, or other stimuli, changes in hearing, change in alertness (including sleepiness, unconsciousness, and coma), personality, mood, or emotional changes, confusion or loss of memory, difficulty swallowing, changes in taste, difficulty writing or reading, loss of coordination, loss of balance, clumsiness, trouble walking, dizziness or abnormal sensation of movement (vertigo), lack of control over the bladder or bowels. IX. Medical and Surgical Management Medical Management Ideal Treatment for stroke depends on the type of stroke (ischemic or hemorrhagic) and how long the patient has had stroke symptoms. This is why it is very important that a person seek medical care immediately when stroke symptoms develop. This gives the doctor adequate time to image the brain, determine the type of stroke, and plan the most effective treatment strategy. Treatment for an ischemic stroke may include: Tissue plasminogen activator (TPA) There is opportunity to use alteplase (TPA) as a clot-buster drug to dissolve the blood clot that is causing the stroke. There is a narrow window of opportunity to use this drug. The earlier that it is given, the better the result and the less potential for the complication of bleeding into the brain.

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Present American Heart Association guidelines recommend that if used, TPA must be given within 4 1/2 hours after the onset of symptoms. for patients who waken from sleep with symptoms of stroke, the clock starts when they were last seen in a normal state. TPA is injected into a vein in the arm but, the time frame for its use may be extended to six hours if it is dripped directly into the blood vessel that is blocked requiring angiography, which is performed by an interventional radiologist. Not all hospitals have access to this technology. TPA may reverse stroke symptoms in more than one-third of patients, but may also cause bleeding in 6% patients, potentially making the stroke worse. For posterior circulation strokes that involve the vertebrobasilar system, the time frame for treatment with TPA may be extended even further to 18 hours. Heparin and aspirin Drugs to thin the blood (anticoagulation; for example, heparin) are also sometimes used in treating stroke patients in the hopes of improving the patient's recovery. It is unclear, however, whether the use of anticoagulation improves the outcome from the current stroke or simply helps to prevent subsequent strokes (see below). In certain patients, aspirin given after the onset of a stroke does have a small, but measurable effect on recovery. The treating doctor will determine the medications to be used based upon a patient's specific needs. Managing other Medical Problems Blood pressure will be tightly controlled often using intravenous medication to prevent stroke symptoms from progressing. This is true whether the stroke is ischemic or hemorrhagic. Supplemental oxygen is often provided. In patients with diabetes, the blood sugar (glucose) level is often elevated after a stroke. Controlling the glucose level in these patients may minimize the size of a stroke. Patients who have suffered transient ischemic attacks, the patient may be discharged with blood pressure and cholesterol medications even if the blood pressure and cholesterol levels are within acceptable levels. Smoking cessation is mandatory. Rehabilitation When a patient is no longer acutely ill after a stroke, the health care staff focuses on maximizing the individuals functional abilities. This is most often done in an inpatient rehabilitation hospital or in a special area of a general hospital. Rehabilitation can also take place at a nursing facility.

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The rehabilitation process can include some or all of the following: 1. speech therapy to relearn talking and swallowing;

2. occupational therapy to regain as much function dexterity in the arms and hands as possible; 3. physical therapy to improve strength and walking; and

4. family education to orient them in caring for their loved one at home and the challenges they will face. The goal is for the patient to resume as many, if not all, of their pre-stroke activities and functions. Since a stroke involves the permanent loss of brain cells, a total return to the patient's pre-stroke status is not necessarily a realistic goal in many cases. However, many stroke patients can return to vibrant independent lives. Actual Complete rest was given. Intake and output were monitored strictly. Vital signs were monitored timely and were recorded in TPP chart. Intake and output chart was strictly maintained. Health education was provided about the nature of illness, diet, and medicines. Different diagnostic procedures were done to rule out the disease. Physical therapy was conducted daily. Oxygen therapy was given. Intravenous fluid was given. Nasogastric tube was used to assist in the nutrition of the patient. Drugs administered are as follows: Pantoprazole 40 mg1 tab OD Anti-secretory drug that inhibits gastric acid secretion Citicholine 500 mg 1 tab TID Increases a brain chemical that facilitates brain function Cilostazol 100 mg 1 tab BID Prevents platelet aggregation Rosuvastatin 20 mg 1 tab at bedtime Anti-lipidemic grug that reduces production of cholesterol in the blood Piracetam 1.2 g 1 tab TID Neurotonic drug that increases brain cell energy Digoxin 0.25 mg 1 tab OD Increases hearts force of contraction and decreases heart rate Mannitol 100 cc IV every 4 hours Hinders reabsorption of water which helps in lowering blood pressure Cefuroxime 750 mg IV every 8 hours (ANST) Antibacterial- cephalosporin Ampicillin 750 g IV every 8 hours Antibacterial- penicillin Paracetamol 1 tab PO TID Antipyretic which reduces body temperature

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 Surgical Management Ideal Several types of surgery may be performed to help treat a stroke, or help to prevent a stroke from occurring, including the following: Carotid endarterectomy Carotid endarterectomy is a procedure used to remove plaque and clots from the carotid arteries, located in the neck. These arteries supply the brain with blood from the heart. Endarterectomy may help prevent a stroke from occurring. Carotid stenting A large metal coil (stent) is placed in the carotid artery much like a stent is placed in a coronary artery. The femoral artery is used as the site for passage of a special hollow tube to the area of blockage in the carotid artery. This procedure is often done in radiology labs, but may be performed in the cath lab.

Craniotomy A craniotomy is a type of surgery in the brain itself to remove blood clots or repair bleeding in the brain. Surgery to repair aneurysms and arteriovenous malformations (avms) An aneurysm is a weakened, ballooned area on an artery wall that has a risk for rupturing and bleeding into the brain. An AVM is a congenital (present at birth) or acquired disorder that consists of a disorderly, tangled web of arteries and veins. An AVM also has a risk for rupturing and bleeding into the brain. Surgery may be helpful, in this case, to help prevent a stroke from occurring. Patent foramen ovale (PVA) closure The foramen ovale is an opening that occurs in the wall between the two upper chambers of a baby's heart before birth. It functions to provide oxygen-rich blood to the baby from the mother's placenta while in the womb. This opening normally closes soon after birth. If the flap does not close, blood flows from the right atrium directly to the left atrium. It then flows out to the central circulation of the body. If this blood contains any clots or air bubbles, they can pass into the brain circulation causing a stroke or transient ischemic attack (TIA). PFO closure procedure can be performed through a percutaneous (through the skin) approach. Signs and symptoms of a PFO may not occur until early or middle adulthood and may even go undetected.

Actual The patient did not undergo any surgical interventions since the physician did not advise her to do so. Instead, home medications were advised to be taken religiously and to continue physical therapy.

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X. Nursing Care Plan

Assessment Subjective: Nastroke siya, as verbalized by significant other. Objective: Right sided hemiplegia; altered level of consciousness; memory loss; changes in motor/sensory responses; restlessness Oxygen and Glucose cannot reach part of brain Brain cells die (infarction) Blood flow is disrupted Diagnosis P- Ineffective cerebral tissue perfusion E- r/t interruption of blood flow secondary to stroke Cerebral artery Brain Inference Clot, thrombus or embolism forms within cardiovascular system Maintain usual or improved LOC, cognition, and motor and sensory function. Demonstrate stable vital signs and absence of signs of increased ICP. Planning After 10 hours of nursing interventions, the patient will: Intervention 1) Determine factors related to individual situation, cause for coma, decreased cerebral perfusion, and potential for ICP. 2) Monitor and document neurological status frequently and compare with baseline. 3) Monitor vital signs noting: Hypertension or hypotension; compare blood pressure (BP) readings in both arms 4) Position with head slightly elevated and in neutral position. 5) Maintain bedrest, provide quiet environment, and restrict visitors or activities, as indicated. Provide rest periods between care activities, limiting duration of procedures. 6) Assess for nuchal rigidity, twitching, increased restlessness, irritability, and onset of seizure activity. 7) Administer supplemental oxygen, as indicated. Rationale 1) Influences choice of interventions. Deterioration in neurological signs and symptoms or failure to improve after initial insult may reflect decreased intracranial adaptive capacity, which requires that client be admitted to critical care area for monitoring of ICP and for specific therapies geared to maintaining ICP within a specified range. 2) Assesses trends in LOC and potential for increased ICP and is useful in determining location, extent, and progression or resolution of CNS damage. 3) Fluctuations in pressure may occur because of cerebral pressure or injury in vasomotor area of the brain. Hypertension or hypotension may have been a precipitating factor. 4) Reduces arterial pressure by promoting venous drainage and may improve cerebral circulation and perfusion. 5) Continual stimulation can increase ICP. 6) Indicative of meningeal irritation, especially in hemorrhagic disorders. Seizures may reflect increased ICP or reflect location and severity of cerebral injury, requiring further evaluation and intervention. 7) Reduces hypoxia. Evaluation After 10 hours of nursing interventions, the patient maintained usual LOC, motor and sensory function. Her vital signs were stable but there were still signs of increased ICP like decreased level of consciousness, and motor weakness.

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Subjective: Mula nung na-stroke si nanay, hindi na siya masyadong nakakagalaw, as verbalized by significant other. Objective: Impaired ability to perform ADLs, e.g., inability to bring food from receptacle to mouth; inability to wash body part(s); impaired ability to put on/take off clothing; difficulty completing toileting tasks

P- Self-Care Deficit E- r/t Neuromuscular impairment, decreased strength and endurance, loss of muscle control/coordi nation, Perceptual/cog nitive impairment

Brain death Destruction of neuromuscular junctions

After 10 hours of nursing interventions, the patient will: Demonstrate

Impaired neuromuscular conduction Hemiplegia

techniques/lifes tyle changes to meet self-care needs. Perform selfcare activities within level of own ability. Identify personal/com munity resources that can provide assistance as needed.

1) Assess abilities and level of deficit (04 scale) for performing ADLs. 2) Avoid doing things for patient that patient can do for self, but provide assistance as necessary. 3) Maintain a supportive, firm attitude. Allow patient sufficient time to accomplish tasks. 4) Provide self-help devices, e.g., button/zipper hook, knife-fork combinations, long-handled brushes, extensions for picking things up from floor; toilet riser, leg bag for catheter; shower chair. Assist and encourage good grooming and makeup habits. 5) Encourage significant other O to allow patient to do as much as possible for self. 6) Assess patients ability to communicate the need to void and/or ability to use urinal, bedpan for voiding if appropriate. 7) Identify previous bowel habits and reestablish normal regimen. Increase bulk in diet; encourage fluid intake, increased activity. 1) Assess functional ability/extent of impairment initially and on a regular basis. Classify according to 04 scale. 2) Change positions at least every 2

1) Aids in anticipating/planning for meeting individual needs. 2) These patients may become fearful and dependent, and although assistance is helpful in preventing frustration, it is important for patient to do as much as possible for self to maintain self-esteem and promote recovery. 3) Patients need empathy and to know caregivers will be consistent in their assistance. 4) Enables patient to manage for self, enhancing independence and self-esteem; reduces reliance on others for meeting own needs; and enables patient to be more socially active. 5) Reestablishes sense of independence and fosters self-worth and enhances rehabilitation process. 6) Patient may have neurogenic bladder, be inattentive, or be unable to communicate needs in acute recovery phase, but usually is able to regain independent control of this function as recovery progresses. 7) Assists in development of retraining program (independence) and aids in preventing constipation and impaction (long-term effects).

After 10 hours of nursing interventions, the patient performed self care activities within her ability and identified personal resources for assistance. The patient showed willingness to do self-care but failed to because of weakness

Subjective: Haan ko maigaraw daytoy kannawan nga bagik nakkong, as

P- Impaired physical mobility E- r/t Neuromuscular

Brain death Destruction of neuromuscular junctions

After 10 hours of nursing interventions, the patient will:

1) Identifies strengths/deficiencies and may provide information regarding recovery. Assists in choice of interventions, because different techniques are used for flaccid and spastic paralysis.

After 10 hours of nursing interventions, the patient

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verbalized by patient. Objective: Right sided paralysis Inability to purposefully move within the physical environment; impaired coordination; limited range of motion; decreased muscle strength/control

involvement: weakness, paralysis; Perceptual/cog nitive impairment Hemiplegia Impaired neuromuscular conduction

Maintain/incre ase strength and function of affected or compensatory body part. Maintain optimal position of function. Demonstrate techniques/beh aviors that enable resumption of activities. Maintain skin integrity. 6) 5) 4) 3)

7)

hours (supine, sidelying) and possibly more often if placed on affected side. Observe affected side for color, edema, or other signs of compromised circulation. Inspect skin regularly, particularly over bony prominences. Gently massage any reddened areas and provide aids such as sheepskin pads as necessary. Begin active/passive ROM to all extremities (including splinted) on admission. Encourage exercises such as quadriceps/gluteal exercise, squeezing rubber ball, extension of fingers and legs/feet. Assist to develop sitting balance (e.g., raise head of bed; assist to sit on edge of bed, having patient use the strong arm to support body weight and strong leg to move affected leg; increase sitting time) and standing balance (e.g., put flat walking shoes on patient, support patients lower back with hands while positioning own knees outside patients knees, assist in using parallel bars/walkers). Set goals with patient/SO for participation in activities/exercise and position

2) Reduces risk of tissue ischemia/injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown/decubitus. 3) Edematous tissue is more easily traumatized and heals more slowly. 4) Pressure points over bony prominences are most at risk for decreased perfusion/ischemia. Circulatory stimulation and padding help prevent skin breakdown and decubitus development. 5) Minimizes muscle atrophy, promotes circulation, helps prevent contractures. Reduces risk of hypercalciuria and osteoporosis if underlying problem is hemorrhage 6) Aids in retraining neuronal pathways, enhancing proprioception and motor response. 7) Promotes sense of expectation of progress/improvement, and provides some sense of control/independence. 8) May respond as if affected side is no longer part of body and needs encouragement and active training to reincorporate it as a part of own body. 9) Promotes even weight distribution, decreasing pressure on bony points and helping to prevent skin breakdown/decubitus formation. Specialized beds help with positioning,enhance circulation, and reduce venous stasis to decrease risk of tissue injury and complications such as orthostatic pneumonia.

maintained optimal position of function and skin integrity as evidenced by absence of contractures and decubitus ulcer. The patient is willing to resume ADLs but due to the paralysis, she was unable.

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Subjective: Haan nak makagaraw nga kasla idin nakkong, as verbalized by patient. Objective: Right sided paralysis; unable to sit and stand alone; limited motion.

P- Risk for injury E- r/t right hemiplegia secondary to CVA

CVA patient is at risk for injury since it may affect the cerebral artery leading to an infarction in the motor strip of the frontal cortex and this may cause hemiplegia. With the manifestations it may predispose an individual for any injury since part of their body is not functioning well.

After 2 weeks of nursing interventions, the patient will: be able to seek help to perform tasks that are beyond her capabilities be able to remain free from injury

changes. 8) Encourage patient to assist with movement and exercises using unaffected extremity to support/move weaker side. 9) Provide egg-crate mattress, water bed, flotation device, or specialized beds (e.g., kinetic), as indicated. 1) Establish rapport 2) Monitor vital signs 3) Assess clients muscle strength, gross and fine motor coordination 4) Assess mood, coping abilities, personality styles (e.g. Temperament, aggressions, impulsive behavior, level of selfesteem) 5) provide safe environment: - raise the side rails - obstacles in the room 6) Discuss importance of self monitoring of conditions /emotions

1) 2) 3) 4)

To promote cooperation To have a baseline data To identify risk for falls May result in carelessness /increased risk taking without consideration of consequences 5) Minimize falls and injury 6) In can contribute as to the occurrence of injury (e.g. Fatigue, anger, irritability)

After 2 weeks of nursing interventions, the patient was able to reduce risk of injury by seeking help from SO and as evidenced by absence of abrasion/falls

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XI. Drug Study

Name of the Drug, Dose, Route and Frequency Pantoprazole 40 mg 1 tab OD Drug Class Therapeutic Action Indication Contraindication Adverse Effects Nursing Responsibilities

Anti-secretory drug Proton pump inhibitor

Gastric acid-inhibitor: suppresses gastric secretions by specific inhibition of the hydrogen-potassium atpase enzyme system at the secretory surface of the gastric parietal cells; blocks the final step of acid production.

Short-term treatment of active duodenal ulcer. Short-term treatment of active benign gastric ulcer. Treatment of pathological hypersecretory conditions Indicated for Cerebrovascular Diseases.

Contraindicated with hypersensitivity to proton pump inhibitors or its components.

Headache Dizziness Vertigo Anxiety Rash Alopecia Pruritus Dry skin Diarrhea Abdominal pain Cough Fever Back pain Fever Restlessness Headaches Nausea and vomiting Diarrhea Low or high blood pressure Tachycardia Insomnia Blurred vision Chest pains

Administer before meals. Caution the patient to swallow capsules whole---not to open, chew or crush them. Administer antacids with the drug, if needed. Instruct the client to report severe headaches, worsening of symptoms, fever, chills and severe diarrhea.

Citicholine 500 mg 1 tab TID

Neurotonics Nootropics

Increases a brain chemical called phosphatidylcholine. This brain chemical is important for brain function. Citicoline might also decrease brain tissue damage when the brain is injured. Citicoline, which is a co-enzyme, accelerates the biosynthesis of lecithin in the body.

Precaution in patients with acute, severe & progressive disturbance of consciousness Precautions in administration with hemostatics Precautions in intracranial pressure relieving drugs.

Citicholine may be taken with or without food. Take it with or between meals. The supplement should not be taken in the late afternoon or at night because it can cause difficulty sleeping. Citicholine therapy should be started within 24 hours of a stroke.

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Cilostazol 100 mg 1 tab BID

Anti-platelet

Reversely inhibits platelet aggregation induced by variety of stimuli; produces vascular dilation in vascular beds with specificity for femoral beds; seems to have no effects on renal arteries.

Reduction of symptoms of intermittent claudication allowing increased walking distance.

Contraindicated with allergy to cilostazol, heart failure of any severity, active bleeding, hemostatic disorders. Use cautiously with renal dysfunction. With allergy to Rosuvastatin, active hepatic disease and persistent elevations of transaminase, impaired endocrine function, history of liver disease and alcoholism

Dizziness Headache Heart failure Tachycardia Palpitations Diarrhea Nausea Peripheral edema Infection Back pain Headache Flatulence Abdominal pain Cramps Constipation Dyspepsia Heartburn Sinusitis

Rosuvastatin 20 mg 1 tab at bedtime

Antihyperlipidimic HMG-coa reductase inhibitor

Inhibits HMG-coa reductase, the enzyme that catalyzes the first step in the cholesterol synthesis pathway, resulting in a decrease in serum cholesterol, serum ldls and increases serum hdls thus, lowering triglyceride level

Reduction of risk of MI and stroke in patients with diabetes and those with multiple risk factors for CAD. Adjunct to diet in treatment of elevated cholesterol level Treatment for post-stroke patients.

Do not administer to patients with heart failure; decreased survival rate has been reported. Administer drug on an empty stomach, at least 30 minutes before or 2 hours after breakfast and dinner. Encourage patient to avoid the use of grapefruit juice. Establish safety precautions to prevent injury and bleeding. Ensure that patient has tried cholesterol lowering diet regimen for 3-6 months before beginning therapy Administer drug without regard to meals but at same time each day Do not combine with other HMG-coa reductase inhibitors

Piracetam 1.2 g 1 tab TID

Neurotonic Nootropic

Acts selectively upon the telencephalon by improving its associative function. It increases the energy output of brain cell and activates its neurophysiological potentialities.

Contraindicated in patients with allergy to piracetam or its components. Precautions with renal disease.

Weight gain Nervousness Somnolence Depression Vertigo Abdominal pain Diarrhea Nausea and vomiting Ataxia Impaired balance

Monitor heart rate, ECG and BP periodically throughout the therapy. Drug has strong taste. Mixing oral form with orange juice mask the taste. Assess patient to clear airway. Provide support ventilation, if it is needed. Assess and support cardiac function.

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Insomnia

Reassure patient that communication abilities will return as the medication wears off. Monitor apical pulse for 1 minute before administering. Hold if pulse is lower than 60 bpm. Avoid IM injection; very painful. Avoid giving with meals; delays absorption. Have potassium salts, lidocaine, phenytoin, atropine and cardiac monitor readily available in case toxicity develops. Do not give electrolyte-free mannitol with blood. If bllod must be given, add at least 20 mEq of sodium chloride to each liter of mannitol solution. Do not expose to low temperatures; crystallization may occur. If crystals are seen, place the bottle in a hot water bath then cool to body temperature before administering. Make sure the infusion set contains a filter if giving concentrated mannitol. Monitor serum electrolytes periodically with prolonged therapy.

Digoxin 0.25 mg 1 tab OD

Cardiac glycoside Cardiotonic

Increases intracellular calcium and allows more calcium to enter the myocardial cell during depolarization via a sodium-potassium pump mechanism; this increases force of contraction and decreases heart rate.

Heart failure Atrial fibrillation

Contraindicated with allergy to cardiac glycosides, ventricular tachycardia, heart block, sick sinus syndrome, acute MI and electrolyte imbalances.

Headache Weakness Drowsiness Mental status change Arrhythmias GI upset Anorexia

Mannitol 100 cc IV every 4 hours

Diagnostic agent Osmotic diuretic Urinary irrigant

Elevates the osmolarity of the glumerular filtrate, thereby hindering the reabsorption of water and leading to loss of water, sodium, chloride; creates an osmotic gradient in the eye between plasma and ocular fluids, thereby reducing IOP.

Reduction of intracranial pressure and treatment of cerebral edema; of elevated IOP when the pressure cannot be lowered by other means. Promotion of excretion of toxic substances.

Contraindicated to patients with severe renal disease. Use cautiously with pulmonary congestion, active intracranial bleeding, dehydration, renal disease, heart failure.

Dizziness Headache Blurred vision Hypertension Edema Phlebitis Chest pain Infiltration Nausea Thirst Hyponatremia Pulmonary congestion Rhinitis

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Cefuroxime 750 mg IV every 8 hours (ANST)

Antibiotic Cephalosporin

Bactericidal: Inhibits synthesis of bacterial cell wall, causing cell death.

Dermatologic infections caused by S.

Aureus, S. Pyogenes, E. Coli, K. Pneumonia, Enterobacter.

Contraindicated with allergy to cephalosporins or penicillins. Use cautiously with renal failure.

Paracetamol 1 tab PO TID

Analgesic Antipyretic

Antipyretic: Reduces fever by acting directly on the hypotha-lamic heat-regulating center to cause vasodilation and sweating, which helps dissipate heat.

Temporary reduction of fever; temporary relief of minor aches and pains caused by common cold and headache.

Contraindicated with allergy to paracetamol. Use cautiously with impaired hepatic function.

Ampicillin 750 g IV every 8 hours

Antibiotic Penicillin

Bactericidal action against sensitive organisms; inhibits synthesis of bacterial cell wall, causing cell death.

Prevention of bacterial endocarditis following dental, oral, or respiratory procedures in very high risk patients.

Contraindicated with allergies to penicillins, cephalosporins and other allergens. Use cautiously with impaired renal function.

Headache Dizziness Lethargy Paresthesias Nausea Vomiting Diarrhea Anorexia Abdominal pain Flatulence Nephrotoxicity Decreased WBC Decreased platelets Decreased Hct Headache Chest pain Dyspnea Jaundice Acute renal failure Hematuria, leucopenia Rash Fever Lethargy Hallucinations Seizures Heart failure Stomatitis Rash Thrombosis at the site

Culture infection site, and arrange for sensitivity test before and during therapy if expected response is not seen. Give oral drug with food to decrease GI upset and enhance absorption. Have Vit. K available in case hypoprothrombinemia occurs. Discontinue if hypersensitivity occurs.

Do not exceed the recommended dosage. Reduce dosage with hepatic impairment. Give drug with food if GI upset occurs. Discontinue if hypersensitivity occurs.

Culture infection site, and arrange for sensitivity test before and during therapy if expected response is not seen. Check IV site carefully for signs of thrombosis or drug reaction. Do not give IM injections in the sme site, atrophy can occur. Monitor injection sites.

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XII. Promotive and Preventive Nursing Management

Most of the controllable risk factors for stroke relate to cardiovascular fitness. Because stroke is a form of cardiovascular disease, it makes sense that keeping your heart and blood vessels as healthy as possible will reduce your risk of stroke. The following are the most important measures you can take to control your stroke risk. Regular Medical Check-ups

Risk factors such as heart disease, high blood pressure, and elevated blood cholesterol must be monitored by your physician on a regular basis. These risk factors can be changed or, at minimum, controlled by proper medical treatment and appropriate diet and lifestyle modifications. Control Blood Pressure

High blood pressure (hypertension) is the single most important risk factor for stroke. Even mild hypertension, if not adequately treated, increases stroke risk. In general, blood pressure should be below 120/80. Elevated blood pressure promotes atherosclerosis and puts abnormal pressure on blood vessel walls, which can cause a rupture at a weak spot. Hypertension is often called the"silent killer" because there may be no obvious symptoms. It is important to check your blood pressure regularly. Controlling blood pressure, whether by a low-sodium diet, weight control, stress management and/or medication will reduce your risk of stroke. Remember: medication to control hypertension is effective only if taken on a regular basis, so it is important to follow your physician's instructions. Treatment of hypertension in older adults is also important. However, in elderly individuals, an abrupt fall in blood pressure may actually cause a stroke. Therefore, treatment of high blood pressure in the elderly may need to start with small doses of medication, so that blood pressure is reduced gradually. Treat Heart Disease

A variety of heart conditions, including irregular heart rhythms (atrial fibrillation), heart attacks and heart valve disorders, can cause stroke. Treatment of these disorders can reduce stroke risk. Improve Diet

Consumption of foods high in fat, cholesterol and salt increases the risk for stroke. The following recommendations are among the most important for stroke prevention. Ask your doctor for more help in identifying dietary culprits and making appropriate substitutions. 1) Avoid excess fat: High intakes of fat, particularly saturated fat, and cholesterol may contribute to atherosclerosis, which is associated with stroke. Dietary fat and cholesterol may be reduced by limiting fat or oil added in cooking, trimming fat and skin from meats and poultry, using low-fat or non-fat dairy products, broiling and baking foods rather than frying, and limiting eggs to no more than three a week. 2) Avoid excess sodium: Excess sodium in the diet is linked to hypertension. Table salt is the primary source of dietary sodium. There is also "hidden" salt in most processed and canned foods. Disodium phosphate, monosodium glutamate, sodium nitrate, or any similar compounds in the list of ingredients indicate high sodium content. Try to eat fresh food whenever possible. 3) Limit alcohol intake: Individuals who drink alcoholic beverages (more than two drinks per day) have an increased risk of stroke. For heavy drinkers, the risk of stroke increases further. Healthy young adults are just as susceptible to the risk of stroke incurred by heavy alcohol consumption as are older persons.

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Maintain a Healthy Weight

Being overweight strains the heart and blood vessels and is associated with high blood pressure. Obesity also predisposes a person to heart disease and diabetes, both of which increase the risk for stroke. Keeping your weight to recommended levels for your height and build is a prudent preventive measure. Exercise Regularly

The percentage of fat in our bodies tends to increase with age. Regular exercise helps keep this increase to a minimum. There appears to be an inverse relationship between exercise and atherosclerosis, i.e., more exercise is linked to lower levels of atherosclerosis. If you have not exercised regularly and would like to start an exercise program, or if you have medical problems or family history of serious disease, consult your physician before beginning an exercise program. Select an exercise program that is most suitable for you. Experts recommend at least 20 to 30 minutes of aerobic exercise three to four times a week in order to achieve and maintain an improved level of fitness. Treat Diabetes

The association between diabetes and increased stroke risk seems to be related to the circulatory problems caused by diabetes. Good control of diabetes appears to reduce the cardiovascular complications of the disease. Reduce Stress

Because stress may increase blood pressure, it is linked indirectly to stroke risk. A one-time stressful event rarely causes a stroke, but long-term unresolved stress can contribute to high blood pressure. Stress management, including relaxation techniques, biofeedback, exercise and counseling, appear to be useful in the treatment of high blood pressure, thus lowering the risk of stroke. Family or Individual History

A history of cerebrovascular disease in a family appears to be a contributing factor to stroke. While you have no control over your family history, you can take steps to decrease your risk through diet, exercise and other means discussed in this guide. If you have experienced a stroke or TIA in the past, you are at increased risk for having a stroke in the future. Therefore, all the preventive measures discussed in this section are of particular importance.

XIII. Discharge Plan

Medications Explain to the patient and family members the importance of taking medicines. Discuss to the patient and family the dosage, frequency and adverse effects of the drugs. Encourage to follow the dosages and proper timing of his meds such as the following: 1) Citicholine 500 mg 1 tab twice a day

2) Piracetam 1.2 g 1 tab three times a day 3) Pantoprazole 40 mg 1 tab at bedtime 4) Digoxin 0.25 mg 1 tab once a day 5) Rosuvastatin 20 mg 1 tab at bedtime 6) Coamoxiclav 1 g 1 tab twice a day for six days 7) Cilostazol 100 mg 1 tab twice a day

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 Economic status and Exercise Explain to significant others that the rehabilitation may be prolonged to be able for the family to prepare financial needs. Have occupational therapist to help re-learn everyday activities or ADL. Inform the patient to avail to some government programs such as Philhealth.

Treatment Tell the patient that she should have self-monitoring by checking hers vital signs regularly. Increase water intake up to 8-10 liters a day or as tolerated. Monitor intake and output.

Health teachings Improve nutritional status by avoiding high salt and high fat diet. Emphasize the importance of proper hygiene for comfort. Put emphasis on importance of continuing physical therapy. Assist patient in ADLs.

Out-patient Instruct patient on her follow-up check-up with Dr. Ong and Dr. Velasco.

Diet Eat five or more servings of vegetables and fruit daily. Follow low salt and low fat diet as orders by the Physician. Intake of fluids 8-10 glasses a day to avoid constipation and to maintain skin turgor.

XIV. Updates
Telestroke Networks Can Be Cost-Effective For Hospitals, Good For Patients Article Date: 22 Dec 2012 - 0:00 PST Telestroke networks that enable the remote and rapid diagnosis and treatment of stroke can improve the bottom line of patients and hospitals, researchers report. A central hub hospital delivering rapid stroke diagnosis and treatment partnering with typically smaller spoke hospitals in need of those services means more patients recover better and the network - and hospitals - make money, according to a study in the American Heart Association journal Circulation: Cardiovascular Quality and Outcomes. "We measure stroke treatment in reduced disability and improved function and we have clear evidence that patients who get timely intervention do best," said Dr. Jeffrey A. Switzer, stroke specialist at the Medical College of Georgia at Georgia Health Sciences University. "If you are hospital administrator, you may like the idea conceptually but you have to be concerned about the risks of investing up front to do this. This is the first study to show that if it's set up correctly, a telestroke network will more than pay for itself." Switzer is corresponding author on the study using five years of patient and hospital data from telestroke networks at GHSU and the Mayo Clinic. Researchers plugged the data into a model designed to compare effectiveness and hospital costs with and without a telestroke network. The telestroke model has one hub and

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seven spokes, the average network size in the United States. They found that annually with a network: 45 more patients would receive the clot buster tPA, or tissue plasminogen activator, the only Food and Drug Administration-approved stroke drug 20 more patients would receive endovascular therapy such as mechanically removing the clot from a blood vessel Six more patients would be discharged to their home instead of a nursing home The network made nearly $360,000, with each spoke hospital making more than $100,000 Major costs of telestroke networks include technology, technical support, transferring patients and paying physicians to take the extra call, said Switzer. "The question is whether it's in the interest of hospitals to develop networks that set up these telestroke relationships." The study suggests it is. It supports a model emerging across the nation, where large, hub hospitals such as GHS Medical Center pay equipment and other costs smaller hospitals incur using their network. In the vast majority of cases, patients are seen via the network by stroke specialists in Augusta, eligible patients are given tPA at the spoke hospital then transported to GHS Health System for follow-up care. A new iteration in recent years has larger, urban hospitals also utilizing the guaranteed acute stroke care but keeping most patients at their hospital afterward. The larger hospitals pay for their own telestroke equipment but also receive larger reimbursement from public and private insurance for their service, benefiting hospitals and patients, Switzer said. "Patients receive quality care and can stay closer to home." A major driver behind these types of stroke-care extenders is a lack of stroke specialists. Georgia, for example, is nestled in the stroke belt and has less than 20 fellowship-trained stroke specialists to treat a population of 10 million. Each year only 50-60 stroke specialists complete training at centers across the nation such as MCG and GHS Health System. The long-distance approach appears to work well: MCG researchers showed in a 2003 study published in the journal Stroke that stroke patients in rural communities could be assessed and treated via the wireless Internet program just as well as they could be in person. While tPA has been FDA-approved for 16 years, still fewer than 5 percent of patients receive it, often because they don't get a definitive stroke diagnosis within the three-hour time frame the drug should be given. Three separate clinical trials in the United States and Europe have shown it improves the likelihood of patients resuming normal or near-normal lives. Dr. David Hess, stroke specialist and Chair of the MCG Department of Neurology, helped developed the Augusta system a dozen years ago, initially connecting with a small number of rural hospitals. Today, GHS Health System serves as the hub for 17 spokes. The biotech company, REACH Health, Inc., emerged about six years ago to help other hospitals and states develop similar networks.

Gut Metagenome Changes Protect Against Stroke Article Date: 19 Dec 2012 - 1:00 PST Researchers at the University of Gothenburg, Sweden, and the Chalmers University of Technology, Sweden, demonstrate that an altered gut microbiota in humans is associated with symptomatic atherosclerosis and stroke. These findings are presented in a study published inNature Communications. The human body contains ten times more bacterial cells than human cells, most of which are found in the gut. These bacteria contain an enormous number of genes in addition to our host genome, and are collectively known as the gut metagenome. How does the metagenome affect our health? This question is currently being addressed by researchers in the rapidly expanding field of metagenomic research. Several diseases have been linked to variations in the metagenome.

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Researchers at Chalmers University of Technology and Sahlgrenska Academy, University of Gothenburg, now also show that changes in the gut metagenome can be linked to atherosclerosis and stroke. The researchers compared a group of stroke patients with a group of healthy subjects and found major differences in their gut microbiota. In particular, they showed that genes required for the production of carotenoids were more frequently found in gut microbiota from healthy subjects. The healthy subjects also had significantly higher levels of a certain carotenoid in the blood than the stroke survivors. Carotenoids are a type of antioxidant, and it has been claimed for many years that they protect against angina and stroke. Thus, the increased incidence of carotenoid-producing bacteria in the gut of healthy subjects may offer clues to explain how the gut metagenome affects disease states. Carotenoids are marketed today as a dietary supplement. The market for them is huge, but clinical studies of their efficacy in protecting against angina and stroke have produced varying results. Jens Nielsen, Professor of Systems Biology at Chalmers, says that it may be preferable to take probiotics instead - for example dietary supplements containing types of bacteria that produce carotenoids. "Our results indicate that long-term exposure to carotenoids, through production by the bacteria in the digestive system, has important health benefits. These results should make it possible to develop new probiotics. We think that the bacterial species in the probiotics would establish themselves as a permanent culture in the gut and have a long-term effect". "By examining the patient's bacterial microbiota, we should also be able to develop risk prognoses for cardiovascular disease", says Fredrik Bckhed, Professor of Molecular Medicine at the University of Gothenburg. "It should be possible to provide completely new disease-prevention options". The researchers have now started a company, Metabogen, to further develop their discoveries relating to the metagenome. Their success is based on close cooperation between engineers, microbiologists and doctors. Jens Nielsen and Fredrik Bckhed both agree that one of the challenges in the rapidly developing area of metagenomics is its multidisciplinary facets, requiring novel collaborations and merging of research fields.

Eating tomatoes is shown to slash stroke risk in half Wednesday, October 17, 2012 by: John Phillip Lycopene from tomatoes and tomato-based foods dramatically lowers stroke risk in men After determining the amount of lycopene consumed by the participants, researchers found that 9.7 percent of those men with the lowest intake of lycopene experienced a stroke. 4.2 percent of the men with the highest lycopene consumption had a stroke over the study period. The study team determined that people with the highest amounts of lycopene in their blood were 55 percent less likely to have a stroke than people with the lowest amounts of lycopene in their blood. When the researchers further broke down the results, they found that those with the highest levels of lycopene were 59 percent less likely to have an ischemic stroke (caused by a blood clot, the most common type of stroke) than those with the lowest levels. Lead research author, Dr. Jouni Karppi concluded "This study adds to the evidence that a diet high in fruits and vegetables is associated with a lower risk of stroke... the results support the recommendation that people get more than five servings of fruits and vegetables a day, which would likely lead to a major reduction in the number of strokes worldwide, according to previous research." Interestingly, the scientists reviewed blood levels of the antioxidants alpha-carotene, beta-carotene, alphatocopherol and retinol, but found no association between the blood levels and risk of stroke. This provides further support for consumption of a varied diet from a wide array of fruits, vegetables, nuts and seeds supplying a rainbow of antioxidant compounds and omega-3 fats to prevent disease. Health-conscious individuals will want to include one to two daily servings of tomatoes and tomato-based foods to dramatically lower stroke risk.

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XV.

Bibliography A. Books

Brunner and Suddarth, Textbook of Medical-Surgical Nursing 12th ed. Lippincott, Nursing Drug Guide, 2011

Thomson, Medical-Surgical Nursing: an integrated approach, Asian ed. Taylor,,Lillis, and LeMone, Fundamentals of Nursing, 5th ed Weber and Kelly, Health assessment in Nursing, 3rd ed. Clayton Stock Cooper, Basic Pharmacology for Nurses, 15th ed. MIMS Philippines, drug handbook, 116th edition Robbins-Cotran, Pathologic Basis of Disease, 2nd ed. Black J. and Hawks, J.H., Medical and Surgical Nursing: Clinical Management for Positive outcomes, 8th ed. Elaine N. Marieb, Essentials of Human Anatomy and Physiology, 9th ed.

B. Internet

www.emedicine.medscape.com www.library.med.utah.edu www.nurseslabs.com www.nursingcdxcasepres.blogspot.com www.nursingcrib.com www.buzzle.com www.healthcaremagic.com www.mayoclinic.com www.ygoy.com www.freemd.com www.medi-info.com www.scribd.com www.webmd.com

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