INTRODUCTION 4.

gather the personal and medical data of the patient;

“I walked and sat up…when I felt a confusion and indistinctness in my head which lasted, I 5. obtain and discuss the health history, past and present condition concerning
suppose about half a minute. Soon after I perceived that I had suffered a paralytic stroke, and the patient;
that my Speech was taken from me.” 6. trace the familial lineage of diseases with its corresponding legends;
Samuel Johnson, England, 1783 7. present the past health history including the contributing factors to the
Just what happens when you have a stroke? Most people only get to see the after effects of a illness;
stroke. Few actually get to hear some of the less personal details. Only two people, the stroke 8. present the current health history of the patient with the precipitating events
survivor and the stroke caregiver get to know it all. They see, hear and live the whole horror of to the illness;
what really goes on when stroke happens. 9. evaluate the patient’s developmental data according to Erik Erikson’s
Today, men, women and children are at risk and 80% of the burden is in low- and middle- Psychosocial theory;
income countries. Heart disease and stroke not only take lives, but also cause a huge economic 10. evaluate the patient’s developmental data according to Robert Havighurst’s
burden. Stroke is the brain equivalent of a heart attack. Blood must flow to and through the Developmental theory;
brain for it to function. If its flow is obstructed, by a blood clot moving to the brain, or by 11. perform a systematic and accurate cephalocaudal assessment of the patient;
narrowing or bursting of blood vessels, the brain loses its energy supply, causing damage to 12. define the complete diagnosis of the client at least in 5 sources;
tissues leading to stroke. People get hospitalized when they are so sick that they cannot be 13. illustrate and discuss the anatomy and physiology of the brain that is related
treated in the clinic or at home. Among hospitalized patients, degree of illness can range from to the study;
stable to life-threatening. Obviously, the sickest go to the ICU. A stroke patient is often or 14. trace the pathophysiology of the complete diagnosis of the client in diagram
occasionally than not, treated with supportive care in an intensive care which needs medical form;
attention. 15. briefly discuss the pathophysiology in narrative form;
Currently, the group is assigned at the Sand Pedro Hospital – Intensive Care Unit – Elective 16. list the actual and possible tests and their rationales why they are and should be
rotation. Here, the rotation provides an opportunity for the group and/or to the students to conducted;
explore and area of their choice; the placement further encourages students to transfer clinical 17. enumerate the different drugs prescribed and administered to the patient and provide
skills to other settings and to observe different approaches to patient management from a pertinent information that includes the brand name, generic name, mode of action,
socio-cultural perspective and to reflect on their practice. indication, contraindication, side effects, adverse reaction, and the nursing
Annually, 15 million people worldwide suffer a stroke. Of these, 5 million die and another 5 responsibilities upon and after administration and its picture;
million are left permanently disabled, placing a burden on family and community. An estimated 18. identify our patient’s problem which helps the group in formulating our Nursing Care
17 million people die of CVDs, particularly heart attacks and strokes, every year. A substantial Plan for the patient;
number of these deaths can be attributed to tobacco smoking, which increases the risk of dying 19. provide the health teachings and discharge plan using the METHOD style;
from coronary heart disease and cerebrovascular disease 2–3 fold. (WHO, 2009) 20. evaluate the patient’s prognosis of our patient’s recovery, based on the criteria which
During the Elective nursing rotation, the group has chosen the case of Ms. Jaire which is a 53 are formulated as the basis of our conclusion, and
year old. She was admitted due to a decrease in sensorium, and then was later rushed to the 21. list all the drugs prescribed for the patient and confer its significance and its
San Pedro Hospital – ER. The group has chosen Ms. Jaire because it somehow aimed to study corresponding nursing responsibilities; and
more and/or deeply about her case. 22. list all the references that have been used in the completion of this
The Nursing implications of doing this case study in terms of nursing practice, is that, the comprehensive case study.
group will gain experience and skills with regards to handling patients inflicted with this disease.
The group will be able to differentiate the kinds of CVA and its characteristics in future patients PATIENT'S DATA
and will be able to render the appropriate nursing actions. With the help of this case study, the NAME: JAIRE, HAJI MAYMONA
nursing educators and students will be able to learn and acquire deeper knowledge about the SEX: FEMALE
condition “Cerebrovascular Accident” or stroke. Through this, the group will be able to boost and AGE: 53
develop the confidence in relating, socializing and or sympathizing with the family member, to ADDRESS: 464 BARANGAY 23-C, QUEZON STREET, BOULEVARD, DAVAO CITY, 8000
conduct an interview, for us to gather the needed informations concerning with the patient. BIRTHDAY: JUNE 05, 1955
In nursing education, the group will learn firsthand about the patient’s case. The group will be TELEPHONE NO.: +63929-8611976
the one who will learn themselves and learn all about cerebrovascular accident or stroke. RELIGION: ISLAM
Education and learning is not limited to the confines of a classroom but it is also achieved EDUCATIONAL ATTAINMENT: HIGH SCHOOL GRADUATE
through effort and exposure to actual cases. OCCUPATION: DOMESTIC HELPER
Nursing research implication is that this case study will serve as a research material in which CURRENTLY ON VACATIONUNEMPLOYED
the case is thoroughly studied and is criticized. This will give the future researchers a CIVIL STATUS: SINGLE
background on the disease and a literature on CVA and basis for future studies. SOCIO-ECONOMIC STATUS:
To conclude, this case study will serve as a learning tool for the student nurses and will give DUBAI: P10, 000/month
experience that will broaden the group’s skills in handling patients with this condition, use of
interpersonal skills, acquire knowledge and stimulate critical thinking. MEDICAL DATA
HOW ADMITTED: STRETCHER
OBJECTIVES DATE ADMITTED: FEBRUARY 20, 2009
The general objective of this study is that at the end of 4-weeks exposure in Intensive Care Unit TIME ADMITTED: 07:40 AM
at San Pedro Hospital, the group has chosen a patient to come up with a comprehensive a case ATTENDING PHYSICIAN:
study. Through this case study, it will contribute to the knowledge of the practitioner about the • DR. HIMAGAN, J.
patient, its condition, treatments and as well as providing knowledge, promoting health and • DR. LAO, A.
rendering nursing care to the chosen patient, Ms. Jaire. • DR. LAGAPA, E.
Specific Objectives:
• DR. ENCARNACION, L.
More specifically, to guide the group in completion of the comprehensive case study, the group
CHIEF COMPLAINT: DECREASE IN SENSORIUM
has formulated the following specific objectives:
DIAGNOSIS: LEFT FRONTOPARIETAL BLEED
1. to establish rapport and have a good working relationship with our client and
OPERATION DONE: LEFT PARIETAL CRANIOTOMY
with her support persons to gain cooperation and trust;
EVALUATION OF HEMATOMA
2. present a brief introduction related to the condition with corresponding
DATE OF OPERATION: FEBRUARY 20, 2009
statistics and the nursing implication that is being studied;
TIME OF OPERATION: STAT
3. formulate specific, measurable, attainable, realistic, time-bonded objectives;
 PRE-OP DIAGNOSIS: LEFT FRONTOPARIETAL BLEED PROBABLY HYPERTENSIVE
POST-OP DIAGNOSIS: LEFT FRONTOPARIETAL BLEED
On the maternal side, both of our client’s grandparents who are Sophia, 92 years old and
Hadji, 90 years old are deceased due to old age. They had 12 children. Jairatul 92 years old died
due to old age. Musahari is no where to be found while fishing in the age of 25. The watcher
cannot remember from 3rd to 6th the siblings of her mother. Suratol 30 years old died due to
sepsis. Jaibatol died during birth. Jailani, 67 years old died due to lung cancer. Hadja, 68 years
old due to CVA and she is hypertensive. Halima, 54 years old, who is the mother of our client,
she is hypertensive, diabetic and died due to myocardial infarction. Abdul, 66 years old the only
one who is still alive. He is hypertensive and diabetic.
On the paternal side, both of our client’s grandparents are deceased due to unrecalled
diseases. They had 4 children namely Hadjimusa, Arabar, Hadjijun and Jundam. Hadjimusa, 74
years old the father of our client, once hospitalized due to COPD. Arabar, 72 years old no
serious diseases identified. Hadjijun, 55 years old died due to lung cancer. Jundam, 68 years old
also no serious diseases identified.
Hadjimusa and Halima married each other and had 10 children namely Hadja, our client, 53
years old. She is hypertensive and diagnosed with CVA bleed and undergone craniectomy,
second is Jainal, 52 years old, serious diseases identified. Third is Johona, 28 years old who is
hypertensive. Forth is Noro, 46 years old who is also hypertensive. Firth is Unting, 26 years old
when he died due to vehicular accident. Sixth is Sitimodsha, 44 years old next is Keram, 40
years old and then Aiam 38 years old who are also hypertensive. Moktar, 35 years old and
Dayang, 33 years old who are no identified serious illnesses.
HEALTH HISTORY
PAST:
She was born through normal spontaneous vaginal delivery at without any complications.
According to her sister, her immunizations was not clear because they live in a far flung area
and just waited for health care provider to come to their home and give immunizations.
According to her watcher, during her childhood, she had just experienced uncomplicated
illnesses such as fever, cough, and colds. She had not experienced hospitalization during his
younger years. The patient had no known allergies. In 2001, she ventured her way to work
outside the country and was hired as a Domestic Helper in Dubai, Qatar. She worked there for 7
years. She had her regular check ups there in Dubai or every time she goes home here in the
Philippines. In 2006, she was diagnosed to have one of the complications of hypertension which
is cardiomegaly as seen on her 2d echo by Dr. Himayan. She continued working and continued
taking her meds. The diet that she had was more on fish and vegetables because it’s the most
affordable and readily available food in their community. In a day, according to her watcher,
they will have three meals meals, the normal breakfast, lunch, dinner and 2 coffee breaks. They
would start their breakfast at 7 am, lunch at 12, and dinner by 7. Watcher claimed that she had
gone through childhood illnesses such as measles and chicken pox.
PRESENT:
In 1999, she had consulted with a physician because of some vague signs and symptoms and
was diagnosed to have hypertension she was given a maintenance drug but the watcher could
not recall what drug has she taken.
1 week prior to admission patient was so worried about the news that their house will be
demolish for the project of mayor Duterte. 1 day prior to admission patient was so stressed
because the demolition team went to their house and the project will pursue and their house
will be affected. The patient cannot sleep that night because of that issue.
Hours prior to admission the patient suddenly cannot obey commands with associated
episode of vomiting followed by decrease in sensorium. Patient was then brought to institution
for further management and evaluation.
DEVELOPMENTAL DATA:
Robert Havighurst’s Developmental Task
Robert Havighurst believed that learning is basic to life and that people continue to learn
through out life. He defines a developmental task as a task which arises at or about a certain
period in the life of an individual, successful achievement of these tasks leads to his happiness
and to success and later tasks, while failure leads to unhappiness in the individual, disapproval
by society and difficulty in later tasks.
Miss Maymona Jaire, a 53 year old female, belongs to the middle age group of Havighurst’s
developmental task theory. According to this theory, the following task must be achieved to
attain happiness and success of later tasks.
1. Achieving adult civic and social responsibility
2. Establishing and maintaining an economic standard of living.
3. Assisting teenage children become responsible and happy adults.
4. Developing adult leisure-time activities.
5. Relating oneself to one's spouse as a person.
6. Accepting and adjusting to the physiologic changes of middle age.
7. Adjusting to aging parents.
Ms. Jaire has been a single blessed lady and has been living on her own away from her family.
She had maintained an economic standard of living for herself and would sometimes help her
family especially her siblings and father.
She works as a domestic helper abroad. Her leisure time activities include watching
television, and going to parks and place of worship and if her masters would go on a tour, they
would bring her with them. As a single blessed lady, the only way she could relate to other is
through her work but not going into an intimate relationship. In their family it is also a common
practice to be single. She was able to adjusts to physiologic changes by consulting to medical
specialist every year or when ever she will go back here in the Philippines to have her vacation.
Also while she was still in abroad she used to consult medical doctors there to consult and
monitor her hypertension. She had accepted the responsibility of watching their properties if
she can or while she will be on vacation. At the time of her attack, what really stressed her a lot
is the incident of demolition in their area. Their house is one of those that to be removed and its
their ancestral home. Based on Havighurst's Developmental Task Theory, the client has been
able to cope up efficiently and effectively to the tasks necessary for her age though she was not
able to have a partner in life.
Erik Erikson Stages of Development
Erik Erikson envisions life as a sequence of levels of achievement. Each stage signals a task
that must be achieved. The resolution of the task can be complete, partial or unsuccessful.
Erikson believes that the greater the task achievement, the healthier the personality of the
person; failure to achieve a task influences the person’s ability to achieve the next task. Our
patient is at the stage of adulthood (ages 25- 65 years old) which has a central task of
achieving generativity versus stagnation. She achieved her task for she had develop a positive
resolution as evidenced by creativity, productivity, and her concern for others. She has a stable
job abroad, was able to help her parents and siblings financially and though she does not have a
partner in life. She is not that self centered individual. While she was in the hospital, her sisters
and nieces and nephew would always check on her status. Even her sister abroad has a great
concern for her, evidence that she is good to them.
With this task according to Erikson, our patient, Ms. Jaire had achieved a positive resolution.
DEFINITION OF COMPLETE DIAGNOSIS
HEMORRHAGIC STROKE
1. The most frequently fatal stroke is a spontaneous hemorrhage into the brain substance. With
rupture of a blood vessel, hemorrhage into the brain tissue occurs, resulting in edema,
compression of the brain contents, or spasm of the adjacent blood vessels. The most common
predisposing factors are advancing age and hypertension. Other causes of hemorrhage are
aneurysm, trauma, erosion of the vessels by tumors, arteriovenous malformations, blood
coagulation disorders, vasculitis, and drugs. A cerebral hemorrhage occurs suddenly, usually
when the person is active. Vomiting commonly occurs at the onset, and headache often occurs.
Focal symptoms depend on which vessel is involved. In the most common situation,
hemorrhage into the basal ganglia results in contralateral hemiplegia, with initial flaccidity
progressing to spasticity. The hemorrhage and resultant edema exert great pressure on the
brain substance, and the clinical course progress rapidly to coma and frequently death. Recent
research has focused on the ultra-early (within 4 hours after onset of hemorrhage) use of
hemostatic therapy with recombinant activated factor VII in the treatment of acute intracerebral
hemorrhage.
Book Source:
Porth, C.M. Essentials of Pathophysiology. 2nd ed. Philadelphia: Wolter kluwer Business. ©
2007. P. 842.
2. It is primarily caused by intracranial or subarachnoid hemorrhage. It is caused by bleeding
into the brain tissue, ventricles or subarachnoid space. Primary intracerebral hemorrhage from
spontaneous rupture of blood vessels accounts for solution of hemorrhagic strokes and is
caused by chiefly by uncontrolled hypertension.
Book Source:
Smeltzer, S. C., et. al. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 11th
ed. Vol 2. Philadelphia: Lippincott Williams & Wilkins. © 2008. P. 2225.

3. It occurs when a blood vessel in the brain leaks or ruptures, resulting in bleeding into the
brain. Parts of the brain affected by the bleeding can become damaged, and if enough blood
accumulates, it can put pressure on the brain. The amount of hemorrhage (bleeding)
determines the severity of the stroke. Common causes are • Hypertension (high blood pressure)
is a major risk factor for hemorrhagic strokes. • In older persons, cerebral amyloid angiopathy (a
condition that weakens blood vessels in the brain) can lead to hemorrhagic strokes. •
Aneurysms (tiny blood-filled pouches that balloon out from weakened areas on blood vessel
walls) are prone to leaking or bursting. • Cerebral arteriovenous malformations are clumps of
interconnected abnormal blood vessels that are present from birth and can bleed later in life. •
Blood vessels in brain tumors may be prone to bleeding.
Book Source:
Parmet, S. et. al. The Journal of the American Medical Association. Vol. 292 (15). United
States: American Medical Association. ©2004.
4. Hemorrhagic strokes include bleeding within the brain (intracerebral hemorrhage) and
bleeding between the inner and outer layers of the tissue covering the brain (subarachnoid
hemorrhage).
There are two main types of hemorrhagic strokes: intracerebral hemorrhage and
subarachnoid hemorrhage. Other disorders that involve bleeding inside the skull include
epidural and subdural hematomas, which are usually caused by a head injury. These disorders
cause different symptoms and are not considered strokes.
Web Source: http://www.merck.com/mmhe/sec06/ch086/ch086d.html
5. Intracranial hemorrhage is the accumulation of blood anywhere within the skull vault. A
distinction is made between intra-axial hemorrhage (blood inside the brain) and extra-axial
hemorrhage (blood inside the skull but outside the brain). Intra-axial hemorrhage is due
to intraparenchymal hemorrhage orintraventricular hemorrhage (blood in the ventricular
system). The main types of extra-axial hemorrhage are epidural hematoma (bleeding between
the dura mater and the skull), subdural hematoma (in thesubdural space) and subarachnoid
hemorrhage (between the arachnoid mater and pia mater). Most of the hemorrhagic stroke
syndromes have specific symptoms (e.g. headache, previous head injury).Intracerebral
hemorrhage (ICH) is bleeding directly into the brain tissue, forming a gradually
enlarginghematoma (pooling of blood)
Web Source: http://en.wikipedia.org/wiki/Stroke
PHYSICAL ASSESSMENT:
The assessment to Ms. Haji Maymona Jaire was conducted last February 21, 2009, Saturday at
1:00 pm in Intensive Care Unit, cubicle 14 of San Pedro Hospital, Davao City.
I- General Surveys
Received lying on bed, asleep; responsive to speech stimulation; not in respiratory distress.
With symmetrical lung expansion. With IVF of PNSS 1 liter + 60 meqs KCl @ 80cc/ hour, infusing
well at left cephalic vein at 800 cc level. With side drip in soluset of PNSS 90cc + 10cc of
dopamine @ 20cc/ hour at 70 cc level. With NGT @ right nostril for feeding and medication
purposes, closed distal end. Attached to mechanical ventilator with the set up of RR= 14, Tidal
Volume= 475, Mode= assist control, FiO2= 60%. With endotrachel tube at right side at 22 level.
Attached to cardiac monitor with sinus rhythm. With foley catheter fr. 14 draining to urobag with
yellowish urine at 380 cc urine output. Her body built is endomorphic and looked according to
her age. Hygiene was well maintained and grooming was good. No body odor was noted.
Distress noted on her facial expression.
II- Vital Signs
Upon taking his vital signs, Ms. Jaire has an axillary temperature of 37 oC (35.6-37.4oC), a pulse
rate of 84 bpm, a cardiac rate of 90 bpm (70-90 bpm), a respiratory rate of 15 cpm (20-25
cpm), and a blood pressure of 140/90 mmHg (110/70-130/90).
III- Skin
He has a light brown-toned skin and uniformed skin color to those exposed to the sun and there
are no signs of edema and/or lesions noted. Skin was warm to touch and has good skin turgor
with a good capillary circulation of 3-4 seconds. Dry skin not noted. Scars were noted on the
lower extremities.
IV- Head
Head is rounded and normocephalic and symmetrical to the body parts. Has a smooth skull
contour. He has evenly distributed hair. With dressing on left frontal side, dry and intact. No
presence of infection or lesions noted upon palpation. No nodules or masses noted. His facial
movements a symmetric as evidenced by elevating and lowering the eyebrows, closing of the
eyes tightly. No dandruffs noted on his scalp.
VI. Eyes
Eyebrows symmetrically aligned; equal in movement. Hair is evenly distributed and skin intact.
Have equally distributed and normal curl of eyelashes. Eyelids close symmetrically, with normal
blinking. When lids open, no visible sclera above cornea and upper and lower borders of cornea
are slightly covered.
Has normal symmetry of the eye. Pupils are black in color, equal in size, with 3 mm in diameter
and reacts to any stimuli. Pupils equally round and briskly reacting to light. Iris is flat and round.
No tenderness or edema on the lacrimal duct upon palpation. Both eyes move coordinate and in
unison with parallel alignment.
VII. Ears
Both pinna are same in color as facial skin and aligned with outer canthus of eye upon
inspection. Pinna are mobile, firm and non tender upon palpation. Pinna recoils after it is folded.
Presence of discharges was not observed on external canal. Pinna is also free from lesions,
swelling, and masses. Hearing acuity is well. He was able to hear normal voice tones and
whispering on both ears.
VIII. Nose
Nose is symmetric and straight with no presence of discharges, swelling, and flaring upon
inspection and with uniform color. It is also non tender and with no lesions upon palpation. Air
moves freely as the client breathes through the nares. Mucosa is pink, with clear watery
discharge and no lesions. Nasal septum is intact and in midline upon inspection. Maxillary and
frontal sinuses are not tender upon palpation.
IX. Mouth
Lips and buccal mucosa are uniformly pink in color. It was also soft, moist and smooth in
texture. The tongue is midline and pink in color. It is also moist with thin whitish coating upon
inspection. The base of the tongue is smooth with prominent veins. Palate is soft, smooth and
lighter pink in color. Hard palate is lighter pink and has a regular texture than the soft palate.
Gag reflex is present.
X. Neck
No lymph nodes upon palpation. There is symmetry of posterior and anterior portions of neck.
Lesions were not noted. Thyroid gland is not palpable. Neck muscles are equal in size and head
is centered. Head movement is coordinated and smooth movements were done with no
discomfort. Can flex head 45 degrees and can move chin to the chest. The head can
hyperextend up to 60 degrees and can move it backwards. Head flexes laterally 40 degrees,
and can rotate 70 degrees. Head has equal strength. Shoulders have no equal strength; in the
right side is weak while in the left side is strong. The trachea is in central placement in midline
of the neck upon palpation.
XI. Breast and Axilla
His breasts are both symmetrical in shape and size and even with the chest wall. Skin smooth
and intact and in uniform color. His areola is round and light brown in color with irregular
replacement of sebaceous glands on the surface upon inspection with no discharges noted and
no masses were noted upon palpation. The nipples are round, everted and equal in size, similar
in color, soft, smooth and both points in the same direction. No discharges were noted. No
tenderness or masses noted upon palpation.
XII. Chest and Lungs
Chest is symmetric and spine was vertically aligned with straight spinal column. Skin is intact
with uniform temperature upon palpation. The posterior chest has a full and symmetric chest
expansion. He has a bilateral symmetry of vocal fremitus. Fremitus is heard most clearly at the
apex of the heart. Vesicular and bronchovesicular breath sound were heard upon auscultation.
Anterior thorax is quiet and rhythmic and effortless to respirations. Has a full symmetric lung
excursion upon palpation. With nitroglycewrin patch noted at left side of the chest.
XIII. Heart
He has a regular cardiac rhythm. Point of maximal impulse was auscultated at the left
intercostal space, left midclavicular line. His apical, aortic, pulmonic and tricuspid pulses are
clearly audible. Carotid arteries has symmetric pulse volume and no bruit was heard upon
auscultation. Jugular veins were not visible upon inspection.
XIV. Abdomen
Abdomen is unblemish and has a uniform skin color. No striae noted. No dilated veins visible.
Abdomen is soft, round and not distended. Bowel sounds is normal.
XV. Genito-Urinary
Genitals are free from lesions and warts. She is with clean diaper. Pubic hair is free from
dandruff and lice. No abnormalities were noted.
XVI. Extremities
There is symmetry on both arms and legs in size and are appropriate for body proportion. Also
have symmetrical and strong pulses. Muscle strength is not equal on both hands. The right hand
and foot is weak while in the left hand and foot is strong. Fingers and toes are complete.
Fingernails and toenails are properly trimmed.
XVII. Neurological Assessment
The client’s neurological function is RLS score of 1-2 and GCS score of 11.
Cranial Nerve Assessment:
CN RESULT
1 Not applicable. Patient cannot talk because she is intubated.
2 He can do head movement and can shrug his shoulders against resistance of hands
in the left side only.
3 We cannot assess the swallowing capacity of the patient because she is intubated.
4 She cannot move tongue side to side and up and down.
5 She was able to hear spoken words and whispers while her eyes were closed.
6 Facial expression like smiling, raising eyebrows, frowning and closing the eyes
tightly were well done. Where not able to assess identifying various tastes because
she is intubated.
7 She can move his eyeball laterally and be able to see his periphery.
8 She elicit blink reflex upon light touch to the lateral sclera. She can feel sensation
on the skin of face while she closes his eyes.
9 She can move the eyeball downward and laterally.
10 Extraocular eye movement was good because when we ask her to follow the
procedure, she has a good result. The pupil constricts upon the introduction of light
and has a diameter of 3 mm
11 She can see us even in the distance of 5 meters.
12 Not applicable. Patient cannot talk because she is intubated.
ANATOMY AND PHYSIOLOGY
The image on the left is the outside of the brain, viewed from the side, showing the major lobes
(frontal, parietal, temporal and occipital) and the brain stem structures (pons, medulla
oblongata, and cerebellum).
The image on the right is a side-view showing the location of the limbic system inside the brain.
The limbic system consists of a number of structures, including the fornix, hippocampus,
cingulate gyrus, amygdala, the parahippocampal gyrus and parts of the thalamus.
Amygdala – limbic structure involved in many brain functions, including emotion, learning and
memory. It is part of a system that processes "reflexive" emotions like fear and anxiety.
Cerebellum – governs movement.
Cingulate gyrus – plays a role in processing conscious emotional experience.
Fornix – an arch-like structure that connects the hippocampus to other parts of the limbic
system.
Frontal lobe – helps control skilled muscle movements, mood, planning for the future, setting
goals and judging priorities.
Hippocampus – plays a significant role in the formation of long-term memories.
Medulla oblongata – contains centers for the control of vital processes such as heart rate,
respiration, blood pressure, and swallowing.
Limbic system – a group of interconnected structures that mediate emotions, learning and
memory.
Occipital lobe – helps process visual information.
Parahippocampal gyrus – an important connecting pathway of the limbic system.
Parietal lobe – receives and processes information about temperature, taste, touch, and
movement coming from the rest of the body. Reading and arithmetic are also processed in this
region.
Pons – contains centers for the control of vital processes, including respiration and
cardiovascular functions. It also is involved in the coordination of eye movements and balance.
Temporal lobe – processes hearing, memory and language functions.
Thalamus – a major relay station between the senses and the cortex (the outer layer of the
brain consisting of the parietal, occipital, frontal and temporal lobes).
Divisions of the Brain
Mesencephalon- midbrain
Function:
Controls Responses to Sight,Eye Movement, Pupil Dilation, Body Movement,Hearing
Location:
The mesencephalon is the most rostral portion of the brainstem. It is located between the
forebrain and brainstem.
Structures:
The mesencephalon consists of the tectum and tegmentum.
Prosencephalon- forebrain
Function:
Chewing ,Directs Sense Impulses Throughout the Body, Equilibrium, Eye Movement, Vision,
Facial Sensation, Hearing, Phonation, Intelligence, Memory, Personality, Respiration,
Salivation,Swallowing , Smell, Taste
Location:
The prosencephalon is the most anterior portion of the brain. It is also called the forebrain.
Structures: Frontal Lobes
The prosencephalon consists of the telencephalon, striatum, diencephalon, lateral ventricle and Function:
third ventricle. Motor Functions, Higher Order Functions, Planning, Reasoning, Judgement, Impulse, Control,
Diencephalon Memory
Function: Location:
Chewing , Directs Sense Impulses Throughout the Body, Equilibrium, Eye Movement, Vision, The frontal lobes are the anterior portion of the cerebral cortex.
Facial Sensation, Hearing, Phonation, Respiration, Salivation, Swallowing, Smell, Taste Occipital Lobes
Function:
Location: Controls Vision, Color Recognition
The diencephalon is located between the cerebral hemispheres and above the midbrain. Location:
Structures: The occipital lobes are the most caudal portion of the cerebral cortex.
The diencephalon includes the thalamus, hypothalamus, the optic tracts, optic chiasma, Parietal Lobes
infundibulum, Ventricle III, mammillary bodies, posterior pituitary gland and the pineal gland. Function:
Thalamus Cognition, Information Processing, Pain and Touch Sensation, Spatial Orientation, Speech, Visual
Function: Perception
Motor Control,Receives Auditory, Somatosensory, Visual Sensory Signals, Relays Sensory Location:
Signals to the Cerebral Cortex The parietal lobes are superior to the occipital lobes and posterior to the central sulcus (fissure)
Location: and frontal lobes.
The thalamus is a large, dual lobed mass of grey matter cells located at the top of the Temporal Lobes
brainstem, superior to the hypothalamus. Function:
Telencephalon Emotional Responses,Hearing, Memory, Speech
Function: Location:
Determines Intelligence, Determines Personality, Interpretation of Sensory Impulses, Motor The temporal lobes are anterior to the occipital lobes and lateral to the Fissure of Sylvius.
function, Planning and Organization, Sense of Smell, Touch Sensation Insula
Location: Function:
The telencephalon is the anterior portion of the brain, rostral to the midbrain. Associated With Visceral Functions, Integrates Autonomic Information
Structures: Location:
The telencephalon consists of the cerebral cortex, basal ganglia, corpus striatum and olfactory The insula is located within the cerebral cortex, beneath the frontal, parietal and temporal
bulb. opercula.
Basal ganglia Broca's Area
Function: Function:
Controls Cognition, Movement Coordination, Voluntary Movement Controls Facial Neurons, Controls Speech Production, Understanding Language
Location: Location:
The basal ganglia is located deep within the cerebral hemispheres in the telencephalon region Broca's area is located in the left frontal lobe, around the opercular and triangular sections of
of the brain. It consists of the corpus stratium, subthalamic nucleus and the substantia nigra. the inferior frontal gyrus.
Rhombencephalon Wernicke's Area
Function: Function:
Attention and Sleep, Autonomic Functions, Complex Muscle Movement, Conduction, Pathway for Language Comprehension
Nerve Tracts, Reflex Movement, Simple Learning Location:
Location: Wernicke's area is located in the left temporal lobe, posterior to the primary auditory complex.
The rhombencephalon is the inferior portion of the brainstem. Brainstem
Structures: Function:
The rhombencephalon is comprised of the metencephalon, the myelencephalon, and the Alertness, Arousal, Breathing, Blood Pressure, Contains Most of the Crainal Nerves, Digestion,
reticular formation. Heart Rate, Other Autonomic Functions, Relays Information Between the Peripheral Nerves and
Myelencephalon Spinal Cord to the Upper Parts of the Brain
Function: Location:
Autonomic Functions, Breathing, Conduction Pathway for Nerve Tracts, Digestion, Heart Rate, The brainstem is located at the juncture of the cerebrum and the spinal column. It consists of
Swallowing, Sneezing the midbrain, medulla oblongata, and the pons.
Location: Cerebellum
The myelencephalon is the most inferior portion of the brainstem. Function:
Structures: Controls Fine Movement Coordination, Balance and Equilibrium, Muscle Tone
The myelencephalon is composed of the medulla oblongata. Location:
The cerebellum is located just above the brainstem, beneath the occipital lobes at the base of
STRUCTURES OF THE BRAIN the skull
Cerebral Cortex
CEREBRAL CORTEX LOBES Function:
Structure:
 Determines Intelligence, Determines Personality, interpretation of Sensory Impulses, Motor
Function, Planning and Organization, Touch Sensation
• It is tightly regulated to meet the brain's metabolic demands, and on the average must be

Location: maintained at a flow of 50 milliliters of blood per 100 grams of brain tissue per minute in adult
The cerebral cortex is the outer portion (1.5mm to 5mm) of the cerebrum. It is divided into humans.
lobes: frontal, parietal, temporal and occipital. The insula is also found in this region of the • It must be maintained within narrow limits because too much blood can raise intracranial
brain. pressure (ICP), which can compress and damage delicate brain tissue, and too little blood
Cerebrum causes ischemia, or inadequate blood supply.
Function:
Determines Intelligence, Personality, Interpretation of Sensory Impulses, Motor Function • An excess of 55 to 60 ml per 100 g per minute, called hyperemia, is more than the brain needs
Planning and Organization, Touch Sensation and can contribute to an increase in intracranial pressure.
Location:
The cerebrum is located in the anterior portion of the forebrain. It is divided into two
• It is determined by a number of factors, such as viscosity of blood, how dilated blood vessels

hemispheres that are connected by the corpus callosum. are, and the net pressure of the flow of blood into the brain, known as cerebral perfusion
pressure, which is determined by the body's blood pressure and intracranial pressure.
Corpus Callosum • Functional magnetic resonance imaging (MRI) and positron emission tomography (PET) are
Function: neuroimaging techniques that can both be used to measure CBF.
Connects the Left and Right Hemispheres
Location:
The corpus callosum is a thick band of fibers located between the cerebral hemispheres.
Cranial Nerves
Function:
Directs Sense Impulses Throughout the Body, Chewing, Equilibrium, Eye Movement, Vision,
Facial Sensation, Hearing, Phonation, Respiration, Salivation, Swallowing, Smell
Taste
Location:
The olfactory, optic, oculomotor and trochlear cranial nerves are located in the anterior portion
of the brain. The trigeminal, abducens, and facial nerves arise in the pons. The
vestibulocochlear nerve arises in the inner ear and goes to the pons. The glossopharyngeal,
vagus, accessory and hypoglossal nerves are attached to the medulla oblongata.
Fissure of Sylvius (Lateral Sulcus)
Function:
The fissure of sylvius is the large deep groove or indentation that separates the parietal and
temporal lobes.
Medulla Oblongata
Function:
Controls Autonomic Functions
Relays Nerve Signals Between the Brain and Spinal Cord
Location:
The medulla oblongata is the lower portion of the brainstem. It is inferior to the pons and
anterior to the cerebellum.
Pons
Function:
Arousal, Assists in Controlling Autonomic Functions, Relays Sensory Information Between the
Cerebrum and Cerebellum, Sleep
Location:
The pons is the portion of the brainstem that is superior to the medulla oblongata.

Cerebral blood flow or CBF

• It is the blood supply to the brain in a given time.

• The amount of blood that the cerebral circulation carries.
• 750 ml/min or 15% of the cardiac output

• It is equal to the cerebral perfusion pressure (CPP) divided by the cerebrovascular resistance
(CVR)
• CBF = CPP / CVR

Cerebral circulation
The brain, though representing 2% of the total body weight, it receives one fifth of the resting
cardiac output. This blood supply is carried by the two internal carotid arteries (ICA) and the two
vertebral arteries that anastomose at the base of the brain to form the circle of Willis.
Carotid arteries and their branches (referred to as the anterior circulation) supply the anterior
portion of the brain while the vertebrobasilar system (referred to as posterior circulation)
supplies the posterior portion of the brain.
• The movement of blood through the network of blood vessels supplying the brain.
• The arteries deliver oxygenated blood, glucose and other nutrients to the brain and the veins
carry deoxygenated blood back to the heart, removing carbon dioxide, lactic acid, and other
metabolic products.
• The cerebral circulatory system has many safeguards. Since the brain is very vulnerable to
compromises in its blood supply, failure of these safeguards results in cerebrovascular
accidents, commonly known as strokes.
Cerebral arteries
• There are four cerebral arteries.
• The largest are the two internal carotid arteries, the left and right branches of the common
carotid arteries in the neck which enter the skull, as opposed to the external carotid branches
which supply the facial tissues.
• The two smaller arteries are the vertebral arteries, which branch from the subclavian arteries
which primarily supply the shoulders, lateral chest and arms.
• Within the cranium, which houses the brain, the two vertebral arteries fuse into the basilar
artery, which is located underneath, and primarily supplies, the brainstem.
• Both internal carotid arteries, within and along the floor of the cerebral vault, are
interconnected via the anterior communicating artery.
• Both internal carotid arteries are interconnected with the basilar artery via bilateral posterior
communicating arteries.
• The Circle of Willis considered to be an important anatomic vascular formation, it provides
backup circulation to the brain. In case one of the supply arteries is occluded, the Circle of Willis
provides interconnections between the internal carotid arteries and basilar artery along the floor
of the cerebral vault, providing blood to tissues that would otherwise become ischemic.
Cerebral venous drainage
• The venous drainage of the cerebrum can be separated into two subdivisions:
• Superficial system
a) It is composed of dural venous sinuses, which have wall composed of dura mater
as opposed to a traditional vein.
• Deep system
a) It is primarily composed of traditional veins inside the deep structures of the brain,
which join behind the midbrain to form the Vein of Galen
• The dural sinuses are, therefore located on the surface of the cerebrum.
• Superior saggital sinus the most prominent sinus in which flows in the saggital plane under the
midline of the cerebral vault, posteriorly and inferiorly to the torcula, forming the Confluence of
sinuses, where the superficial drainage joins with the sinus the primarily drains the deep venous
system.
• Two transverse sinuses bifurcate and travel laterally and inferiorly in an S-shaped curve that
form the sigmoid sinuses which go on to form the two jugular veins.
• In the neck, the jugular veins parallel the upward course of the carotid arteries and drain blood
into the vena cava.
• This vein merges with the Inferior saggital sinus to form the Straight sinus which then joins the
superficial venous system.
Cerebral perfusion pressure or CPP
• The net pressure of blood flow to the brain.
• It must be maintained within narrow limits because too little pressure could cause brain tissue
to become ischemic (having inadequate blood flow), and too much could raise intracranial
pressure (ICP).
• CPP = MAP − ICP
• It is regulated by two balanced, opposing forces:
1. Mean arterial pressure, or MAP
The arithmetic mean of the body's blood pressure, is the force that pushes blood into
the brain, and intracranial pressure is the force that keeps it out.
• Increase MAP raises CPP.
• Increase ICP lowers CPP (this is one reason that increasing ICP in traumatic brain injury is
potentially deadly).
• CPP= MAP minus ICP, is normally between 70 and 90 mmHg in an adult, and cannot go below
70 mmHg for a sustained period without causing ischemic brain damage.
• Children require pressures of at least 60 mmHg.
Autoregulation
• It is a process wherein the brain maintains proper CPP.

• To lower pressure, blood vessels in the brain called arterioles dilate, or widen, creating more
room for the blood, and to raise pressure they constrict, or narrow.
• Changes in the body's overall blood pressure do not normally alter cerebral perfusion pressure
drastically.
• At their most constricted, blood vessels create a pressure of 150 mmHg, and at their most
dilated the pressure is about 60 mmHg.
• Pressure-passive flow is a situation When pressures are outside the range of 50 to 150 mmhg,
the blood vessels' ability to autoregulate pressure through dilation and constriction is lost, and
cerebral perfusion is determined by blood pressure alone.
• Factors that can cause loss of autoregulation include:
a. free radical damage
b.nervous stimulation, and
c.alterations in blood gas content
• Amounts of carbon dioxide and oxygen in the blood affect constriction and dilation even in the
absence of autoregulation: excess carbon dioxide can dilate blood vessels up to 3.5 times their
normal size, lowering CPP, while high levels of oxygen constrict them.
• Hypoxia, or inadequate oxygen, also dilates blood vessels and increases blood flow
• Blood vessels also dilate in response to low pH.
• Activity in a given region of the brain is heightened, the increase in CO 2 and H+ concentrations
causes cerebral blood vessels to dilate and deliver more blood to the area to meet the
increased demand.
• Stimulation of the sympathetic nervous system raises blood pressure and blocking it lowers
pressure.
Anatomy of the cerebral circulation
The brain receives its blood supply from the heart by way of the aortic arch that gives rise to
the brachiocephalic (innominate) artery, left common carotid artery (CCA) and the left
subclavian artery.
A. Carotid Arterial System
1. Common Carotid artery (CCA):
The left CCA arises from the aortic arch while the right arises from the bifurcation of
the innominate artery.
2. External carotid artery (ECA)
It starts at the CCA bifurcation. Its branches supply the jaw, face, neck and meninges. The bulk
of the meningeal circulation is supplied by the middle meningeal artery, the most important
branch of the maxillary artery which is one of the two terminal branches of the ECA (the other
terminal branch is the superficial temporal artery). These two terminal branches in addition to
the occipital artery can serve as collateral channels for blood supply to the brain in instances of
obstruction of the ICA. The ascending pharyngeal artery can serve as a source of blood in
instances of occlusion of the ICA.
3. Internal carotid artery (ICA)
It starts at the carotid sinus at bifurcation of CCA at the level of the upper border of the thyroid
cartilage at the level of the fourth cervical vertebra. It ascends just behind and lateral to the
hypopharynx where it can be palpated. It passes up the neck without any branches to the base
of the skull where it enters the carotid canal of the petrous bone. It then runs through the
cavernous sinus in an S-shaped curve (the carotid siphon), then it pierces the dura (beginning
its subarachnoid course) and exits just medial to the anterior clinoid process and then ascends
to bifurcate into anterior cerebral artery and the larger middle cerebral artery.
Branches of the ICA include:
1. Ophthalmic artery
It arises in the cavernous sinus as the first major branch of the ICA. It passes through the optic
canal to supply the eye and other structures of the orbit. Central artery of the retina is its most
important branch. It ends by supplying a patch of skin on the medial aspect of the forehead.
2. Posterior communicating artery (PoCA)
It arises just before the termination of the ICA and passes backward to join the first part of the
posterior cerebral artery (PCA). This connection can be a vital link to one or the other in
instances of disease. Unfortunately, in over twenty per cent of cases the artery on one or the
other side is small and can not serve this function. It supplies the optic tract, chiasma, the
thalamus, hypothalamus and the midbrain.
3. Anterior choroidal artery
It originates occasionally from the PoCA or the middle cerebral artery (MCA), the anterior
choroidal artery usually arises from the ICA just beyond the origin of the PoCA. It supplies the
choroid plexus of the lateral ventricle, the optic tract, the internal capsule, medial parts of the
basal ganglia, the medial parts of the temporal lobe, the thalamus, the lateral geniculate body,
the proximal optic radiation and the midbrain. The anterior and posterior choroidal arteries join
the carotid and the vertebrobasilar systems.
4. Anterior cerebral artery (ACA)
It passes anteromedially via the horizontal plane to enter the interhemispheric fissure,
anastomoses with the contralateral ACA via the anterior communicating artery (ACoA) forming
the anterior portion of the circle of Willis. It supplies the anterior and the medial parts of the
cerebral hemispheres. Small branches (medial striate arteries) also supply parts of the optic
nerve and chiasma, hypothalamus, anterior basal ganglia and internal capsule. One of these
branches is of sufficient size to be named: the recurrent artery of Heubner, which supplies the
anterior limb of the internal capsule.
5. Middle cerebral artery (MCA)
It is the largest branch of ICA and appears almost as its direct continuation. It passes laterally
entering the Sylvian fissure and divides into two to four branches supplying the lateral parts of
the cerebral hemispheres. It supplies most of the hemisphere including the bulk of the convexity
except for thin superior and inferior strips. From its main stem, a medial and lateral group of
tiny lenticulostriate arteries pass upwards to penetrate the base of the brain and supply the
basal ganglia and the superior portion of the anterior and posterior limbs of the internal
capsule.
B. Vertebrobasilar System
1. Vertebral artery
It arises from the proximal subclavian artery and ascends through the transverse foramina of
the first cervical vertebra. It then passes posteriorly around the articular process of the atlas to
enter the skull through the foramen magnum. The two vertebral arteries join each other at the
level of the pontomedullary junction to form the basilar artery. The vertebral artery gives rise to
anterior and posterior spinal arteries, the posterior inferior cerebellar artery and branches to the
medulla.
2. Basilar artery
It is formed by the two vertebral arteries joining each other in the midline. It ascends along the
ventral aspect of the pons. It ends at the ponto-midbrain junction where it divides into two
posterior cerebral arteries. It gives rise to anterior inferior cerebellar artery, superior cerebellar
artery and numerous paramedian, short and long circumferential penetrators. The internal
auditory (labyrinthine) artery arises from the basilar artery in about 20 % of the population
whereas in the remainder it arises from the anterior inferior cerebellar artery.
3. Posterior cerebral artery (PCA)
The basilar artery ends by dividing into the two posterior cerebral arteries. They encircle the
midbrain close to the occulomotor nerve at the level of tentorium cerebelli and supply the
inferior part of the temporal lobe and the occipital lobe. Soon after their origin, they
anastomose with the posterior communicating arteries to complete the circle of Willis. Many
small perforating arteries arise from PCA to supply the midbrain, the thalamus, hypothalamus
and geniculate bodies. In fifteen per cent of the population, the PCA is a direct continuation of
the PoCA, its main blood supply then comes from the ICA rather than from the vertebrobasilar
system
 9. Hyper LDLs transport cholesterol to the arteries and can be
PATHPHYSIOLOGY retained there by arterial proteoglycans starting the
lipidemia formation of plaques, increased levels are associated
PREDISP with atherosclerosis, and thus heart attack, stroke and
OSING P A RATIONALE peripheral vascular disease. This is why cholesterol
FACTORS inside LDL lipoproteins is called bad cholesterol. Still, it
is not the cholesterol that is bad; it is instead how and
where it is being transported, and in what amounts over
The chance of having a stroke more than doubles for
time.
each decade of life after age 65. While stroke is
1. Age  10. Heart  People with coronary heart disease or heart failure have
common among the elderly, a lot of people under 65
disease a higher risk of stroke than those with hearts that work
also have strokes.
normally. Dilated cardiomyopathy (an enlarged heart),
Stroke is more common in men than in women. In most heart valve disease and some types of congenital heart
age groups, more men than women will have a stroke in defects also raise the risk of stroke.
2. Sex
gender a given year. However, more than half of total stroke

deaths occur in women. At all ages, more women than
men die of stroke. Use of birth control pills and PRECIP RATIONALE
pregnancy pose special stroke risks for women. ITATIN AB
G PRESENT SE
African Americans or Blacks have a much higher risk of FACTO NT
death from a stroke than Caucasians do. This is partly RS
3. Race 
because blacks have higher risks of high blood pressure, Stress promotes vasoconstriction of the blood vessels.
1. Stre
diabetes and obesity. Narrowing of the blood vessel thus increase blood flow
ss 
pressure causing the vessels to rupture.
High blood pressure is the most important controllable risk
Close relatives are at greater risk than non-genetically
factor for stroke. Many people believe the effective
4. Hered related family members of a stroke patient. Diabetes 2.
 treatment of high blood pressure is a key reason for the
ity and hypertension show familial propensity thus clouding Hypert 
accelerated decline in the death rates for stroke.
the significance of pure hereditary factors. ension
Hypertension is a major factor in the development of
Increase glucose in blood would cause a viscose blood thrombotic cerebral infarction and intracranial hemorrhage.
that would cause decrease blood supply to the brain.
5. Diabe Diabetes is an independent risk factor for stroke. Many SYMPTOMATOLOGY
tes people with diabetes also have high blood pressure, A JUSTIFICATION
 PRESEN
Mellit high blood cholesterol and are overweight. This SYMPTOMS BSE
T
us increases their risk even more. While diabetes is NT
treatable, the presence of the disease still increases Due to the temporary reduction of cerebral blood flow
your risk of stroke. 1.LOSS OF and therefore a shortage of oxygen to the brain. This
6. CONSCIOUS  leads to light headedness or a "black out" episode.
Socioec There's some evidence that strokes are more common NESS
onomic  among low-income people than among more affluent Due to the vascular lesions of the middle cerebral artery
2. BROCA’S
factors people. of the dominant hemisphere, the hemisphere
APHASIA 
responsible for mediation language.
The risk of stroke for someone who has already had one This condition usually affects the extremities equally, but
is many times that of a person who has not. Transient in some cases it affects one extremity more than the
ischemic attacks (TIAs) are "warning strokes" that 3. other. The most common stroke location in affected
7. History HEMIPARES patients is the posterior limb of the internal capsule,
of produce stroke-like symptoms but no lasting damage. 
 TIAs are strong predictors of stroke. A person who's had IS which carries the descending corticospinal and
stroke corticobulbar fibers. Other stroke locations include the
one or more TIAs is almost 10 times more likely to have
a stroke than someone of the same age and sex who pons, midbrain, and medulla.
hasn't. Recognizing and treating TIAs can reduce your 4. Due to the sudden disturbance in the blood supply to the
risk of a major stroke. HEMIANOPS brain and caused by a blocked blood vessel.
In recent years, studies have shown cigarette smoking IA 
8.
to be an important risk factor for stroke. The nicotine When the blood supply to a part of the brain is
Cigarett
and carbon monoxide in cigarette smoke damage the interrupted or severely reduced, depriving brain tissue of
e  5.
cardiovascular system in many ways. The use of oral  oxygen and nutrients, brain cells begin to die, causing
Smoking DYSARTHRI
contraceptives combined with cigarette smoking greatly damage to the cerebellum, which may result to the
increases stroke risk. A damage in the spinal cord and peripheral nerves that
connects the cerebellum to the muscles.
An excessive reactivity of cranial arteries to various
stimuli, there is a general as well as focal reduction in
6. SUDDEN
the cerebral blood flow likely due to the vasoconstriction
HEADACHE 
of brain arterioles mainly in areas corresponding to the
particular neurological symptoms.
7. TONGUE  The tongue deviates to the affected sides since the
 unaffected part of the tongue is stronger than the latter,
DEVIATION
causing it to push on the other side.
8. It is due to the decrease in the cerebral blood flow and
RESTLESSN  an increase in ICP this the patient may feel uneasiness
ESS and restlessness with what she feels.
When the affected area is the frontal lobe, the memory
9. and affect is disrupted or disturbed thus the patient may

CONFUSION experience confusion or sometimes would develop into
temporary psychosis if not addressed.
With an increase in ICP and decrease cerebral perfusion,
10.
the client would experience drowsiness for the function
DROWSINE 
of neurons and other brain functions will also be
SS
affected.
11.VOMITIN Most common is projectile vomiting due to the

G compressio0n of the brain stem.

The precipitating factors that include stress and hypertension together with the predisposing
factors (age, gender, diabetes mellitus, family history, history of stroke, hyperlipidemia,
cigarette smoking, and race) would cause an increase blood flow to the brain causing now the
disruption and compromise of the cerebral arterioles’ integrity thus resulting to the deposition
of lipid and hyaline materials in the arterial wall. This event would eventually weaken the walls
forming the Chalcot- Bouchard aneurysm. This aneurysm is common to hypertensive clients.
Through imaging using the MRI and CT scan, the degree of bleeding caused by the rupture of
aneurysm will be seen and identified. The degree and severity of the bleed will also be
established. As of the case of our patient, the left frontal lobe was the affected area so most
probably; the artery that had ruptured was the anterior cerebral artery. This artery supplies
blood to the frontal lobe. Base on the symptoms manifested by our client, the rupture of the
artery had caused inflammation, alteration in the brain component, hematoma formation and
presence of blood in the interstitial areas of the brain.
The inflammatory process had triggered the occurrence of fever, and through the laboratory
examination, a leukocytosis might develop. Alteration in the brain component , hematoma
formation and also inflammation would cause an increase in the intracranial pressure of IC. An
increase in the ICP could be observed with the patient’s manifestation of the following;
restlessness, changes in LOC, sudden headache, confusion, and drowsiness. Diagnostic
examination such as cerebral angiography, PET scan, would verify this finding. An the ICP
increases, the body would initiate compensatory mechanism to restore homeostasis and
prevent complications. As a compensatory mechanism, the body would initiate three regulatory
mechanisms. The first one is autoregulation in which continual cerebral perfusion of brain tissue
regardless of changes in systemic arterial pressure happens. The second is CSF regulation. It
will regulate the production and reabsorption of the CSF with any changes in intra cerebral
perfusion. The last mechanism is the metabolic regulation in which a decrease in the oxygen ACTUAL DIAGNOSTIC EXAMS:
being fed to the brain and subsequent increase in the carbon dioxide would cause vasodilation. HEMATOLOGY
Vasodilation occurs to permit increase blood to the brain. But with the on going compensatory
mechanisms, on going damage to the brain will also accompany it. There will be decrease 02/20/09 02/21/09
oxygen supply, further swelling amd edema, and compression of the brain components will 1. CBC 2. S. 4. ABG 5. HGT
further happen. Uf the compensatory mechanisms are not that effective, a decrease in ocygen ELECTROLYTES
supply would eventually precede to ischemia causing an irreversible damage and death of the N R N R N R
neurons. Furthermore, the ischemia causes scar formation that can be seen through x- rays, CT Hg 140- 121 Na 137- 13 pH 7.35 7 (7-3) (7-3)
scan and MRI. Ischemia would stimulate the vasomotor centers to increase the systemic 180 145 8 - .47 11am 11Am
pressure to maintain cerebral blood flow and to prevent further damage. These occurrences will 120- N 7.45 5 159 173
be manifested through a slow bounding pulse, and through respiratory irregularities. Another 160 D mg/dL mg/dL
effect of ischemia is the alteration in the function of the part of the brain affected. On our RBC 4.5-5 3.9 K 3.6- 2.8 PC 35- 3 (3-11)
patient’s case, it is the frontal lobe thus causing now the symptoms of Broca’s aphasia, 4-5 D 5.0 D 02 45 0.7 5pm
dysarthria, hemiparesis, and difficulty to or is incapable of abstract thinking. D 154
Presence of free blood in the interstitial areas of the brain will stimulate the formation of clots mg/dL
or thrombus and the destruction of the cell membrane. This destruction would further cause MC 27-33 31.1 Ca 2.10 2.3 P0 80- 7 1
cellular edema, vasospasm, electrolyte imbalances and acidosis that through ABG and serum H - N 2 100 2.3 1Pm –
electrolyte test be verified. 2.55 176
All of these complications if not treated at an early stage would further lead to comatose, mg/dL
brain herniation, stupor and eventually death. But through medical and surgical interventions, MC 80-96 95 M .7- .6 HC 22- 2 (11-7)
complications being discussed san be prevented causing a FAIR OR GOOD PRONOSIS. V g 1.0 D 03 28 2.3 5am
N 200
mg/dL
WB 5-10 12.7 3. S. TC 23- 2 ª Used to evaluate respiratory function and provide a measure for determining acid-base
C I CREATININE 02 30 3.2 balance.
N .25-.40 .71 Cr 53- 10 B. -2- .1 ª Based on the result, the patient is in respiratory alkalosis
I 115 7 E. +2
L .55-.65 .22 5. Hemoglucose test
D  It measures the blood sugar levels.
M .25-.40 .04
D ª Based on the results showed in tabular form, the patient’s HGT results progresses each day
E .02-.05 .03 ª The patient has high blood sugar levels
B .000-. .00
005 IMAGING STUDIES
Hct .40-.48 0.37 02 80- 9 DATE 02/19/09 02/20/09
.37-.45 Sa 100 5.2
Procedur CRANIAL CT SCAN X-RAY
t 0%
e
Plt 150- 230
Multiple plain axial CT images of the Study taken in AP projection in
300
head were observed. poor inspiratory effort which may
explain the crowding of the
Interpretation:
As irregular hypperdense collection pulmonary vascular flow.
1. Complete Blood Count
surrounded by thin hypodense edema
 It is used to help diagnose disease, better understand the disease process, and monitor is seen in the frontoparietal area and Lung fields are clear.
levels of therapeutic drugs have an approximate volume of 88cc
The heart is magnified but
 Certain tests, ordered by the physician as part of a regular check-up, provide general This collection slightly displaces the appears enlarged with left
information, while others are used to identify specific health concerns midline structures to the left and ventricular prominence.
compresses the ipsilateral ventricle;
 It can detect brain and/or spinal cord infection, bone marrow disease, hemorrhage, blood
similar attenuating fluid collection is Aortic knob is calcified.
vessel damage, toxins that affect the nervous system, and the presence of antibodies that
also noted in the ventricular system.
signal the presence of an autoimmune disease
Right hemidiaphragm appears
 It is also used to monitor levels of therapeutic drugs used to treat epilepsy and other No other abnormal density changes significantly elevated than the
neurological disorders seen in the rest of the brain and brain left.
stem parechyma.
 Genetic testing of DNA extracted from white cells in the blood can help diagnose Diaphragm and castoprhenic sulci
Huntington’s disease and other congenital diseases The extra-axial CSF spaces are effaced are intact
 Analysis of the fluid that surrounds the brain and spinal cord can detect meningitis, acute calcifications are seen in both internal
carotid arteries The rest of the included structures
and chronic inflammation, rare infections, and some cases of multiple sclerosis
Sella, orbits, petromastoids and are unremarkable.
 Chemical and metabolic testing of the blood can indicate protein disorders, some forms of visualized paranasal sinuses are not
muscular dystrophy and other muscle disorders, and diabetes unusual.
Calvarium and visualized basal bones
ª Red blood cells are decreased with a result of 3.9 are intact.
ª White blood cells are increased and its specific components showed that neutrophils are No other significant findings.
increased with a result of .71; lymphocytes are decreased as well as the monocytes, with a
result of .22 and .04 accordingly Impressi ª Acute bleed, left frontoparietal ª Suggestive left
on area with slight massive effect ventricular cardiomegaly
2. Serum Electrolytes and intraventricular extension with atherosclerotic aorta
ª Bilateral internal carotid ª Elevated right
 Maintenance of the osmotic pressure of the blood and tissue fluids by the maintenance of arteriosclerosis hemidiaphragm may be
a proper balance between the normal electrolytes in the fluid, and at the same time related to
maintaining adequate concentrations of calcium and magnesium and the proper acid-base subdiaphragmatic venous
balance. subpulmonic pathology.

ª Serum Potassium results in 2.8 which is decreased

ª Serum Magnesium also resulted to decreased level showing .6
1. X-RAY
 X-rays of the patient’s chest and skull are often taken as part of a neurological work-up
3. Serum Creatinine
ª Based on the given data, it is within normal range  In a conventional x-ray, also called a radiograph, a technician passes a concentrated
burst of low-dose ionized radiation through the body and onto a photographic plate

4. Arterial Blood Gas

 are used to monitor pH and levels of O2 and CO2
 Hyperventilation to try to keep the PaCO2 between 25 – 30 to manage vasoconstriction
 Since calcium in bones absorbs x-rays more easily than soft tissue or muscle, the bony
structure appears white on the film
 Any vertebral misalignment or fractures can be seen within minutes
 Tissue masses such as injured ligaments or a bulging disc are not visible on
conventional x-rays
 This fast, noninvasive, painless procedure is usually performed in a doctor’s office or at ª A small capsule containing a radiopaque dye (one that is
a clinic highlighted on x-rays) is passed over the guide wire to the site of
release
2. Brain CT scan ª The dye is released and travels through the bloodstream into the
 Computed tomography scan. head and neck

 A series of detailed pictures of areas inside the body taken from different angles ª A series of x-rays is taken and any obstruction is noted

 The pictures are created by a computer linked to an x-ray machine ª Patients may feel a warm to hot sensation or slight discomfort as
the dye is released
 Also called computerized tomography and computerized axial tomography (CAT) scan
4. Single ª It monitors brain activity through the skull. EEG is used to help
 Scanning takes about 20 minutes (a CT of the brain or head may take slightly longer) Photon diagnose certain seizure disorders, brain tumors, and brain
and is usually done at an imaging center or hospital on an outpatient basis Emissio damage from head injuries, inflammation of the brain and/or
n spinal cord, alcoholism, certain psychiatric disorders, and
Comput
3. Neurological exam
ed
metabolic and degenerative disorders that affect the brain his
painless, risk-free test can be performed in a doctor’s office or at
ª A series of questions and tests to check brain, spinal cord, and nerve function. Tomogr a hospital or testing facility. Prior to taking an EEG, the person
ahy must avoid caffeine intake and prescription drugs that affect the
ª The exam checks a person’s mental status, coordination, ability to walk, and how well nervous system
the muscles, sensory systems, and deep tendon reflexes work.
ª Certain disorders requires performing an EEG during sleep, which
ª Assesses motor and sensory skills, the functioning of one or more cranial nerves, takes at least 3 hours
hearing and speech, vision, coordination and balance, mental status, and changes in
mood or behavior, among other abilities 5. Polysom ª (also called evoked response) measure the electrical signals to
nogram the brain generated by hearing, touch, or sight. These tests are
ª Items including a tuning fork, flashlight, reflex hammer, ophthalmoscope, and needles used to assess sensory nerve problems and confirm neurological
conditions including multiple sclerosis, brain tumor, acoustic
POSSIBLE neuroma (small tumors of the inner ear), and spinal cord injury.
ª Evoked potentials are also used to test sight and hearing
(especially in infants and young children), monitor brain activity
1. Brain ª A powerful magnet linked to a computer is used to make detailed among coma patients, and confirm brain death.
MRI pictures of areas in the body ª Testing may take place in a doctor’s office or hospital setting. It
scan is painless and risk-free. Two sets of needle electrodes are used
ª These pictures are viewed on a monitor and can also be printed to test for nerve damage. One set of electrodes, which will be
2. Doppler ª Ultrasonography is another procedure for viewing areas inside used to measure the electrophysiological response to stimuli, is
ultrasou the body attached to the patient’s scalp using conducting paste. The
nd - a second set of electrodes is attached to the part of the body to be
blood ª High-frequency sound waves that cannot be heard by humans tested. The physician then records the amount of time it takes
flow enter the body and bounce back for the impulse generated by stimuli to reach the brain. Under
normal circumstances, the process of signal transmission is
study
ª Their echoes produce a picture called a sonogram instantaneous.
ª These pictures are shown on a monitor like a TV screen and can ª Auditory evoked potentials (also called brain stem auditory
be printed on paper evoked response) are used to assess high-frequency hearing
ª Mechanical radiant energy with a frequency greater than 20,000 loss, diagnose any damage to the acoustic nerve and auditory
hertz (cycles per second) pathways in the brainstem, and detect acoustic neuromas. The
patient sits in a soundproof room and wears headphones.
3. Thermo ª It can detect the degree of narrowing or obstruction of an artery Clicking sounds are delivered one at a time to one ear while a
graphy or blood vessel in the brain, head, or neck. masking sound is sent to the other ear. Each ear is usually
tested twice, and the entire procedure takes about 45 minutes.
ª It is used to diagnose stroke and to determine the location and
size of a brain tumor, aneurysm, or vascular malformation. ª Visual evoked potentials detect loss of vision from optic nerve
damage (in particular, damage caused by multiple sclerosis).
ª This test is usually performed in a hospital outpatient setting and The patient sits close to a screen and is asked to focus on the
takes up to 3 hours, followed by a 6- to 8-hour resting period. center of a shifting checkerboard pattern. Only one eye is tested
ª The patient, wearing a hospital or imaging gown, lies on a table at a time; the other eye is either kept closed or covered with a
patch. Each eye is usually tested twice. Testing takes 30-45
that is wheeled into the imaging area
minutes.
ª While the patient is awake, a physician anesthetizes a small area
ª Somatosensory evoked potentials measure response from stimuli
of the leg near the groin and then inserts a catheter into a major
artery located there to the peripheral nerves and can detect nerve or spinal cord
damage or nerve degeneration from multiple sclerosis and other
ª The catheter is threaded through the body and into an artery in degenerating diseases. Tiny electrical shocks are delivered by
the neck electrode to a nerve in an arm or leg. Responses to the shocks,
which may be delivered for more than a minute at a time, are
ª Once the catheter is in place, the needle is removed and a guide recorded. This test usually lasts less than an hour
wire is inserted
6. Positron ª Performed in the interspaces between the lumbar vertebrae,
Emissio usually at the L4-L5 level
n e
Tomogr ª Sedative medication may be required in children or in the
aphy confused or combative patient
7. Electro ª A type of x-ray that uses a continuous or pulsed beam of low-
myogra dose radiation to produce continuous images of a body part in
phy motion
ª The fluoroscope (x-ray tube) is focused on the area of interest
and pictures are either videotaped or sent to a monitor for
viewing
ª A contrast medium may be used to highlight the images
ª It can be used to evaluate the flow of blood through arteries
8. Discogr ª It involves the removal and examination of a small piece of
aphy
tissue from the body
ª A Muscle or nerve biopsies are used to diagnose neuromuscular
disorders and may also reveal if a person is a carrier of a
defective gene that could be passed on to children. A small
sample of muscle or nerve is removed under local anesthetic and
studied under a microscope. The sample may be removed either
surgically, through a slit made in the skin, or by needle biopsy, in
which a thin hollow needle is inserted through the skin and into
the muscle. A small piece of muscle or nerve remains in the
hollow needle when it is removed from the body. The biopsy is
usually performed at an outpatient testing facility
ª A brain biopsy, used to determine tumor type, requires surgery
to remove a small piece of the brain or tumor. Performed in a
hospital, this operation is riskier than a muscle biopsy and
involves a longer recovery period
9. Biopsy ª It is often suggested for patients who are considering lumbar
surgery or who’s lower back pain has not responded to
conventional treatments
ª This outpatient procedure is usually performed at a testing
facility or a hospital
ª The patient is asked to put on a metal-free hospital gown and lie
on an imaging table. The physician numbs the skin with
anesthetic and inserts a thin needle, using x-ray guidance, into
the spinal disc
ª Once the needle is in place, a small amount of contrast dye is
injected and CT scans are taken. The contrast dye outlines any
damaged areas. More than one disc may be imaged at the same
time
ª Patient recovery usually takes about an hour. Pain medicine may
be prescribed for any resulting discomfort
10. Flourosc ª Is used to diagnose nerve and muscle dysfunction and spinal
opy cord disease. It records the electrical activity from the brain
and/or spinal cord to a peripheral nerve root (found in the arms
and legs) that controls muscles during contraction and at rest.
ª During an EMG, very fine wire electrodes are inserted into a
muscle to assess changes in electrical voltage that occur during
movement and when the muscle is at rest. The electrodes are
attached through a series of wires to a recording instrument
ª Testing usually takes place at a testing facility and lasts about an
hour but may take longer, depending on the number of muscles
and nerves to be tested. Most patients find this test to be
somewhat uncomfortable
11. Lumbar ª Scans provide two- and three-dimensional pictures of brain
Punctur activity by measuring radioactive isotopes that are injected into
the bloodstream
ª PET scans of the brain are used to detect or highlight tumors and
diseased tissue, measure cellular and/or tissue metabolism,
show blood flow, evaluate patients who have seizure disorders
that do not respond to medical therapy and patients with certain
memory disorders, and determine brain changes following injury
or drug abuse, among other uses. PET may be ordered as a
follow-up to a CT or MRI scan to give the physician a greater
understanding of specific areas of the brain that may be involved
with certain problems. Scans are conducted in a hospital or at a
testing facility, on an outpatient basis. A low-level radioactive
isotope, which binds to chemicals that flow to the brain, is
injected into the bloodstream and can be traced as the brain
performs different functions. The patient lies still while overhead
sensors detect gamma rays in the body’s tissues. A computer
processes the information and displays it on a video monitor or
on film. Using different compounds, more than one brain
function can be traced simultaneously
ª PET is painless and relatively risk-free. Length of test time
depends on the part of the body to be scanned. PET scans are
performed by skilled technicians at highly sophisticated medical
facilities.
12. Evoked ª It measures brain and body activity during sleep. It is performed
respons over one or more nights at a sleep center.
e test
ª Electrodes are pasted or taped to the patient’s scalp, eyelids,
and/or chin. Throughout the night and during the various
wake/sleep cycles, the electrodes record brain waves, eye
movement, breathing, leg and skeletal muscle activity, blood
pressure, and heart rate. The patient may be videotaped to note
any movement during sleep
ª Results are then used to identify any characteristic patterns of
sleep disorders, including restless legs syndrome, periodic limb
movement disorder, insomnia, and breathing disorders such as
obstructive sleep apnea. Polysomnograms are noninvasive,
painless, and risk-free
13. EEG ª A nuclear imaging test involving blood flow to tissue, is used to
(electro evaluate certain brain functions. The test may be ordered as a
enceph follow-up to an MRI to diagnose tumors, infections, degenerative
alogram spinal disease, and stress fractures. As with a PET scan, a
) radioactive isotope, which binds to chemicals that flow to the
brain, is injected intravenously into the body. Areas of increased
blood flow will collect more of the isotope.
ª As the patient lies on a table, a gamma camera rotates around
the head and records where the radioisotope has traveled. That
information is converted by computer into cross-sectional slices
that are stacked to produce a detailed three-dimensional image
of blood flow and activity within the brain. The test is performed
at either an imaging center or a hospital
14. Arteriog ª uses infrared sensing devices to measure small temperature
raphy changes between the two sides of the body or within a specific
organ
ª Also known as digital infrared thermal imaging, thermography
may be used to detect vascular disease of the head and neck,
soft tissue injury, various neuromusculoskeletal disorders, and
the presence or absence of nerve root compression. It is
performed at an imaging center, using infrared light recorders to
take thousands of pictures of the body from a distance of 5 to 8
 feet
ª The information is converted into electrical signals which results
in a computer-generated two-dimensional picture of abnormally
cold or hot areas indicated by color or shades of black and
white. Thermography does not use radiation and is safe, risk-
free, and noninvasive
DRUG STUDY
Generic name: Captopril
Brand name: Apo-Capto, capoten, Novo-captopril, Nu-capto
Classification: ACE inhibitor, Antihypertensive
Mode of Action:
Blocks ACE from converting angiotensin I to angiotensin II, a powerful vasoconstrictor,
leading to decreased BP, decreased aldosterone secretion, a small increase in serum potassium
levels, and sodium and fluid loss; increased prostaglandin synthesis also may be involved in the
antihypertensive action.
Indication:
• Treatment of hypertension alone or in combination with thiazide-type diuretics
• Treatment of CHF in patients unresponsive to conventional therapy; used with
diuretics and digitalis
• Treatment of diabetic nephropathy
• Treatment of left ventricular dysfunction after MI
• Unlabeled uses: Management of hypertensive crises; treatment of rheumatoid
arthritis; diagnosis of anatomic renal artery stenosis, hypertension related to
scleroderma renal crisis; diagnosis of primary aldosteronism, idiopathic edema;
Bartter's syndrome; Raynaud's syndrome
Contraindication:
• Contraindicated with allergy to captopril, history of angiodema, second or third
trimester of pregnancy.
• Use cautiously with impaired renal function; CHF; salt or volume depletion,
lactation.
Adverse effects
• CV: Tachycardia, angina pectoris, MI, Raynaud's syndrome, CHF, hypotension in salt-
or volume-depleted patients
• Dermatologic: Rash, pruritus, scalded mouth sensation, pemphigoid-like reaction,
exfoliative dermatitis, alopecia, photosensitivity
• GI: Gastric irritation, aphthous ulcers, peptic ulcers, dysgeusia, cholestatic jaundice,
hepatocellular injury, anorexia, constipation
• GU: Proteinuria, renal insufficiency, renal failure, polyuria, oliguria, urinary frequency
• Hematologic: Neutropenia, agranulocytosis, thrombocytopenia, hemolytic anemia,
pancytopenia
• Other: Cough, malaise, dry mouth, lymphadenopathy
Dosages
ADULTS
• Hypertension: 25 mg PO bid or tid; if satisfactory response is not noted within 1–2 wk,
increase dosage to 50 mg bid–tid; usual range is 25–150 mg bid–tid PO with a mild
thiazide diuretic. Do not exceed 450 mg/day.
• CHF: 6.25–12.5 mg PO tid in patients who may be salt or volume depleted. Usual
initial dose, 25 mg PO tid; maintenance dose, 50–100 mg PO tid. Do not exceed
450 mg/day. Use in conjunction with diuretic and digitalis therapy.
• Left ventricular dysfunction after MI: 50 mg PO tid, starting as early as 3 days post-MI.
Initial dose of 6.25 mg, then 12.5 mg tid, increasing slowly to 50 mg tid.
• Diabetic nephropathy: 25 mg PO tid.
Nursing Responsibilty
• Take drug 1 hour before meals; do not take with food. Do not stop without consulting
your health care provider.
• Be careful of drop in blood pressure (occurs most often with diarrhea, sweating,
vomiting, dehydration); if light-headedness or dizziness occurs, consult your health
care provider.
• Severe fetal damage can occur if captopril is taken during pregnancy. Use of
contraceptives is advised; if pregnancy should occur, stop drug and notify your health
care provider.
• Avoid over-the-counter medications, especially cough, cold, allergy medications that
may contain ingredients that will interact with ACE inhibitors. Consult your health care
provider.
• You may experience these side effects: GI upset, loss of appetite, change in taste
perception (limited effects, will pass); mouth sores (frequent mouth care may help);
rash; fast heart rate; dizziness, light-headedness (usually passes after the first few
days; change position slowly, and limit your activities to those that do not require
alertness and precision).
• Report mouth sores; sore throat, fever, chills; swelling of the hands, feet; irregular
heartbeat, chest pains; swelling of the face, eyes, lips, tongue, difficulty breathing.
Generic name: Furosemide
Brand name: Lasix Apo-furosemide
Classification: Loop diuretic
Mode of Action:
Inhibits the reabsorption of sodium and chloride from the ascending limb of the loop
of Henle, leading to a sodium-rich diuresis.
Indication:
• Oral, IV: Edema associated with CHF, cirrhosis, renal disease
• IV: Acute pulmonary edema
• Oral: Hypertension
Contraindication:
• Contraindicated with allergy to furosemide, sulfonamides; allergy to tartrazine (in oral
solution); anuria, severe renal failure; hepatic coma; pregnancy; lactation.
• Use cautiously with SLE, gout, diabetes mellitus.
Adverse Effect/ Side effect:
Dizziness, lightheadedness, or fainting when sitting up or standing; fast heartbeat; flushing of
face and neck; headache; irritation at site of patch; nausea; vomiting.
• CNS: Dizziness, vertigo, paresthesias, xanthopsia, weakness, headache, drowsiness,
fatigue, blurred vision, tinnitus, irreversible hearing loss
• CV: Orthostatic hypotension, volume depletion, cardiac arrhythmias,
thrombophlebitis
• Dermatologic: Photosensitivity, rash, pruritus, urticaria, purpura, exfoliative
dermatitis, erythema multiforme
• GI: Nausea, anorexia, vomiting, oral and gastric irritation, constipation, diarrhea,
acute pancreatitis, jaundice
• GU: Polyuria, nocturia, glycosuria, urinary bladder spasm
• Hematologic: Leukopenia, anemia, thrombocytopenia, fluid and electrolyte
imbalances, hyperglycemia, hyperuricemia
• Other: Muscle cramps and muscle spasms
Dosages
ADULTS
• Edema: Initially, 20–80 mg/day PO as a single dose. If needed, a second dose may be
given in 6–8 hr. If response is unsatisfactory, dose may be increased in 20- to 40-mg
increments at 6- to 8-hr intervals. Up to 600 mg/day may be given. Intermittent
 dosage schedule (2–4 consecutive days/wk) is preferred for maintenance, or 20– IV adults: 50-100 mg q 10-15 min until arrythmias is abolished. 15 mg/kg have been given, or
40 mg IM or IV (slow IV injection over 1–2 min). May increase dose in increments of toxic occurs.
20 mg in 2 hr. High-dose therapy should be given as infusion at rate not exceeding 4 PO adults: 200-600 mg/day in divided doses.
mg/min.
Nursing Resposibilty:
• Acute pulmonary edema: 40 mg IV over 1–2 min. May be increased to 80 mg IV given • Seizure: assess location, duration, frequency and characteristics of seizure activity.
over 1–2 min if response is unsatisfactory after 1 hr. • Arrythmias: Monitor ECG contiously during treatment of arrythmias
• Hypertension: 40 mg bid PO. If needed, additional antihypertensive agents may be • Assess patient for phenytoin hypersensitivity syndrome( fever, skin rash,
lymphopathy). Rash usually occurs within the first 2 weeks of therapy.
added.
Nursing Resposibilty: • Assess oral hygiene. Vigorous oral cleaning beginning within 10 days of initiation of
phenytoin therapy may help control gingival hyperplasia.
• Administer with food or milk to prevent GI upset.
• May cause increase serum alkaline phosphates,GTT and glucose level.
• Reduce dosage if given with other antihypertensives; readjust dosage gradually as BP
responds.
• Give early in the day so that increased urination will not disturb sleep.
• Avoid IV use if oral use is at all possible.
Generic name: Nitroglycerin Transdrmal patch
• WARNING: Do not mix parenteral solution with highly acidic solutions with pH below Brand name: Nitro-bid, Minitran, Nitrogard, Nitro par, NitroQuick
3.5. Classification: Anti anginal
• Do not expose to light, may discolor tablets or solution; do not use discolored drug or Mode of Action:
solutions. Nitroglycerin Patch is a nitrate vasodilator. It works by relaxing blood vessels in the
• Discard diluted solution after 24 hr. body, which allows them to widen (dilate). This allows more blood to flow through the blood
vessels easier, which reduces the workload on the heart.
• Refrigerate oral solution.
Indication:
• Measure and record weight to monitor fluid changes. • Prophylactic management of anginal pectoris
• Arrange to monitor serum electrolytes, hydration, liver and renal function. • For acute angina attack
• Arrange for potassium-rich diet or supplemental potassium as needed. • Acute myocardial infarction
• Weigh yourself on a regular basis, at the same time and in the same clothing, and Contraindication:
record the weight on your calendar. • Hypersensitive to drug or adhesive
• Blood glucose levels may become temporarily elevated in patients with diabetes after • Close-anginal glausonma
starting this drug.
• Orthostatic hypotension
• You may experience these side effects: Increased volume and frequency of urination;
• Allergy on Transdermal patch
dizziness, feeling faint on arising, drowsiness (avoid rapid position changes;
Side Effect:
hazardous activities, like driving; and consumption of alcohol); sensitivity to sunlight
(use sunglasses, wear protective clothing, or use a sunscreen); increased thirst (suck • Dizziness
on sugarless lozenges; use frequent mouth care); loss of body potassium (a • lightheadedness, or fainting when sitting up or standing
potassium-rich diet or potassium supplement will be needed). • fast heartbeat
• Report loss or gain of more than 3 pounds in 1 day, swelling in your ankles or fingers, • flushing of face and neck
unusual bleeding or bruising, dizziness, trembling, numbness, fatigue, muscle • headache; irritation at site of patch
weakness or cramps. • nausea
• vomiting
Nursing Resposibilty:
Generic name: Phenytoin • Remove patch from foil pouch immediately prior to application.
Brand name: Dilantin
Classification: Anti convulsant • Remove protective liner from patch and apply to any area of the body except
Mode of Action: the extremities below the knee or elbow; the chest is preferred site. Press the
Limit seizure propagation by altering ion transport. Antiarryhythmic poperties as a patch on the skin and smooth down.
result of improvement I AV conduction. May also decrease synaptic transmission.
Indication:
• Apply only to area that is clean, dry, and hairless. If hair is likely to interfere
Treatment/prevention of tonic clonic (grand mal) seizures and complex partial seizure. with patch adherence, clip, do not shave, the area before application.
• As an antiarrhythmic, particularly for arrhythmias associated with cardiac glycoside • Do not apply patch to skin areas with cuts or irritation or immediately after
toxicity. Management of painful syndromes, including trigeminal neuralagia. showering or bathing.
Contraindication:
• Hypersensitivity
• If the patch becomes dislodged, discard it and put a new one on at a different
skin site.
• Alcohol intolerance
• Sinus bradycadia • Do not discharge cardioverter/defribrillator through paddle electrode that
• Heart block overlies a transdermal patch. May cause current arching that can damage the
• Stroke syndrome paddles and burn the patient.
Side Effect: • Nitroglycerin Patch may give you daily headaches. This should become less
• drowsiness , difficulty focusing (vision), unsteady gate, tiredness, abnormal noticeable with time.
involuntary movements, nausea, vomiting, constipation, abdominal pain, loss of
appetite, Dizziness • Nitroglycerin Patch takes about 1 to 2 hours to start working and should not be
Dosage used for a sudden chest pain attack.
 • Use Nitroglycerin Patch with caution in the ELDERLY because they may be more
sensitive to its effects.
• Nitroglycerin Patch is not recommended for use in CHILDREN; safety and
effectiveness have not been confirmed.
• PREGNANCY and BREAST-FEEDING: If you become pregnant, discuss with your
doctor the benefits and risks of using Nitroglycerin Patch during pregnancy. It is
unknown if Nitroglycerin Patch is excreted in breast milk. Do not breast-feed while
taking Nitroglycerin Patch.
Generic name: Ranitidine
Brand name: Zantac
Classification: Anti ulcer drug
Mode of Action:
Inhibits the action of histamine at the H2 receptor site located primarily in gastric
parietal cells, resulting in inhibition of gastric acid secretion.
Indication:
• Prevention and treatment of self stress induce upper GI bleeding in critically ill
patient.
• Short term treatment of active duodenal ulcers and benign ulcer.
• Prophylaxis of duodenal ulcer.
• Management of GERD.
• Prevention and treatment of heartburn, acid ingeston and sour stomach
Contraindication:
• Porphyria, Hypersensitivity, Renal impairement, Some products of alcohol must be
avoided, Some products contains as partame and should be avoided I patients with
phenylketonuria
Side effect:
• headache (may be severe); drowsiness, dizziness; sleep problems (insomnia);
decreased sex drive, impotence, or difficulty having an orgasm; or swollen or tender
breasts (in men); nausea, vomiting, stomach pain; or Diarrhea or constipation.
drowsiness, dizziness; decreased sex drive, impotence, or difficulty having an orgasm;
or swollen or tender breasts (in men); nausea, vomiting, stomach pain; or Diarrhea or
constipation
Dosage:
IM,IV adultd: 50 g q 6-8 hrs ( no to exceed 400 mg/day). Continuous IV infusion 6.25
mg/hr. gastric hypersecretory condition-1mg/kg/hr; may be increase by 0.5 mg/kg/hr ( not
to exceed 2.5 mg/kg/hr).
Nursing Resposibilty:
• Assess for epigastric pain or abdominal pain and frank or occult blood in the stool,
emesis or gastric aspirate.
• Antagonize effects of pentagstrin and histamine during gastric acid secretion testing
• May cause uncrease in serum transaminase and serum creatinine
• Ranitidine may cause false positive results for urine protein, test with sulfosalicylic
acid.
• Instruct the patient to take the medication as directed for the full course of therapy,
even if feeling better.
• Inform the patient that smoking interferes with the action of histamine antagonist.
• Advise the patient to avoid alcohol products containing to avoid aspirin or NSAIDS,
and foods that may cause increase in GI irritation.
• Inform the patient that increase fluid and fiber intake and exercise may minimize
constipation.
Generic name: Ketolac
Brand name: Remopain, Acular
Classification: Nonsteroidal Anti-inflammatory Drug (NSAID
Mode of Action:
It acts on cyclooxigenase route, inhibits prostaglandins synthesis and may be
considered a strong analgesic, both peripherally and centrally, besides having anti-
inflammatory and antipyretic effects. Ketorolac reduce the mild to severe pain at emergency
cases, musculosceletal pain, post minor or major operative, renal cholic & pain in cancer at
adults or children. Ketorolac has analgesic efficacy equivalent to morphine or pethidin. Initial
analgesic effects of ketorolac may be slower, but the duration longer than opioid.
Indication:
• ::: Ketorolac is indicated for the short-term (≤ 5 days) management of moderate and
severe acute pain that requires analgesia at the opioid level.
Contraindication:
• Ketorolac tromethamine or in patients in whom aspirin or other NSAIDS induce serious
allergic manifestations
• patients with recent gastrointestinal bleeding or perforation and in patients with a
history of peptic ulcer disease or gastrointestinal bleeding
• Patients with severe renal impairment or patients at high risk of renal failure.In labor
and delivery, it may adversely affect fetal circulation and inhibit uterine
contraindications, thus increasing the risk of uterine hemorrhage
• Nursing mother because of the potential adverse effects of prostaglandin inhibiting
drugs on neonates
Adverse Effect:
Central nervous system: Headache (17%)
Gastrointestinal: Gastrointestinal pain (13%), dyspepsia (12%), nausea (12%)
>1% to 10%:
Cardiovascular: Edema (4%), hypertension
Central nervous system: Dizziness (7%), drowsiness (6%)
Dermatologic: Pruritus, purpura, rash
Gastrointestinal: Diarrhea (7%), constipation, flatulence, GI bleeding, GI fullness, GI perforation,
GI ulcer, heartburn, stomatitis, vomiting
Hematologic: Anemia, bleeding time increased
Hepatic: Liver enzymes increased
Local: Injection site pain (2%)
Renal: Renal function abnormal
Dosage
I.V.: Initial dose: 0.5 mg/kg, followed by 0.25-1 mg/kg every 6 hours for up to 48 hours
(maximum daily dose: 90 mg) Oral: 0.25 mg/kg every 6 hours
Nursing Resposibilty:
• Monitor response (pain, range of motion, grip strength, mobility, ADL function),
• Should be used cautiously in patients receiving anticoagulant therapy and patients
with hemophilia.
• Haematological effects : Ketorolac inhibits thrombocyte aggregation and prolong
bleeding time. Because of that ketorolac should not be used before surgery and use
with caution if there is hemostasis disturbances.
• Should be used with caution in patients with cardiac decompensation, acute renal
failure, hypertension or other conditions associated with fluid retention.
• Ketorolac tromethamine should be used with caution in patients with impaired hepatic
function or patients with history of hepatic desease.
• Hepatic effects : Ketorolac therapy increases hepatic enzymes and in hepatic disease
patients, severe hepatic risk reaction may occur. Administration of ketorolac should
be discontinued if abnormality of hepatic function test occurs after ketorolac
administration.
• Ketorolac tromethamine is not recommended for children under 16 years (Safety and
efficacy have not been established).
Generic name: Co amoxiclav
Brand name: amoxcil
Classification: Antibiotics
Mode of Action:
Co-amoxiclav is an antibiotic that is a combination of a penicillin (amoxicillin)and a
substance called clavulanic acid. It kills bacteria, by interfering with their ability to form cell
walls. The bacteria therefore break up and die.
Indication:
• Abdominal infections
 • Animal bites
• Infections of the organs associated with breathing, including nasal passages, sinuses,
windpipe and lungs (respiratory tract)
• Infections of the sex organs and organs associated with urination (genito-urinary
infections)
• Inflammation of connective tissue, commonly the skin (cellulitis)
Contraindication:
• History of allergies, Severe hepatic impairment, Geriatric patient, Aortic stenosis,
Pregnancy, lactation, Liver disease
Side Effect:
• Diarrhea, Vomiting, Jaundice, Fever, Pseudomembranous colitis, Angina, Bradycardia,
Flushing, Nausea, Gingival hyperplasia
Dosage;
• Standard adult dosages for respiratory tract, urinary, abdominal and dental infections
as well as cellulitis and animal bites is co-amoxiclav 250/125 (one tablet Augmentin
250) taken every 8 hours, which may be doubled in severe infections (as a single
tablet of co-amoxiclav 500/125 Augmentin 500, but not as two co-amoxiclav 250/125
tablets which would double the maximum recommended dose of clavulanic acid
Nursing Resposibilty:
• Assess for infection
• Obtain specimens for culture and sensitivity prior to therapy. First dose may be given
before receiving the result
• Monitor bow function
• Instruct the patient to take the medication around the cock and to finish the drug
completely as directed.
• Review use and preparation of tablets for oral suspension
• Instruct female patients taking oral contraceptives to use an alternate or additional
non-hormonal method contraception during therapy with amoxicillin and until next
menstrual period.
• Advise the patient to report signs of superinfection ( furry overgrowth on the tongue,
vagina itching or discharge, foul-smelling stools.and allergy.
Generic Name: Paracetamol
Brand Name: Biogesic
Classification: AntipyreticAnalgesic (nonopioid)
Mode of Action:
Reduces fever by acting directll on the hypothalamic heat regulating center to cause
vasodilation and sweating, which helps dissipate heat.
Indication: for mild pain and fever
Indication:
Analgesic-anipyretic in patients with aspirin allergy, hemostatic disturbances,
bleeding diatheses, upper GI disease, gouty arthritis. Arthritis and rheumatic disorders involving
musculoskeletal pain (but l acks clinically significant antirheumatic and anti-inflammatory
effects)Common cold, flu, other viral and bacterial infections with pain and fever Unlabeled use:
Prophylactic for children receiving DPT vaccination to reduce incidence of fever and pain .
Contraindication:
Contraindicated with allergy to acetaminophen.Use cautiously with impaired hepatic
function, chronic alcoholism, pregnancy, lactation
Ordered Dose: 500mg prn for fever
Drug Interaction:
Increased toxicity with long-term, excessive ethanol ingestion. Increased
hypoprothrombinemic effect of oral anticoagulants. Increased risk of hepatotoxicity and possible
decreased therapeutic effects with barbiturates, carbamazepine, hydantoins, rifampin,
sulfinpyrazone. Possible delayed or decreased effectiveness with anticholinergics. Possible
reduced absorption of acetaminophen with activated charcoal
Possible decreased effectiveness of zidovudine
Side Effects:
Headache, Chest pain, dyspnea,
Adverse Effects: Rash, fever Methemoglobinemia—cyanosis; hemolytic anemia—hematuria,
anuria; neutropenia, leukopenia, pancytopenia, thrombocytopenia, hypoglycemia Acute kidney
failure, renal tubular necrosis
*Hepatic toxicity and failure, jaundice, myocardial damage when doses of 5–8 g/day are
ingested daily for several weeks or when doses of 4 g/day are ingested for 1 yr
Nursing Responsibilities:
• Do not exceed the recommended dosage.
• Consult physician if needed for children < 3 yr; if needed for longer than 10 days; if
continued fever, severe or recurrent pain occurs (possible serious illness).
• Avoid using multiple preparations containing acetaminophen. Carefully check all OTC
products.
• Give drug with food if GI upset occurs.
• Discontinue drug if hypersensitivity reactions occur.
• Treatment of overdose: Monitor serum levels regularly, N-acetylcysteine should be
available as a specific antidote; basic life support measures may be necessary.
• Do not exceed recommended dose; do not take for longer than 10 days.
• Take the drug only for complaints indicated; it is not an anti-inflammatory agent.
• Avoid the use of other over-the-counter preparations. They may contain
acetaminophen, and serious overdosage can occur. If you need an over-the-counter
preparation, consult your health care provider.
• Report rash, unusual bleeding or bruising, yellowing of skin or eyes, changes in
voiding patterns.
Generic Name: Potassium chloride
Brand Name: Kalium Durule
Classification: Electrolyte
Mode of Action:
Principal intracellular cation of most body tissues, participates in a number of
physiologic processes—maintaining intracellular tonicity, transmission of nerve impulses,
contraction of cardiac, skeletal, and smooth muscle, maintenance of normal renal function; also
plays a role in carbohydrate metabolism and various enzymatic reactions.
Indication:
Prevention and correction of potassium deficiency; when associated with alkalosis, use
potassium chloride; when associated with acidosis, use potassium acetate, bicarbonate, citrate,
or gluconate. IV: Treatment of cardiac arrhythmias due to cardiac glycosides
Contraindication:
Contraindicated with allergy to tartrazine, aspirin (tartrazine is found in some preparations
marketed as Kaon-Cl, Klor-Con); severe renal impairment with oliguria, anuria, azotemia;
untreated Addison's disease; hyperkalemia; adynamia episodica hereditaria; acute dehydration;
heat cramps; GI disorders that delay passage in the GI tract. Use cautiously with cardiac
disorders, especially if treated with digitalis, pregnancy, lactation.
Drug Interaction:
Drug-drug
Increased risk of hyperkalemia with potassium-sparing diuretics, salt
substitutes using potassium
Side Effects & Adverse Effects:
Dermatologic: Rash
GI: Nausea, vomiting, diarrhea, abdominal discomfort, GI obstruction, GI bleeding, GI
ulceration or perforation
Hematologic: Hyperkalemia—increased serum K+, ECG changes (peaking of T waves,
loss of P waves, depression of ST segment, prolongation of QTc interval)
Local: Tissue sloughing, local necrosis, local phlebitis, and venospasm with injection
Nursing Responsibilities:
• Arrange for serial serum potassium levels before and during therapy.
• Administer liquid form to any patient with delayed GI emptying.
• Administer oral drug after meals or with food and a full glass of water to decrease GI
upset.
• Caution patient not to chew or crush tablets; have patient swallow tablet whole.
• Mix or dissolve oral liquids, soluble powders, and effervescent tablets completely in
3–8 oz of cold water, juice, or other suitable beverage, and have patient drink it
slowly.
• Arrange for further dilution or dose reduction if GI effects are severe.
 • Agitate prepared IV solution to prevent "layering" of potassium; do not add potassium
to an IV bottle in the hanging position.
• Monitor IV injection sites regularly for necrosis, tissue sloughing, phlebitis.
• Monitor cardiac rhythm carefully during IV administration.
• Caution patient that expended wax matrix capsules will be found in the stool.
• Caution patient not to use salt substitutes.
• Take drug after meals or with food and a full glass of water to decrease GI upset. Do
not chew or crush tablets, swallow tablets whole. Mix or dissolve oral liquids, soluble
powders, and effervescent tablets completely in 3–8 ounces of cold water, juice, or
other suitable beverage, and drink it slowly. Take the drug as prescribed; do not take
more than prescribed.
• Do not use salt substitutes.
• You may find wax matrix capsules in the stool. The wax matrix is not absorbed in the
GI tract.
• Have periodic blood tests and medical evaluation.
• You may experience these side effects: Nausea, vomiting, diarrhea (taking the drugs
with meals, diluting them further may help).
• Report tingling of the hands or feet, unusual tiredness or weakness, feeling of
heaviness in the legs, severe nausea, vomiting, abdominal pain, black or tarry stools,
pain at IV injection site.
Generic name: Citicoline
Brand name: Zynapse
Drug Class:
• Neuroprotective
• CNS Drugs & Agents for ADHD
Indication:
Treatment of cerebrovascular accident in acute and recovery phase, symptoms and
signs of cerebral insufficiency eg, dizziness, memory loss, poor concentration, disorientation,
recent cranial trauma and their sequelae.
Therapeutic Action:
Pharmacology: Somazine contains as its single active component, cytidine-5-
diphosphate choline. CDP-choline is a biologic product. It is found in the body and takes part in
the biosynthesis of phospholipids which integrate into the structures of the nervous system
especially in the membranes of the neurons. The formation of phospholipids is needed for the
re-structuring of cell membranes by the damaged neurons.
Citicoline is an interneuronal communication enhancer. It increases the neurotransmission levels
because it favors the synthesis and production speed of dopamine in the striatum, acting then
as a dopaminergic agonist thru the inhibition of tyrosine-hydroxylase. Citicoline acts as a
presynaptic cholinergic agent which favors the synthesis of acetylcholine. It also decreases the
release of serotonin. Citicoline improves neuronal metabolism in those cases where there is a
neuronal deterioration due to degenerative, toxic or ischemic cause. The cause of poor neuronal
metabolism is brought about by a decrease in neuronal activity which makes the astrocytes
swell. Swelling is due to electrolyte imbalance. Active neurons release potassium ions. These
are taken up by astrocytes (K+ buffers) and distributed to regions with less K+. When neuronal
activity decreases, less K+ is released, astrocytes take up Na+ instead of K+. The hydrated Na+ is
larger than the hydrated K+ and so the astrocyte swells. Improvement of neurometabolism is
demonstrated by citicoline's ability of restoring the activity of mitochondrial ATPase and of
membranal Na+/K+ ATPase. Citicoline also increases glucose incorporation aside from
metabolism while at the same time decreasing lactate accumulation in the brain. Citicoline
makes the neurons more active, causing the astrocytes to loosen their grip on the capillaries,
thus improving microcirculation. By virtue of this action, citicoline has an indirect effect on
microcirculation. It has the ability to slightly increase cerebral blood flow and exerts an anti-
aggregation effect on platelets.
Dosage:
Ordered dose: 1 grm. IV q 12 hrs. / 5 ml TID
Contraindication:
Patients with parasympathetic hypertonia.
Caution:
Somazine must not be administered along with medicaments containing meclophenoxate.
Interaction:
Somazine potentiates the effects of L-dopa. Incompatibilities: Somazine must not be
administered with products containing meclofenoxate (clophenoxate)
Side Effects:
Gastrointestinal disorders. Allergic reaction: Itching or hives, swelling in your face or hands,
swelling or tingling in your mouth or throat, chest tightness, trouble breathing, or rash, Low
blood pressure (faintness, dizziness), Slow or fast heart beat, Headache, Nausea, vomiting, or
diarrhea (loose BMs)
Generic name: Mannitol
Brand name: Osmitrol, Resctisol
Classification: Osmotic diuretic
Mode of Action:
Increase the osmotic pressure of the glomerular filtrate, therapy inhibiting
reabsorbtion of water and electrolytes. Cause excretion of water, sodium, potassium, chloride,
calcium, phosphorus, Magnessium, Urea and uric acid.
Indication:
• Promotion of diuresis in the prevention or treatment of the oliguric phase of acute renal
failure before irreversible renal failure becomes established.
• Reduction of intracranial pressure and brain mass.
• Reduction of high intraocular pressure when the pressure cannot be lowered by other
means.
• Promotion of urinary excretion of toxic materials.
• Eddema
Contraindication:
• Well established anuria due to severe renal disease.
• Severe pulmonary congestion or frank pulmonary edema.
• Active intracranial bleeding except during craniotomy.
• Severe dehydration.
• Progressive renal damage or dysfunction after institution of mannitol therapy,
including increasing oliguria and azotemia.
• Progressive heart failure or pulmonary congestion after institution of mannitol
therapy. Do not administer to patients with a known hypersensitivity to mannitol
Adverse Effect/side effect:
• Pulmonary congestion, fluid and electrolyte imbalance, acidosis, electrolyte
loss, dryness of mouth thirst, marked dieresis, urinary retention, edema,
headache, blurred vision, convulsions, nausea, vomiting, rhinitis, arm pain,
skin necrosis, thrombophlebitis chills, dizziness, urticaria, dehydration,
hypotension, tachycardia, fever, angina-like chest pains.
Nursing Responsibility:
• The cardiovascular status of the patient should be carefully evaluated before rapidly
administering mannitol since sudden expansion of the extracellular fluid may lead to
fulminating congestive heart failure.
• Shift of sodium-free intracellular fluid into the extracellular compartment following
mannitol infusion may lower serum sodium concentration and aggravate pre-existing
hyponatremia.
• By sustaining diuresis, mannitol administration may obscure and intensify inadequate
hydration or hypovolemia.
• Electrolyte-free mannitol solutions should not be given conjointly with blood. If it is
essential that blood be given simultaneously, at least 20 mEq of sodium chloride should be
added to each liter of mannitol solution to avoid pseudoagglutination.
• When exposed to low temperatures, solutions of mannitol may crystalize. If crystals are
observed, the container should be warmed to redissolve, then cooled to body temperature
before administering. See NOTE under how supplied. When infusing 20% or 25%
mannitol concentrations, the administration set should include a filter. Do not infuse
mannitol solution if crystals are present.
• Do not administer unless solution is clear and container is undamaged. Discard unused
portion. Do not administer Mannitol 25% if the Fliptop vial seal is not intact.
Generic name: Magnesium Sulfate
Brand name: Epsom salt
Classification: electrolytes, antiepileptic, laxative
Mode of Action:
 Cofactor of many enzyme system involve in neurochemical transmission and
muscular excitability. Prevent or control seizure by blocking neuromuscular transmission.
Attracts and retain water in intestinal lumen and distends the bowel to promote mass
movement and relieve constipation.
Dosage:
Intramuscular: Adults and older children: For severe hypomagnesemia, 1 to 5 g (2 to 10 mLof
50% solution) daily in divided doses; administration is repeated daily until serum levels have
returned to normal. If deficiency is not severe, 1 g (2 mL of 50% solution) can be given once or
twice daily. Serum magnesium levels should serve as a guide to continued dosage.
Intravenous: 1 to 4 g magnesium sulfate may be given intravenously in 10% to 20% solution,
but only with great caution; the rate should not exceed 1.5 mL of 10% solution or equivalent per
minute until relaxation is obtained.
Intravenous Infusion: 4 g in 250 mL of 5% Dextrose Injection at a rate not exceeding 3 mL per
minute.
Usual Dose Range: 1 to 40 g daily.
Electrolyte Replenisher: Intramuscular 1 to 2 g in 50% solution four times a day until serum
magnesium is within normal limits.
Usual Pediatric Dose: Intramuscular 20 to 40 mg per kg of body weight in a 20% solution
repeated as necessary.
For Eclampsia: Initially 1 to 2 g in 25% or 50% solution is given intramuscularly. Subsequently, 1
g is given every 30 minutes until relief is obtained. The blood pressure should be monitored
after each injection.
Parenteral drug products should be inspected visually for particulate matter and discoloration
prior to administration, whenever solution and container permit.
Indication:
Convulsions (treatment) - Intravenous magnesium sulfate is indicated for immediate control of
life-threatening convulsions in the treatment of severe toxemias (pre-eclampsia and eclampsia)
of pregnancy and in the treatment of acute nephritis in children.
Hypomagnesemia (prophylaxis and treatment) - Magnesium sulfate is indicated for replacement
therapy in magnesium deficiency, especially in acute hypomagnesemia accompanied by signs
of tetany similar to those of hypocalcemia.
Magnesium sulfate is also used to prevent or treat magnesium deficiency in patients receiving
total parenteral nutrition.
Tetany, uterine (treatment) - Magnesium sulfate is indicated in uterine tetany as a myometrial
relaxant.
Contraindication:
Magnesium sulfate should not be administered parenterally in patients with heart
block or myocardial damage.
Adverse Effect/side effect:
Flushing, sweating, sharply lowered blood pressure, hypothermia, stupor and ultimately,
respiratory depression.
When barbiturates, narcotics, or other hypnotics (or systemic anesthetics) are to be given in
conjunction with magnesium, their dosage should be adjusted with caution because of the
additive central depressive effects of magnesium.
Pregnancy - Teratogenic effects: Pregnancy category C. Animal reproduction studies have not
been conducted with Magnesium Sulfate Injection, USP 50%. It is also not known whether
Magnesium Sulfate Injection, USP 50% can cause fetal harm when administered to a pregnant
woman or can affect reproduction capacity. Magnesium Sulfate Injection, USP 50% should be
given to a pregnant woman only if clearly needed.
Nursing Responsibility:
• Use only as a temporary measure to relieve constipation. Do not take if abdominal
pain, nausea, or vomiting.
• You nay experience diarrhea with oral use. If this occurs, discontinue drug and
consultant your health provider.
• Report sweating, flushing, muscle tremors or twitching, inability to extremities.
• Reserve Iv use in eclampsia for immediate life threatening situation
• Do not give oral magnesium sulfate with abdominal pain, nausea or vomiting.
• Monitor bowel function; if diarrhea and cramping occurs, discontinue oral drugs.
• Maintain urine out put at the level of 100 ml q 4 hr. during parenteral administration.
POSSIBLE MEDICAL MANAGEMENT
• PHYSICAL THERAPY
®Physical therapy is a health care profession which provides services to individuals and
populations to develop maintain and restore maximum movement and functional ability
throughout life. This includes providing services in circumstances where movement and function
are threatened by aging, injury, disease or environmental factors. Physical therapy is concerned
with identifying and maximizing quality of life and movement potential within the spheres of
promotion, prevention, treatment/intervention, habilitation and rehabilitation. This encompasses
physical, psychological, emotional, and social well being. It involves the interaction between
physical therapist (PT), patients/clients, other health professionals, families, care givers, and
communities in a process where movement potential is assessed and goals are agreed upon,
using knowledge and skills unique to physical therapists.
● OCCUPATIONAL THERAPY
® Therapists work with the client to relearn activities of daily living and to use assistive devices
that promote independence.
● SPEECH THERAPY
® Speech pathologists work with the client to foster the maximum amount of speech recovery
possible through relearning, accentuation of speech sounds, or use of alternative
communication devices. The swallowing mechanism is also assessed and recommendations are
made for initiation and progression of foods and fluids to decrease the risk for aspiration.
● CASE MANAGEMENT
® To facilitate all care provides and to advocate for the client and family
ACTUAL SURGICAL MANAGEMENT
CRANIECTOMY
Craniectomy is a neurosurgical procedure in which part of the skull is removed to
allow a swelling brain room to expand without being squeezed. It is performed on victims of
traumatic brain injury and stroke. Though the procedure is considered a last resort, some
evidence suggests that it does improve outcomes by lowering intracranial pressure (ICP), the
pressure within the skull. Raised intracranial pressure is very often debilitating or fatal because
it causes compression of the brain and restricts cerebral blood flow. The aim of decompressive
craniectomy is to reduce this pressure. The part of the skull that is removed is called a bone-
flap. A study has shown that the larger the removed bone-flap is, the more ICP is reduced.
POSSIBLE SURGICAL MANAGEMENT
CRANIOTOMY
Surgical removal of part of the skull to expose the brain.
There are two basic ways to open the skull:
• a curving incision from behind the hairline, in front of the ear, arching above the eye
• at the nape of the neck around the occipital lobe
The surgeon marks with a felt tip pen a large square flap on the scalp that covers the
surgical area. Following this mark, the surgeon makes an incision into the skin as far as the thin
membrane covering the skull bone. Because the scalp is well supplied with blood, the surgeon
will have to seal many small arteries. The surgeon then folds back a skin flap to expose the
bone.
Using a high speed hand drill or an automatic craniotome, the surgeon makes a circle of
holes in the skull, and pushes a soft metal guide under the bone from one hole to the next. A
fine wire saw is then moved along the guide channel under the bone between adjacent holes.
The surgeon saws through the bone until the bone flap can be removed to expose the brain.
After the surgery for the underlying cause is completed, the piece of skull is replaced and
secured with pieces of fine, soft wire. Finally, the surgeon sutures the membrane, muscle, and
skin of the scalp.
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.

CRITERIA P F G JUSTIFICATION
The duration of illness is rated fair since the
client has experienced a major stroke which
1. Duration of  left the client hemiplegic but the client is
illness recovering from being unconscious to being
an alert one. And the time for the client to
fully achieve her optimum level of wellness is
going in a smooth way. The stay of the client
and the complication she had developed are
not that life threatening and through therapy
there is a high possibility of complete
recovery.
The onset of illness is rated poor. The client
has experienced abrupt and progressing
symptoms of stroke.
2. Onset of
illness  ® To prevent further deterioration of the client’s condition and recurrence of another
EXERCISES:
This is rated poor since among the
precipitating factors present with the client,
3. Precipitating stress and hypertension had directly triggered
factors  the stroke. Days before the attack, the client
was much stressed brought by the demolition
of their home. She has also a long term
hypertensive with poor compliance in taking
medications.
4. Willingness Brought by the grave consequence of stroke
to take the and the desire to achieve optimal functioning,
medications/co  the client and her family is serious with
mpliance with complying with the therapeutic regimen thus,
therapeutic this rated good.
regimen.
This disease is common among men and
women aged 65 and up, the client is 53 years
5. Age  old which makes her indirectly vulnerable to
the said disease.
This is rated poor the environment where she
6. Environment resides is populated and factors like noise,
 among others, exist which may trigger the
recurrent attack. And the stressful event that
had triggered the attack will be eventually
remembered in that area causing
reoccurrence of another attack and affect the
progress of the therapy.
The client has full support from her family
7. Family thus we rate it good.
Support  stiffness in patients with permanent paralysis.
Discharge Planning
MEDICATION:
1. Discuss all take home medications to the client and her significant others.
The brand and generic names, dosages, frequency, as well as the action of
each drug.
®This enables them to know what drugs are to be taken and its desired dosages.
Exact amount and proper timing is necessary to endure the effectiveness of the
medications.
2. Warn them about the side effects of the medications. And teach them how
watch for those side effects. Also explain and differentiate side effects from
the adverse effects of the medication for further guidance.
®Side effects are those expected effects of the drugs aside from its therapeutic
actions. Warning them ahead of time prevents confusion and anxiety. Adverse
reaction may have a life-threatening effect to the patient. Immediate consultation is
necessary to prevent untoward injuries brought about by its adverse reaction that
might cause death.
3. Encourage to take drugs with food if not contraindicated or take them 1
hour or 2 hours after meal.
®Some drugs may cause GI irritation if taken with empty stomach.
4. Inform family about food and other medications that cause interactions
with the drugs the patient is currently taking.
®There are some drugs or foods that when taken together, may cause untoward
reactions or may cause ineffectiveness of the drug.
5. Instruct the patient not to stop the medications abruptly or even adjust the
dosage without consulting the physician.
® It may aggravate the condition of the client.
6. Encourage and instruct the client and her family to comply with the
medication regimen prescribed by the physician.
attack.
1. Maintain a good and safety environment.
® This may facilitate fast recovery and prevent recurrence of the disease influenced
by unhealthy environment. It may also prevent the patient from injury.
2. Encourage client to have a complete bed rest, as indicated.
® Bed rest is recommended to patients because it increases the strength allowing
nutrition and oxygen to be used for healing process rather than energy needs.
3. If client is lying on bed for hours, instruct family members to turn patient
to sides every 2 hours.
® Turning to sides facilitates blood circulation and prevents depressed areas to suffer
from bedsores.
4. Encourage passive range of motion such as stretching of extremities.
Advance her exercises to achieve optimum recovery but also allowing rest periods for
each session.
® This helps loosen the joint structures, promote wellness and improve circulation. It
would prevent aggravation and exhaustion of the muscles and joints.
5. Help the person solve problems and discover new ways to do things.
® To promote self-reliance and optimal functioning.
6. Help with communication, if the person has speech problems. Include the
stroke survivor in conversations even when the person cannot actively participate.
® To promote self-esteem and stimulate her thinking ability.
7. The patient and family should coordinate with hospital social workers for
rehabilitation.
® To provide optimum health and to provide the patient efficient support group.
8. Advise client for therapies such as:
∗ Physical therapy which involves using exercise and other
physical means such as massage, as prescribed.
® To help patients
regain the use of their arms and legs and prevent muscle
∗ Speech therapy.
® Helps patients regain the ability to speak.
∗ Occupational therapy
® Helps patients regain independent function and relearn basic
skills such as, buttoning a shirt, preparing a meal and bathing.
TREATMENT:
1. Explain purpose of the treatment to be continued at home.
®This adds knowledge to the family that the treatment does not only end at the
hospital but it needs to be continued at home for faster recovery.
2. Determine the caregivers who will work as a partner with the patient to
provide daily care and assistance at home, and teach them the skills they will need.
® These promotes comfort and mastery in rendering quality health care to the client.

HYGIENE:
1. Encourage the family to bath the patient everyday.
®Bathing washes out dirt and microorganisms from the body, and prevents from
acquiring infection.
2. Instruct client to brush her teeth using her right hand, every after meal.
®This prevents lodging of bacteria leading to tartar formation, halitosis and tonsillitis
which may cause heart complications.
3. Encourage family members to trim client’s nails, unless contraindicated.
® To prevent and control the medium of bacterial growth.
OUTPATIENT ORDERS:

1. Remind the client and her watchers on their follow up check-up with their physician.
® To detect any complication and to evaluate the effectiveness of the treatment.
2. Advise client and watchers to decide about special equipment to be used.
® Even after rehabilitation and surgery, some patients continue to have trouble
walking, balancing, or performing certain activities of daily living. Special equipment
can sometimes help. Here are some examples:
Cane: Many people who have had strokes use a cane when walking. For people with
balancing problems, special canes with three or four "feet" are available.

Walker: A walker provides more support than a cane. Several designs are available for
people who can only use one hand and for different problems with walking or balance.

Ankle-foot orthotic devices (braces): Braces help a person to walk by keeping the
ankle and foot in the correct position and providing support for the knee.
Wheelchair: Some people will need a wheelchair. Wheelchairs come in many different
designs. They can be customized to fit the user's needs and abilities. Find out which
features are most important for the stroke survivor.
3. Encourage watchers to make sure that the patient has a safe place to live after discharge.
® To prevent any accidents to happen.
4. Stress out to the family to seek immediate consultation if adverse reaction of drugs occurs.
®Adverse reactions are life-threatening. Immediate medical attention is necessary to
prevent further damage and complications.
5. Encourage them to carry out follow up diagnostic regimen.
® To evaluate worsening condition of the client that needs medical attention.
6. Inform family members to report any signs of abnormalities such as recurrent attacks of
stroke, sudden increase of blood pressure and contractures as soon as possible.
® To prevent further complication.

DIET:
1. Encourage increase oral fluid intake at least 8 to 10 glasses per day.
®Promotes well-being and facilitates in cleansing the body.
2. Instruct client and family members to have the client avoid fatty and salty foods such as fried
meats, “bagoong”, and dried fishes.
®These foods lead to trigger hypertension of client to attack.
3. Encourage family members to prepare and have the client eat foods rich in protein, vitamin
C, potassium, carbohydrates and calcium, if not contraindicated with her condition.
® To boost the immune system. Vitamin C helps in prevention of infections; protein
helps in tissue repair; potassium promotes in heart muscles; carbohydrates replenish
used energy and calcium has important role in blood coagulation.
4. Advise not to skip meals and eat at regular intervals.
® To meet the daily nutritional requirement of the body.
5. Advise to consult a dietician that would help in planning the right food for the client.
® Dieticians will ensure the promotion of the right food for a person.