As an overview about perception and coordination concept, mainly it focuses the normal

functioning of the body which is important in our daily living. It is a mental process by which the

brain selects organization and interpretation of the sensory stimuli that serve as a basis for

understanding learning and knowing or for the motivation of a particular action and the

appropriate response to a stimulus which is the movement of the body parts together through

skilful and balanced movement.

A stroke, previously known medically as a Cerebrovascular Accident (CVA), is the

rapidly developing loss of brain functions due to disturbance in the blood supply to the brain.

This can be due to lack of blood flow caused by blockage or a haemorrhage. As a result, the

affected area of the brain is unable to function, leading to inability to move one or more limbs or

one side of the body, inability to understand or formulate speech, or an inability to see one side

of the visual field.

Stroke can soon be the most common cause of death worldwide. The incidence of

stroke increases exponentially from 30 years of age, and etiology varies by age. Advance age is

one of the most significant stroke risk factor. 95% of strokes occur in people age 45 and older,

and two-thirds of strokes occur in those over the age of 65.

According to the World Health Organization (WHO), 15 million people suffer stroke world

wide each year. One of these, 5 million die, and 5 million are permanently disabled. There were

many risk factor of Cerebrovascular Accident and high blood pressure is a risk factor which

contributes to over 12.7million strokes worldwide. According to the Department of Health, the

disease of the heart was top 7 leading cause of death, out of 100,000 per population of the

Philippines in the year 2006, the mortality rate is 49.3 and hypertension was the top 4 cause of

death and the mortality rate is 522.8. According to the City Health Office, in year 2010 the

Cerebrovascular Accident was the top 2 leading cause of the death, out of 100,000 per

population of the Davao city in the year 2010, the mortality rate is 78.91.

The group had chosen L.S.P., a 70 year old female, who was diagnosed with

Cerebrovascular Accident. Pondering upon these presented facts, the proponents are certain

that they have chosen the right patient. Aside from broadening our knowledge about

Cerebrovascular Accident and challenging ourselves with this very complicated yet interesting

case, the proponents also thought that they can make a difference in the life of the patient

suffering from this dreaded disease through health teachings and nursing interventions.

This case study will let researchers know about Cerebrovascular Accident. We student

nurses must be well educated and up-to-date not only in nursing knowledge and skills but also

1| P a g e

in research findings such as perception and coordination. This will serve as an instrument for us

to develop an effective and efficient health care provider representing our quality of care to the

patient.

In addition, the study will be a significant tool for and will acquire new information to the

other student nurses who will encounter the same case and would open more researches about

the illness to give better and fast recovery of patients. At the same time, the management

rendered can also be used in other countries.

In Nursing Education, apparently, it directly benefits the proponents for they have

acquired another set of knowledge which would be very vital in their journey as student nurses.

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That within the three weeks of clinical exposure at San Lorenzo Ward, the group will be

able to integrate our learning from the lecture of the Perception and Coordination Concept to the

clinical area there by resulting to a comprehensive case study that will allow the student nurses

to apply and widen up their knowledge, improve the skills and attitude towards the care of

patients.

Specifically, the group will be able to:

a. Select a client who is applicable for the area of exposure;

b. establish a good working relationship to our patient including her family;

c. present a rationale that will give an overview of the case;

d. formulate a specific, measurable, attainable, realistic, time-bounded objectives;

e. collect all pertinent data such as client’s personal data, clinical data, past health history

and history of present condition;

f. obtain genographic data that traces all the diseases of the patient’s family in both the

maternal and paternal lineage;

g. compare the development of the patient to the Psychosocial Stages of Development

theory of Erik Erikson and Developmental Tasks theory of Robert Havighurst;

h. conduct a systematic cephalocaudal physical and neurological assessment;

i. define the complete diagnosis of the patient from different medical educational sources;

j. discuss the anatomy and physiology of the system that is affected by the disease;

k. trace the pathophysiology of Cerebrovascular Accident in a schematic diagram form and

in narrative form, with its etiology and symptomatology;

l. discuss the medical management including the actual and possible diagnostic

examinations undergone by the patient and also the therapeutic management rendered;

m. discuss all the different medications prescribed to the client;

n. formulate efficient nursing care plans from the identified problems based on the patient’s

condition;

o. provide the patient a well-organized discharge plan which are essential for her condition;

p. evaluate the client’s prognosis with regards to her condition; and

q. list down the references used in the study.

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Biographical Data

Name : L. S. P.

Gender : Female

Age : 70 years old

Birthday : March 27, 1940

Place of birth : Mati, Davao Oriental

Nationality : Filipino

Address : Mapantao, Brgy. Sainz,Mati Davao Oriental

Religion : Roman Catholic

Educational level : Second year High school

Occupation : Barangay Official (Retired)

Source of Income : Boarding House

Income : Php 6,000/ month

Number of Dependents: None

Number of Siblings : 6

Marital Status : Married (Widow)

Clinical Data

Chief Complaint : Right sided weakness

Date of Admission : January 24, 2011; Time: 10:45am

Ward : San Lorenzo Ward 307- 3

Admitting Diagnosis : Cerebrovascular Accident Infarct

: Diabetes Mellitus Type II

Attending Physician : Dr. Cyrus Estera, MD

: Dr. Anabelle Y. Lao, MD

: Dr. Santos- Carpio, MD

Date of Discharge : January 27, 2011; Time: 4.49pm

Final Diagnosis : Cerebral Infarct Left MCA

: Diabetes Mellitus Type II, Hypertension Type II

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Genogram

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FAMILY HEATLH HISTORY

It is of great importance to get the family health history of the client in order to have a

greater view on the occurrence of the illness whether it’s hereditary or affected by her lifestyle

and environment. Having a precise taking of the family health history will be able us to trace and

acquire more knowledge and understanding on how the disease process started.

Our client namely LSP gave us an opportunity to gather significant information and

details to trace the inherited disease in their family. Through this schematic diagram, it identifies

and explains how these diseases linked together and passed from one member of the family to

another member. Not all diseases cannot be acquired by genetic means.

In the illustration of the previous page, it shows that Melinda, LSP’s grandmother on the

paternal side, had no known serious disease or illness and died but the family doesn’t know the

cause of death. Mr. Juanito, his grandfather, died due to old age. Sir Venancio, LSP’s father,

had a history of hypertension and died due to old age.

On the other hand, LSP’s grandparents on the maternal side are Mr. Pedro and Mrs.

Corazon. Mr. Pedro died because of stroke and had a history of hypertension which wasn’t

properly managed which in the end caused of his death but her grandmother on the other hand

died due to old age. Mrs. Leonila, LSP’s mother, also died due to old age.

Mr. Venancio and Mrs. Leonila were blessed with 6 children. Among them, 4 out of 6

have a history of hypertension namely (Obaldo 83, Teofila 82, Binacio 73, and Lolita 70). The

eldest child, Euphracia, 84 years of age has no known acquired disease. Teofila had a history of

asthma and Binacio also had a history of stroke. On the other hand, Romeo, the youngest

among them, died because of bone cancer in the age of 68.

Our patient is the 5th child among the 6 children in the family. She had been diagnosed

to have diabetes mellitus and stroke. According to our client, she is a smoker in her 30’s, one

pack per day then one to three sticks per day when she reached 60.

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Past Health History

According to Ma’am X (daughter- in- law), Ma’am LSP had a history of being a smoker

when she was 30 years old. She consumes 1 pack of cigarette per day but she’s not fun of

drinking alcoholic beverages. Ma’am LSP was hospitalized and was diagnosed of having

hypertension and Diabetes Mellitus type II when she was on her 40’s. She had already

maintaining antihypertensive drug (amlodipine) since then. She was also advised to look after

her diet by avoiding foods which are high in fats, salt and sweets, as well as to stop her vices.

Ma’am LSP stopped smoking; however she was not able to maintain her drugs as prescribed.

She had negligence on taking her medications most of the time and was not cautious about her

diet, she eat anything most especially those that was prohibited to her due to her condition.

Moreover, Ma’am LSP had also a sedentary life due to her old age and doesn’t do follow up

check-ups to her doctor. Furthermore, last 2009 Ma’am LSP was hospitalized because of

increased blood pressure. It was considered as a mild stroke. She was given amlodipine

sublingual and she was advised by Dr. Catbagan same as before on how to manage her

condition. However, Ma’am LSP still doesn’t comply with her treatment regimen.

In addition, according to Ma’am X, Ma’am LSP can’t remember if she had completed

her immunizations. Moreover, Ma’am LSP does not experience any surgeries. Besides from

that, Ma’am LSP had experienced simple coughs and colds, but can be managed at home. The

recent condition of Ma’am L.P caused her current hospitalization.

Present health History

Two weeks prior to admission at SPH. Ma’am LSP experienced weakness and sudden

immobility of her right lower extremities. Her condition was associated with slurring of speech

and facial asymmetry. According to Ma’am X (daughter –in- law) the night after that incident

Ma’am LSP ate “lechon”, then in the morning Ma’am LSP complained to her grandchild who

lives with her, a feeling of pain at the back of her neck, however her grandchild does not take it

seriously, because according to Ma’am LSP the pain is not that worst so she opted to take a

rest on her room, but as she stand to walk she grabbed something to balance herself because

she was to fall down since she lost her sensation on her lower extremities, then suddenly

Ma’am LSP couldn’t talk clearly and her face was quite deformed . Due to this reason, she was

admitted at Davao Oriental Provincial Hospital. She was then diagnosed of having

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Cerebrovascular accident (CVA). Ma’am LSP’s condition was managed by giving her

medications of citicholin, amlodipine, sinuvastatin, pioglituzer. However, she was referred by

Dr. Pisano (her Attending Physician) to SPH for further supervision of her condition, since she

was advised to have a CT scan for further assessment as well as for physical therapy session

for her rehabilitation.

E.6. Developmental Tasks Erik Erikson – Psychosocial Theory

PSYCHOSOCIAL CRISIS: INTEGRITY VS. DESPAIR (65 years to death)

Erik Erikson emphasizes that life is a succession of levels of achievement. An individual

must undergo and achieve each task. Erikson extends the idea that development is a continued

process throughout the lifespan of a human being. Each task may possibly be completed as

successful, partially successful or unsuccessful. Erikson believes that the greater the task

achievement, the healthier the personality of a person can be. This development task can be

viewed as a series of crises and successful resolution of these crises is supportive to the

person’s ego. Failure to resolve the crises is damaging to the ego.

The final stage of Erikson's theory is maturity stage (age 65 years- death). Erikson

proposes that this stage will have a positive resolution if the elder person already reflects upon

acceptance of one’s own worth and uniqueness of one’s own life, in as much as the idea of

his/her incoming death. Moreover, a sense of withdrawal and denial of death shows anegative

resolution in this stage.

Ma’am LSP a 70 year old widow achieved a sense of integrity. Ma’am LSP had already

adjusted to her aging body, she refrains from doing things which requires her to exert more

efforts. She is quite dependent to her grandchild in terms of doing the household choirs,

because she easily gets tired in doing so. According to Ma’am X (daughter- in- law), Ma’am LSP

is already fulfilled and satisfied as a mother to see her children grown up and have their own

families to live with, without experiencing many difficulties in life, in as much as seeing her

grandchildren grow up as well. Ma’am LSP had already achieved her self- worth as wife who

proved her love to her husband for almost 52 years of marriage and even until her death. Ma’am

LSP had no regrets and frustrations in life, she only make used to recall those happy moments

when she still young and continues share her wisdom of her own experiences to her grand

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children and let them learned from her values she used to instill to her children before. As of

now, Ma’am LSP is already accepted and prepared herself to face her end at any time God will

take away her life and confident enough to face a new life eternally in heaven.

Robert Havighurts – Developmental Task Theory

Stage: Later Maturity

Robert Havighurst believed that learning is basic to life and that people continue to learn

throughout life. He described growth and development as occurring during 6 stages, each

associated with 6 to 10 tasks to be learned. For Havighurst, developmental tasks is a task which

arises at or about a certain period in the life of an individual, successful achievement of which

leads to his happiness and to success with later task, while failure leads to unhappiness in the

individual, disapproval by society, and difficulty with later tasks

a. Adjusting to decreasing physical strength and health (achieved)

Ma’am LSP had already accepted that her body is already aging and she cannot

tolerate to do things which require her to exert much effort. Thus, at this point in her life

she depend her needs on others in terms of cooking her food, doing the laundry and

cleaning her home. Ma’am LSP can no longer tolerate ambulation for a long period of

time. So Ma’am LSP usually has a sedentary life by watching television or stay on her

bed to rest. Accompanied to her age was her disease hypertension and Diabetes

Mellitus II which Ma’am LSP doesn’t take it seriously because she doesn’t cooperate

most of the time in terms of complying to the advises of her doctor because according to

Ma’am X, Ma’am LSP knows what’s good for her.

b. Adjusting to retirement and reduced income (achieved)

Ma’am LSP was able to go to secondary high school until 2nd year level. Due to

financial reasons she was not able to finish her studies. After her marriage at 18 years of

age, she stayed at home as a house wife and attends the needs of her children. Ma’am

LSP depend the financial means of their family to her husband who is a government

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employee. After her children got married and have their families, Ma’am LSP and her

husband sustained her needs through a little a little pension he got from his work, and

rent a room business in which earns 3,000 thousand per month. She was also affiliated

to Philhealth, which helped her a lot in paying her medical bills. Moreover, Ma’am LSP’s

children gave some money for her at times in order to sustain her needs, most especially

her medications.

c. Adjusting to death of spouse (achieved)

The patient is described by her children as a strong woman. Ma’am LSP lost her

husband when she was 67 years old it took her 1 year to grief her lost and adjust to go

on with her ordinary life. According to Ma’am X, (daughter- in- law) Ma’am LSP did

mentioned that she will just eventually go with her husband in heaven.

d. Establishing an explicit affiliation with one’s age group ( not achieved)

Ma’am LSP has a membership on senior citizen. However due to old age she is

not active member. She doesn’t usually go out her home because she easily gets tired.

She never goes out unless if it is not really necessary. Like, when she will be brought to

the hospital for check-ups, other than that she will not agree to go out for stroll. Since,

she’s the one being visited by her children.

e. Meeting social and civil obligations (not achieved)

Ma’am LSP doesn’t involve herself in the community organizations or activities,

because her age. On the other hand, she is being updated about what happens in their

community through her grandchild who lived with her. Moreover, she usually contributes

to the welfare of the by keeping her environment clean and following the rules imposed

on their local government.

f. Establishing satisfactory physical living arrangements (achieved)

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Ma’am LSP is happy and satisfied living in her own house with her 4

grandchildren who are teenagers, they were the one who usually took care of her.

Besides her house, is her small business of a boarding house is located. Through this,

she has a source of income her own without really exerting much effort to earn since it is

just within her residence. Furthermore, she can move easily and comfortably in her own

house because she is oriented to where things are.

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Date: January 26, 2011

GENERAL SURVEY

She was wearing a long sleeping dress and was lying in semi fowler’s position. She was

awake, and responsive to any kind of stimuli. Her body built was an endomorphic type. No body

odor or foul breath was noted. Client responds to any questions asked. She had an IVF of

PNSS liter @ 80cc/hr infusing well at right basilic vein at 600cc level.

VITAL SIGNS

Vital Signs

Actual VS

Normal Ranges

Remarks

Temperatu

re

36.2 ºC 35.6-36.7 ºC Afebrile

Pulse Rate 90 bpm 80-90 bpm Tachycardia

Respirator

y rate

21 cpm 16-20 cpm Tachypnea

Cardiac

Rate

92 bpm 80-90 bpm Tachycardia

Blood

Pressure

140/80

mmHg

110/70-130/90

mmHg

Hypertension

SKIN, HAIR AND NAILS

Upon inspection, the patient has a light brown skin tone, was soft and warm to touch and

has a good skin turgor which is appreciated when skin over the clavicle area returns

immediately to its normal position when pinched up. There were discoloration noted over the

face and extremities due to aging.

Hair on the scalp is evenly distributed, thick and is black in color. Hair is wavy and short

in length and is free from infestations upon inspection. Scalp is smooth, moist and mobile with

presence of dandruff.

Nails are of normal size and are intact but are not kept clean or trimmed. Pinkish

nailbeds are noted will a capillary refill time of 1 to 2 seconds and has a concave curvature of

approximately 160 degrees. No clubbing noted upon performing Schamroth’s test.

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HEAD AND FACE

Head is normocephalic, with no lacerations bulges or masses noted. The skull is round

in shape and is intact. No tenderness, masses and nodules noted. Facial features are

symmetric when being asked to raise eyebrows, puff cheeks, frown, close eyes tightly, smile

and show teeth. There are no signs of difficulty seen or discomfort upon assessment.

EYE STRUCTURE

Eyebrows are equally distributed and are symmetrical. Also, the eyelashes are evenly

distributed and slightly curled outward. The client has bilateral blinking. Outer canthus of the

ears aligns with the tip of the pinna. Conjunctiva is pink and sclera is opaque in color. Client has

brown colored iris. Pupils are equally round but sluggishly reactive to light stimulation and

accommodation with a pupil size of 2mm. When looking straight ahead, the client can see

objects in the peripheral fields but is not very clear according to the client. Eyes can follow the

six ocular movements. Furthermore, the client wears correction eye glasses to aid her with her

sight especially for far away objects.

EARS AND HEARING

Ears appear to be symmetric and with same color of facial skin. No lesions and

discharges were noted but there is presence of thick amounts cerumen. The tip of the auricle is

aligned with the outer canthus of the eye. Client was able to hear normal voice tones and

whispers on both ears.

NOSE AND SINUSES

Upon inspection, the nose is of average size and outer structure is free of lesions. Nasal

septum is intact and is positioned in the midline. No discharges or tenderness noted. Air moves

freely as the client breathes through the nares, patient is able to identify the smell of crackers

and alcohol. No tenderness noted upon palpating the sinuses.

MOUTH

Both upper and lower lips were pale to pinkish in color. The client was able to purse lips.

Her teeth were yellowish in color with minimal tooth decay. Both upper and lower second and

third molars were absent. Client was not using dentures to replace her missing teeth. Gums

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were moist and pinkish in color. The mouth was free from lesions. Her tongue was also pinkish,

positioned in the midline and was moving freely.

NECK

Her neck is located midline and is free from bulging masses. There were no swelling or

enlargement and no tenderness of her lymph nodes upon palpation. She can move her neck

without any discomfort and pain felt. She can flex and extend her neck as well. She was able to

resist the force applied towards the side of her face.

THORAX ANG LUNGS

There is symmetrical chest expansion and clear lung fields noted upon assessment.

Upon assessing the vocal fremitus, client was instructed to say “99” and increased vibrations

were felt over major airways and in a decreasing manner, over the lungs to the periphery of the

lungs.

HEART AND CENTRAL VESSELS

Upon auscultation, no adventitious sound was noted but has a fast rhythmic heartbeat.

The point of maximal impulse is located at the left midclavicular line at the 5 th intercostal space,

slightly below the breast. Jugular veins are not distended and visible.

BREASTS AND AXILLA

The client refused to be assessed on these parts.

ABDOMEN

Skin color is lighter in tone over the area compared to exposed parts of the body. No

lesions were noted on the area, normal bowel sounds was appreciated in all four quadrants.

EXTREMITIES

No swelling, masses or deformities were noted. Skin over the area is uniform in color.

There was a presence of right sided weakness. Client had a difficulty clenching her right hand

and raising her right leg. Patient was able to flex wrists, elbows and ankles of the unaffected

side. There was no pressure ulcers noted in the bony prominences.

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CRANIAL NERVES ASSESSMENT AND NEUROVITAL SIGNS

CRANIAL NERVE RESULTS

1- OLFACTORY We asked our client to close her eyes,

then, we held the chocolate cracker

under one nostril with the other

occluded. We asked her to identify the

scent and she was able to distinguish

it correctly (biscuit). Afterwards, we

test the other nostril and had the

same answer.

2- OPTIC We asked the client to read one

sentence from the book we offered for

a distance of 14 inches and she was

able to read it. She also said that she

uses correction glasses to see objects

from afar clearly. The client had

minimum difficulty in seeing objects in

periphery when looking straight

ahead.

3- OCULOMOTOR Pupils were equally round but

sluggishly reactive to light stimulation

and accommodation. The six

extraocular muscles are active.

4- TROCHLEAR Both eyes were coordinated with

parallel alignment.

5- TRIGEMINAL We tested this by touching her cornea

lightly with ear buds and her eyelids

blinked bilaterally. Also, we used a

plastic ruler to test client's ability to

feel light touch, dull and sharp facial

sensations on both sides of the face

at the forehead, cheek and chin

areas. She was able to identify which

15| P a g e

is sharp, dull and light touch

sensations.

6- ABDUCENS All extraocular muscles are active.

7- FACIAL The client was capable of smiling,

frowning, raising her eyebrows,

puffing out her cheeks and closing

eyes tightly.

8- VESTIBULOCOCHLEAR

The client was able hear normal voice

tone and even whisper.

9- GLOSSOPHARYNGEAL

Client is able to move her tongue from

side to side and up and down and was

able to swallow.

10- VAGUS Gag reflex is present since the client

was able to swallow.

11- ACCESORY Client was able to resist the force

introduced in her head and was able

to shrug shoulders against resistance.

12- HYPOGLOSSAL The client was able to protrude her

tongue at midline and move it side to

side.

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NVS LEFT RIGHT

Pupil Size 2 mm 2 mm

Pupil Reaction Sluggish Sluggish

Hand Grip Strong Weak

Leg Movement Strong Weak

Reaction Level Scale

Actual Score

Alert, Fully Conscious

1

Therefore, the client has a RLS/GCS of 1/15.

EVALUATION

Our patient was assessed in a cephalocaudal manner and found both normal and

irregular findings. She has poor hygiene and poor choices when it comes to her health. She is

unable to ambulate independently due to the weakness of the right side of her body. A fast heart

rate and elevated blood pressure was noted as a compensatory action of the body in response

to her recent accident.

CEREBROVASCULAR ACCIDENT (CVA)17| P a g e

Glasgow Coma Scale

Actual Score

Eye OpeningMotor ResponseVerbal Response

4 Eyes open

spontaneously

6 Obeys commands

5 Oriented

GC Total Score

15

Complete definition of diagnosis

A cerebrovascular accident (CVA) is also called a brain attack or stroke. It leads to

neurologic deficits from decreased blood supply to a local area of the brain.

Source: Burke,K., LeMone,P., Eby,L.(2007). Medical Surgical Nurisng Care. (2nd

ed.).Upper Saddle River, New Jersey: Pearson Education.

A cerebrovascular accident, or stroke, is a prolonged interruption in the flow of blood

through one of the arteries supplying the brain. Brain and cerebral nerve cells are extremely

sensitive to a lack of oxygen; if the brain is deprived of oxygenated blood for 3 to 7 minutes

during stroke, both the brain and nerve cells begin to die.

Source: Timbu,B., Smith,N.(2010).Introductory Medical Surgical Nursing.(10th

ed.).China:Wolters Kluwer Health/Lippincott Williams & Wilkins

A stroke is also known as a cerebrovascular accident (CVA) or a brain attack. Blood

supply is interrupted to part of the brain, causing brain cells to die; this results in the patient

losing brain function in the affected area. Interruption is usually caused by an obstruction of

arterial blood flow (ischemic stroke), such as formation of a blood clot, but can also be caused

by a leaking or ruptured blood vessel (hemorrhagic stroke).

Source: DiGuilio,M., Jackson,D.(2007).Medical-Surgical Nursing Demystified.United

States of America: McGraw-Hill Companies.

Cerebrovascular accident is the infarction of brain tissue caused by the disruption of

blood flow to the brain. It is characterized by focal neurological deficits specific to the area of the

brain involved that do not fully resolve. The patient does not return to baseline functional level.

Source: William, L. (2007). Medical Surgical Nursing. (3rd edition). F.A Davis Company

Philadelphia.

Cerebrovascular accident: The sudden death of some brain cells due to lack of oxygen

when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain. A

CVA is also referred to as a stroke.

Source: http://www.medterms.com/script/main/art.asp?articlekey=2676

NERVOUS SYSTEM

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The nervous system is the master controlling and

communicating system of the body. Every thought,

action, and emotion reflects its activity. Its signaling

device, or means of communicating with body cells, is

electrical impulses, which are rapid and specific an

cause almost immediate responses.

To carry out its normal role, the nervous system

has three overlapping functions.

1.) It uses its millions of sensory receptors to

monitor changes occurring both inside and

outside the body. These changes are called

stimuli, and the gathered information is called

sensory input.

2.) Its process and interprets the sensory input and

makes decisions about what should be done at

each moment a process called integration.

3.) It then effects a response by activating muscles

or glands via motor output.

Structural classificationThe structural classification, which includes all nervous system organs, has two

subdivisions- the central nervous system and the peripheral nervous system.

The central nervous system is consist of the brain and the spinal cord, which occupy the

dorsal body cavity and acts as the integrating and command centers of the nervous system.

They interpret incoming sensory information and issue instructions based on past experience

and current condition.

The peripheral nervous system, the part if the nervous system outside the CNS, consist

mainly if the nerves that extend from the brain and spinal cord. Spinal nerves carry impulses

toad n from the spinal cord. Cranial nerves carry impulses to and from the brain. They link all

parts of the body by carrying impulses form the sensory receptors to the CNS and form the CNS

to the appropriate glands or muscles.

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Functional classificationThe functional classification scheme is concerned only with PNS structures. It divides

them into two principal subdivisions, the sensory or the afferent division and the motor or

efferent division.

The sensory or the afferent division consists of nerve fibers that convey impulses to the

central nervous system form the sensory receptors located in various parts of the body. Sensory

fibers delivering impulses from the skin, skeletal muscles, and joints are called somatic sensory

fibers; whereas those transmitting impulses form the visceral organs are called visceral sensory

fibers or visceral afferents. The sensory divisor keeps the CNS constantly informed of events

going both inside and outside the body.

The motor or efferent division carries impulses from the CNS to effector organs, the

muscles and glands. These impulses activate muscles and glands; that is, they effect a motor

response the motor division has two subdivision, the somatic nervous system and the

autonomic nervous system. The somatic nervous system allows us to consciously, or

voluntarily, control our skeletal muscles. Hence, this subdivision is often referred to as the

voluntary nervous system. However, not all skeletal muscle activity controlled by this motor

division is voluntary. Skeletal muscle reflexes, like the stretch reflex for example are initiated

involuntarily by theses same fibers. The other subdivision, autonomic nervous system regulates

events that are automatic, or involuntary, such as the activity or smooth and cardiac muscles

and glands. This subdivision commonly called the involuntary nervous system, itself has two

parts, the sympathetic and parasympathetic, which typically bring about opposite effects.

Nervous Tissue: Structure and FunctionThe nervous tissue is made up of two principal types of cells, the supporting cells and

the neurons.

Supporting cellsSupporting cells in the CNS are “lumped together” as

neuroglia, literally, “nerve glue”. Neuroglia includes many

types of cells that generally support, insulate and protect the

20| P a g e

delicate neurons. Each different types of neuroglia is simply called glia or glial cells, has special

functions. The CNS glia includes:

a.) Astrocytes: abundant star-shaped cells that account

for nearly half of the neural tissue. Astrocytes form a

living barrier between capillaries and neurons and play

a role in making exchanges between the two. In this

way, they help protect the neurons from harmful

substances that might be in the blood. It also help

control the chemical environment in the brain by

picking up excess ions and recapturing released

neurotransmitters.

b.) Microglia: spiderlike phagocytes that dispose of

debris, including dead brain cells and bacteria.

c.) Ependymal cells: these glial cells line the cavities of

the brain and the spinal cord.

d.) Oligodendrocytes: glia that wrap their flat extension

tightly around the nerve fibers, producing fatty

insulating coverings called myelin sheaths.

Glias are not able to transmit nerve impulses, a function that is highly developed in neurons.

Another important difference is that glia never lose their ability to divide, whereas most neurons

do. Consequently most brain tumors are gliomas, or tumors formed by glial cells. Supporting

cells in the PNS come into two major varieties- Schwann cells and satellite cells. Schwann cells

forms the myelin sheaths around nerve fibers that are found in the PNS. Satellite cells acts as

protective, cushioning cells.

Neurons

Neurons, also called nerve

cells, are highly specialized to

transmit messages from one part of

the body to another. They all have a

cell body, which contains the nucleus

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and is the m metabolic center of the cell, and one or more slender processes extending from the

cell body.

The cell body is the metabolic center of the neuron. It contains the usual organelles

except for cenrtioles. The rough ER called Nissl substance, and neurofibrils, intermediate

filaments that are important in maintaining cell shape, are particularly abundant in the cell body.

The longest arm like processes or fibers is located at the lumbar region of the spine to

the great toe. Neuron processes that convey incoming messages toward the cell body are

dendrites whereas those that generate nerve impulse and typically conduct them away from the

cell body are exons. Neurons may have hundreds of the branching dendrites, depending on the

neuron type, but each neuron has only one axon which arises from a conelike region of the cell

body called the axon hillock.

An occasional axon gives off a collateral branch along its length, but all axons branch

profusely at their terminal end, forming hundreds to thousands of axon terminals. These

terminals contain hundreds of tiny vesicles, or membranous sac, that contain chemicals called

neurotransmitters. Each axon terminal is separated from the next neuron by a tiny gap called

the synaptic cleft. Such a junction is called synapse.

Most long nerve fibers are covered with a whitish, fatty material, called myelin which has

a waxy appearance. Myelin protects and insulates the fibers and increases the transmission

rate of nerve impulses. Axons outside the CNS are myelinated by Schwann cells, specialized

supporting cells that wrap themselves tightly around the axon jelly-roll fashion. When the

wrapping process is done, a tight coil is wrapped membranes, the myelin sheath encloses the

axon. Most of the Schwann cells cytoplasm ends up just beneath the outermost of its plasma

membrane. This part is called neurilemma. Since the myelin sheath is formed by many

individual Schwann cells, it has gaps or indentations, called nodes of Ranvier.

For the most part, cell bodies are found in the CNS in clusters called nuclei. This well-

protected location within the bony skull or vertebral column is essential to the well- being of the

nervous system. The cell body carries out most of the metabolic functions of a neuron, so if it si

damaged the cell dies and is not replaced. Small collections of cell bodies called ganglia are

found in a few fibers running through the CNS are called tracts, whereas in the PNS they are

called nerves. The term white matter and gray matter refer respectively to myelinated wersus

unmyelinated regions of the CNS. The white matter consists of dense collections of mylinated

fibers and gray matter consist mostly unmyelinated fibers and cell bodies.

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ClassificationFunctional classification groups neurons according to the direction the nerve impulse

is traveling relative to the CNS. Neurons carrying impulses from sensory receptors to the CNS

are sensory or afferent neurons. The cell bodies of sensory neurons are always found in a

ganglion outside the CNS. Sensory neurons keep us informed about what is happening both

inside and outside the body.

Neurons carrying impulses from the CNS to the viscera and or muscles and glands are

motor or efferent neurons. The third category of neurons is the association neurons, or

interneurons. They connect the motor and sensory neurons in the neural pathways.

Structural classification is based on the number of processes extending from the cell

body. Neurons with two processes-an axon and a dendrite-are called bipolar neurons. Unipolar

neurons have a single process emerging from the cell body.

The spinal cordThe spinal cord is a

long, thin, tubular bundle

of nervous

tissue and support cells that

extends from

the brain (the medulla

oblongata specifically). The

brain and spinal cord

together make up the central

nervous system. The spinal

cord begins at the Occipital

bone and extends down to

the space between the first

and second lumbar

vertebrae; it does not extend

the entire length of

the vertebral column. It is

around 45 cm (18 in) in men and around 43 cm (17 in) long in women. Also, the spinal cord has

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a varying width, ranging from 1/2 inch thick in the cervical and lumbar regions to 1/4 inch thick in

the thoracic area. The enclosing bony vertebral column protects the relatively shorter spinal

cord. The spinal cord functions primarily in the transmission of neural signals between

the brain and the rest of the body but also contains neural circuits that can independently control

numerous reflexes and central pattern generators. The spinal cord has three major functions: a.)

Serve as a conduit for motor information, which travels down the spinal cord. b.) Serve as a

conduit for sensory information, which travels up the spinal cord. c.) Serve as a center for

coordinating certain reflexes.

Nerves called the spinal nerves or nerve roots come off the spinal cord and pass out

through a hole in each of the vertebrae called the Foramen to carry the information from the

spinal cord to the rest of the body, and from the body back up to the brain. There are four main

groups of spinal nerves which exit different levels of the spinal cord. These are in descending

order down the vertebral column:

Cervical Nerves "C" : (nerves in the neck) supply movement and feeling to the arms,

neck and upper trunk.

Thoracic Nerves "T" : (nerves in the upper back) supply the trunk and abdomen.

Lumbar Nerves "L" and Sacral Nerves "S" : (nerves in the lower back) supply the

legs, the bladder, bowel and sexual organs.

The spinal nerves carry information to and from different levels (segments) in the spinal

cord. Both the nerves and the segments in the spinal cord are numbered in a similar way to the

vertebrae. The point at which the spinal cord ends is called the conus medullaris, and is the

terminal end of the spinal cord. It occurs near lumbar nerves L1 and L2. After the spinal cord

terminates, the spinal nerves continue as a bundle of nerves called the cauda equina. The

upper end of the conus medullaris is usually not well defined.

There are 31 pairs of spinal nerves which branch off from the spinal cord. In the cervical

region of the spinal cord, the spinal nerves exit above the vertebrae. A change occurs with the

C7 vertebra however, where the C8 spinal nerve exits the vertebra below the C7 vertebra.

Therefore, there is an 8th cervical spinal nerve even though there is no 8th cervical vertebra.

From the 1st thoracic vertebra downwards, all spinal nerves exit below their equivalent

numbered vertebrae.

The spinal nerves which leave the spinal cord are numbered according to the vertebra at

which they exit the spinal column. So, the spinal nerve T4, exits the spinal column through the

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foramen in the 4th thoracic vertebra. The spinal nerve L5 leaves the spinal cord from the conus

medullaris, and travels along the cauda equina until it exits the 5th lumbar vertebra.

The level of the spinal cord segments do not relate exactly to the level of the vertebral

bodies i.e. damage to the bone at a particular level e.g. L5 vertebrae does not necessarily mean

damage to the spinal cord at the same spinal nerve level.

Brain

Cerebral HemispheresThe paired cerebral hemisphere,

collectively called the cerebrum, are the most

superior part of the brain and together are a

good deal larger than the other three brain

regions combined. The entire surfac e of the

cerebral hemispheres exhibits elevated ridges

of tissue called gyri, separated by shallow

grooves called sulci. Less numerous are the deeper grooves called fissures, which separate

large regions of the brain. The cerebral hemispheres are separated by a single deep fissure, the

longitudinal fissure. Other fissures are sulci divided each cerebral hemisphere into a number of

lobes, named for the cranial bones that lie over them. Speech, memory, logical and emotional

response, as well as consciousness, interpretation of sensation, and voluntary movement, are

all functions of neurons of the cerebral cortex, and many of the functional areas of the cerebral

hemispheres have been identified. The somatic sensory area is located in the parietal lobe

posterior to the central sulcus. The somatic sensory area allows you to recognize pain,

coldness, or a light touch. The visual area is located in the posterior part of the occipital lobe,

while the auditory area is in the temporal lobe bordering the lateral sulcus, and the olfactory

area is found deep inside the temporal lobe.

The primary motor area that allows us to consciously move our skeletal muscles is

anterior to the central sulcus in the frontal lobe. The axons of these motor neurons form the

major voluntary motor tract- the corticospinal or pyramidal tract, which descends to the cord.

Most of the neurons in this primary motor area control body areas having the finest motor

control; that is the face, mouth, and hands. The body map on the motor cortex is called the

motor homunculus.

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A specialized area that is very involved in our ability to speak is the Broca’s area, is

found at the base of the precentral gryus. Damage to this area which is located in only one

cerebral hemisphere causes inability to say words properly. Areas involved in higher intellectual

reasoning and socially acceptable behavior are believed to be in the anterior part of the lobes.

Complex memories appear to be stored in the temporal and frontal lobes. The speech area is

locate at the junction of the temporal, parietal, and occipital lobes. The cell bodies of neurons

involved in the cerebral hemisphere functions named above are found only in the outermost

gray matter of the cerebrum, the cerebral cortex. Most of the remaining cerebral hemisphere

tissue the deeper cerebral white matter is composed of fiber tracts carrying impulses to or from

the cortex. One very large fiber tract, the corpus callosum, connects the cerebral hemispheres.

DiencephalonThe diencephalon or the interbrain, sits atop

the brain stem and is enclosed by the cerebral

hemisphere. The major structures of the

diencephalon are the thalamus, hypothalamus, and

epithalamus.

The thalamus which encloses the shallow

third ventricle of the brain. The hypothalamus

makes up the floor of the diencephalon. It is an important autonomic nervous system center

because it plays a role in the regulation of body temperature, water balance, and metabolism.

The hypothalamus is also the center for many drives and emotions, and as such it is an

important part of the so-called limbic system. The pituitary gland hangs from the anterior of the

hypothalamus by a slender stalk. The mammillary bodies reflex centers involved in olfaction

bulge from the floor of the hypothalamus posterior to the pituitary gland. The epithalamus forms

the roof of the third ventricle. The important parts of the epithalamus are the pineal body and the

choroid plexus.

Brain stem The brain stem is about the size of thumb in diameter and approximately 3 inches long.

Its structures are the midbrain, pons, and medulla oblongata.

The midbrain is relatively small part of the brain stem. It extends from the mammillary

bodies to the pons inferiorly. The cerebral aquaduct is tiny canal that travels through the

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midbrain and connects the third ventricle of the diencephalon of the fourth ventricle below. The

pons is the rounded structure that protrudes just below the midbrain. The medulla oblongata is

the most inferior part of the stem. It contains centers that control heart rate, blood pressure,

breathing, swallowing, and vomiting. Extending the entire length of the brain stem is a diffuse

mass of gray matter, the reticular formation. The neurons of the reticular formation are involved

in motor control of the visceral organs. Reticular activating system plays a role in consciousness

and the awake/sleep

CerebellumThe cerebellum projects dorsally from

under the occipital lobe of the cerebrum. The

cerebellum also has an outer cortex made up of

gray matter and an inner region white matter.

The cerebellum provides the precise timing for

skeletal muscle activity and controls our balance

and equilibrium.

MeningesThe three connective tissue membranes covering and protecting the CNS structures are

meninges. The outermost layer, the leathery dura mater, meaning “tough or hard mother”, is a

double- layered membrane where it surrounds the brain. The other called the meningeal layer,

forms the outermost covering of the brain and continues as the dura mater of the spinal cord.

The middle meningeal layer is the weblike arachnoid mater. It’s a threadlike extensions span the

subarachnoid space to attach it to the innermost membrane, the pia mater. The subarachnoid

space is filled with cerebrospinal fluid. Specialized projections of the arachnoid villi protrude

through the dura mater.

Cerebrospinal fluidCerebrospinal fluid is a watery similar in its makeup to blood plasma, from which it

forms. However, it contains less protein, more vitamin C, and its ion composition is different.

CSF is continually formed from blood by the choroid plexuses. The CSF in and around the brain

and cord forms a watery cushion that protects the fragile nervous tissue from blows and other

trauma. Inside the brain, CSF is continually moving. It circulates for the two lateral ventricles (in

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the cerebral hemisphere) into the third ventricle ( in the diencephalon), and then through the

cerebral aqueduct of the midbrain into the fourth ventricle dorsal to the pons and medulla

oblongata. The fluid returns to the blood in the dural sinuses through the arachnoid villi.

Cranial nerves

The 12 pairs of cranial nerves primarily serve the head and neck. Most cranial nerves are mixed

nerves; however, three pairs the optic, olfactory and vestibulocochlear nerves are purely sensory in

function.

# Name Nuclei Function

0

Cranial nerve

zero(CN0 is not

traditionally

recognized.)[1]

olfactory trigone, medial

olfactory gyrus,

and lamina terminalis

New research indicates CN0 may play a

role in the detection of pheromones [2]

[3] Linked to olfactory system in human

embryos[4]

I Olfactory nerve Anterior olfactory nucleus

Transmits the sense of smell; Located

in olfactory foramina in theCribriform

plate of ethmoid

II Optic Nerve Ganglion cells of retina [5] Transmits visual information to the brain;

Located in optic canal

III Oculomotor nerve

Oculomotor

nucleus,Edinger-

Westphal nucleus

Innervates levator palpebrae

superioris, superior rectus, medial

rectus, inferior rectus, and inferior

oblique, which collectively perform most

eye movements; Also innervates m.

sphincter pupillae. Located in superior

orbital fissure

IV Trochlear nerve Trochlear nucleus

Innervates the superior oblique muscle,

which depresses, rotates laterally

(around the optic axis), and intorts the

eyeball; Located insuperior orbital

fissure

V Trigeminal nerve Principal sensory Receives sensation from the face and

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trigeminal nucleus, Spinal

trigeminal

nucleus,Mesencephalic

trigeminal

nucleus,Trigeminal motor

nucleus

innervates the muscles of mastication;

Located in superior orbital

fissure (ophthalmic nerve - V1), foramen

rotundum (maxillary nerve - V2),

and foramen ovale(mandibular nerve -

V3)

VI Abducens nerve Abducens nucleus

Innervates the lateral rectus, which

abducts the eye; Located insuperior

orbital fissure

VII Facial nerve

Facial nucleus,Solitary

nucleus,Superior salivary

nucleus

Provides motor innervation to

the muscles of facial expression,

posterior belly of the digastric muscle,

and stapedius muscle, receives the

special sense of taste from the anterior

2/3 of the tongue, and

provides secretomotor innervation to

the salivary glands (except parotid) and

the lacrimal gland; Located and runs

through internal acoustic canal to facial

canal and exits atstylomastoid foramen

VIII

Vestibulocochlear

nerve (or auditory-

vestibular

nerveor statoacoustic

nerve)

Vestibular

nuclei,Cochlear nuclei

Senses sound, rotation and gravity

(essential for balance & movement).

More specifically. the vestibular branch

carries impulses for equilibrium and the

cochlear branch carries impulses for

hearing.; Located in internal acoustic

canal

IX Glossopharyngeal

nerve

Nucleus

ambiguus,Inferior salivary

nucleus,Solitary nucleus

Receives taste from the posterior 1/3 of

the tongue, provides secretomotor

innervation to the parotid gland, and

provides motor innervation to

the stylopharyngeus. Some sensation is

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also relayed to the brain from the

palatine tonsils. Sensation is relayed to

opposite thalamus and some

hypothalamic nuclei. Located injugular

foramen

X Vagus nerve

Nucleus ambiguus,Dorsal

motor vagal

nucleus,Solitary nucleus

Supplies branchiomotor innervation to

most laryngeal and all pharyngeal

muscles (except the stylopharyngeus,

which is innervated by the

glossopharyngeal);

provides parasympatheticfibers to nearly

all thoracic and abdominal viscera down

to thesplenic flexure; and receives the

special sense of taste from the epiglottis.

A major function: controls muscles for

voice and resonance and the soft palate.

Symptoms of

damage: dysphagia(swallowing

problems), velopharyngeal insufficiency.

Located injugular foramen

XI

Accessory

nerve(or cranial

accessory

nerveor spinal

accessory nerve)

Nucleus ambiguus,Spinal

accessory nucleus

Controls sternocleidomastoid and

trapezius muscles, overlaps with

functions of the vagus. Examples of

symptoms of damage: inability to shrug,

weak head movement; Located

in jugular foramen

XII Hypoglossal nerve Hypoglossal nucleus Provides motor innervation to the

muscles of the tongue (except for

the palatoglossus, which is innervated by

the vagus) and other glossal muscles.

Important for swallowing (bolus

formation) and speech articulation.

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Located in hypoglossal canal

The Circle of Willis

Four major arteries

and their branches supply

the brain with blood. The

four arteries are composed

of two internal carotid

arteries (left and right) and

two vertebral arteries that

ultimately join on the

underside (inferior surface)

of the brain to form the

arterial circle of Willis, or

the circulus arteriosus.

The vertebral

arteries actually join to form

a basilar artery. It is this

basilar artery that joins with

the two internal carotid

arteries and their branches

to form the circle of Willis.

Each vertebral artery arises

from the first part of the subclavian artery and initially passes into the skull via holes (foramina)

in the upper cervical vertebrae and the foramen magnum. Branches of the vertebral artery

include the anterior and posterior spinal arteries, the meningeal branches, the posterior inferior

cerebellar artery, and the medullary arteries that supply the medulla oblongata.

The basilar artery branches into the anterior inferior cerebellar artery, the superior cerebellar

artery, the posterior cerebral artery, the potine arteries (that enter the pons), and the labyrinthine

artery that supplies the internal ear.

The internal carotids arise from the common carotid arteries and pass into the skull via

the carotid canal in the temporal bone. The internal carotid artery divides into the middle and

anterior cerebral arteries. Ultimate branches of the internal carotid arteries include the

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ophthalmic artery that supplies the optic nerve and other structures associated with the eye and

ethmoid and frontal sinuses. The internal carotid artery gives rise to a posterior communicating

artery just before its final splitting or bifurcation. The posterior communicating artery joins the

posterior cerebral artery to form part of the circle of Willis. Just before it divides (bifurcates), the

internal carotid artery also gives rise to the choroidal artery (also supplies the eye, optic nerve,

and surrounding structures). The internal carotid artery bifurcates into a smaller anterior

cerebral artery and a larger middle cerebral artery.

The anterior cerebral artery joins the other anterior cerebral artery from the opposite side

to form the anterior communicating artery. The cortical branches supply blood to the cerebral

cortex.

Cortical branches of the middle cerebral artery and the posterior cervical artery supply

blood to their respective hemispheres of the brain.

The circle of Willis is composed of the right and left internal carotid arteries joined by the

anterior communicating artery. The basilar artery (formed by the fusion of the vertebral arteries)

divides into left and right posterior cerebral arteries that are connected (anastomsed) to the

corresponding left or right internal carotid artery via the respective left or right posterior

communicating artery. A number of arteries that supply the brain originates at the circle of Willis,

including the anterior cerebral arteries that originate from the anterior communicating artery.

In the embryo, the components of the circle of Willis develop from the embryonic dorsal aortae

and the embryonic intersegmental arteries.

The circle of Willis provides multiple paths for oxygenated blood to supply the brain if

any of the principal suppliers of oxygenated blood (i.e., the vertebral and internal carotid

arteries) are constricted by physical pressure, occluded by disease, or interrupted by injury. This

redundancy of blood supply is generally termed collateral circulation.

Arteries supply blood to specific areas of the brain. However, more than one arterial branch may

support a region. For example, the cerebellum is supplied by the anterior inferior cerebellar

artery, the superior cerebellar artery, and the posterior inferior cerebellar arteries.

Venous return of deoxygenated blood from the brainVeins of the cerebral circulatory system are valve-less and have very thin walls. The

veins pass through the subarachnoid space, through the arachnoid matter, the dura, and

ultimately pool to form the cranial venous sinus.

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There are external cerebral veins and internal cerebral veins. As with arteries, specific areas of

the brain are drained by specific veins. For example, the cerebellum is drained of deoxygenated

blood by veins that ultimately form the great cerebral vein.

External cerebral veins include veins from the lateral surface of the cerebral hemispheres that

join to form the superficial middle cerebral vein.

Vascular SystemComposition and Functions of blood

Among all of the body’s tissues, blood is unique. It

is the only fluid tissue. Essentially, blood is a complex

connective tissue in which living blood cells, the formed

elements, are suspended in a nonliving fluid matrix called

plasma.

Plasma

Plasma, which is approximately 90 percent water, is the liquid part of the blood. Plasma

proteins are the most abundant solutes in plasma. Except for the antibodies and protein-based

hormones, most plasma proteins are made by the liver.

Erythrocytes

Erythrocytes, or red blood cells, function primarily

to ferry oxygen in blood to all cells of the body. RBCs

differ from other blood cells because they are anucleate;

that is they lack a nucleus. Hemoglobin an iron-bearing

protein, transports the bulk of the oxygen that is carried in

the blood. Moreover, because erythrocytes lack

mitochondria and make ATP by anaerobic mechanisms,

they do not use up of the oxygen they are transporting, making them very efficient oxygen

transport.

Erythrocytes are small cells shaped like biconcave disc that provide a large surface area

relative to their volume, making them ideally suited for gas exchange. RBCs outnumber white

blood cells and the major factor contributing to blood viscosity. As the number of RBCs

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increases, blood viscosity increases. The more hemoglobin molecules the RBCs contain, the

more oxygen they will be able to carry.

LeukocytesLeukocytes are crucial to body

defense against disease. White blood

cells are the only complete cells in the

blood which means they have nuclei and

the usual organelles. Leukocytes form a

protective, movable army that helps

defend the body against damage by

bacteria, viruses, parasites and tumor

cells. WBCs can locate areas of tissue damage and infection in the body by responding to

certain chemicals that diffuse from the damaged cells. WBCs are classified into two major grou

ps, granulocytes and agranulocytes.

Granulocytes includes the:

1. Neutrophis which have a multilobed nucleus and very fine granules that respond

to both acid and basic stains.

2. Eosinophils have blue-red nucleus that resembles an old-fashioned telephone

receiver and sport large brick-red cytoplasmic granules. Their number increases

rapidly during allergies and infections by parasitic worms.

3. Basophils the rarest of the WBCs, contain large histamine-containing granules

that stain dark blue.

Agranulocytes lack visible cytoplasmic granules. The agranulocytes include the

lymphocytes and monocytes.

1. Lymphocytes havea large dark purple nucleus that occupies most of the cell

volume.

2. Monocytes are the largest of the WBCs. When they migrate into the tissues, they

change into marcophages with huge appetites.

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Platelets Platelets are not cells in the strict sense.

They are fragments of bizarre multinucleate cells

called megakaryocytes. Platelets are needed for

the clotting process that occurs in plasma when

blood vessels are ruptured or broken.

HematopoiesisNormally a blood flows smoothly past the

intact lining of blood vessel walls. But if a blood vessel wall breaks, a series of reactions is set in

motion to accomplish hemostasis or stoppage of blood flow. Hemostasis involves three major

phases which are the platelet plug formation, vascular spasms, and coagulation or blood

clotting.

CARDIOVASCULAR SYSTEM The Heart

The heart rests on the

diaphragm, near the midline of the

thoracic cavity. It lies in the

mediastinum, as mass of tissue that

extends from the sternum to the

vertebral column between the lungs.

You can visualize the heart as a

cone lying on its side. The pointed

apex is directed anteriorly, inferiorly,

and to the left. The broad base is

directed posteriorly, superiorly, and to the right. The membrane that surrounds and protects the

heart is the pericardium. It confines the heart to its position in the mediastinum, while allowing

sufficient freedom to movement for vigorous and rapid contraction.

The heart has 3 layers namely the epicardium, myocardium, and endocardium.

Epicardium is the thin, transparent outer layer of the heart wall. The middle myocardium, which

is cardiac muscle tissue, makes up the bulk of the heart and is responsible for is pumping action

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and is an involuntary muscle. The innermost endocardium is at thin layer of endothelium

overlying a thin layer of a connective tissue.

The heart has four chambers. The two chambers are the atria and the two inferior

chambers are the ventricle. On the anterior surface of each atrium is a wrinkled pouchlike

structure called an auricle. The right atrium receives blood from three veins: the superior vena

cava, inferior vena cava, and coronary sinus. Between the right and the left atrium is a thin

partition called the interatrial septum. Blood passes from the right atrium into the right ventricle

through a valve that is called the tricuspid valve. The right ventricle forms most of the anterior

surface of the heart. The right ventricle is separated from the left ventricle by a partition called

the interventricular septum. Blood passes from the right ventricle through the pulmonary valve

into a large artery called the pulmonary trunk, which divides into right and left pulmonary

arteries. The left atrium forms most of the base of the heart. It receives blood from the lungs

through four pulmonary veins. Blood passes from the left atrium into the left ventricle through

the bicuspid valve. The left ventricle forms the apex of the heart. Blood passes from the left

ventricle through the aortic valve into the ascending aorta. Some of the blood in the aorta flows

into the aorta and carry blood to the heart.

Vascular System

Arteries The wall of artery has three coast or tunics:

tunica interna, tunica media, and tuncia externa,

contains a lining of simple squamous epithelium called

endothelium, a basement membrane, and layer of

elastic tissue called the internal elastic lamina. The

endothelium is a continuous layer of calls that line the

inner surface of the entire cardiovascular system. The

tunica interna is closest to the lumen, the hollow center through which blood flows. The middle

coat, or tunica media, is usually the thickest layer. Due to the plentiful elastic fibers, arteries

normally have high compliance, which means that their walls stretch easily or expand without

tearing in response to a small increase in pressure. The outer coat which is the tunica externa is

composed mainly of elastic and collagen fibers.

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Arterioles (resistance vessels)An arteriole is a very small

artery, ranging in diameter from 10

to 100 micrometer that delivers

blood to capillaries. It has tunica

interna composed of smooth

muscle and very few elastic fibers,

and tunica externa composed

mostly of elastic and collagen fiber.

Arterioles play a key role in regulating blood flow from arteries into capillaries by regulating

resistance, the opposition to blood flow.

Capillaries (exchange vessels) Capillaries are microscopic vessels that connect arterioles to venules, they range in

diameter from 4 to 10 micrometer. The flow of blood from arterioles to venules through

capillaries is called the microcirculation. Body tissues with high metabolic requirements such as

muscles, the liver the kidney and the nervous system use more oxygen and nutrients and thus

have extensive capillary network. Tissues with lower metabolic requirements such as tendons

and ligaments contain fewer capillaries.

VenulesWhen several capillaries unite, they form small veins called venules. Venules range in

diameter from 10 to 100 micrometer, collect blood from capillaries and deliver it to veins.

VeinsThe diameter of veins ranges from 0.1mm to greater than 1mm. The tunica interna of

veins is thinner than that of arteries; the tunica media of veins is much thinner than the arteries

with relatively little smooth muscle and elastic fibers, the tunica externa of veins is the thickest

layer and consists of collagen and elastic fibers. They are distensible enough to adapt to

variations in the volume and pressure of blood passing through them, but they are designed to

withstand high pressure.

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PREDISPOSING FACTORS

Factors Present Rationale

Age Although stroke often is considered a disease of

elderly persons, one third of strokes occur in

persons younger than 65 years.

Race Race is an important risk factor. African-

Americans, Native Americans, and Alaskan

Natives are at greater risk compared to

people of other ethnicities, in part because the

African-American population has a greater

incidence of high blood pressure.

Sex Gender plays a role, too, with men being

more likely to have a stroke. However, more

stroke deaths occur in women.

Family History If someone in your family has high history of

stroke, you are more likely to have stroke.

Prior Stroke (Transient Ischemic

Attack)

A transient ischemic attack (TIA) is like a

stroke, producing similar symptoms, but

usually lasting only a few minutes and

causing no permanent damage. Often called

a ministroke, a transient ischemic attack may

be a warning. About one in three people who

have a transient ischemic attack eventually

has a stroke, with about half occurring within

a year after the transient ischemic attack.

PRECIPITATING FACTOR

Factors Present Rationale

BLOOD DISORDERS

38| P a g e

Hypertension High blood pressure is the number one

risk factor for strokes. One cause of

hypertension is a clogged blood vessel

or artery. These clogs can happen from

plaque build up along the blood vessel

walls. If a vessel is completely blocked,

then the owning organ may start to die

off. The brain is no exception. If a blood

vessel ruptures, that can directly affect

the organ that it's in by cutting off the

oxygen supply completely. Therefore,

hypertension could effectively cause a

stroke.

High Cholesterol Levels

Cholesterol is a waxy substance that

circulates, but does not dissolve, in the

blood. If a person has too much low-

density lipoprotein (LDL), also known

as bad cholesterol, it can slowly build

up in the wall of the arteries. Eventually

this buildup forms a thick, hard plaque

that narrows the arteries. If one of

these plaques ruptures, it causes a blot

clot to form, which can block normal

blood flow to the brain and lead to a

stroke.

Sickle cell disease Stroke is a devastating and potentially fatal

complication to sickle cell disease. Strokes

are difficult to explain on the basis of the

central pathological process in sickle cell

disease, namely the occlusion of small

vessels by deformed sickled cells.

Polycythemia As a result of a high concentration of red

blood cells, there would be increased risks of

39| P a g e

clotting or formation of thrombus thus

increasing the risk for stroke.

OTHER DISEASES

Diabetes Mellitus Diabetes affects 1 in 20 older people

and can increase the risk of having a

stroke. Many people with diabetes also

have high blood pressure, high blood

cholesterol and are overweight. Good

control of diabetes is important and

requires attention to diet, regular urine

tests or blood tests and probably some

medication.

LIFESTYLE

Excessive use of alcohol

Alcohol in excess (more than 2 drinks a day)

can contribute to hypertension that we all

know contributes directly to stroke.  Alcohol

can cause certain heart problems that also

contribute to stroke (atrial fibrillation,

cardiomyopathy for example)  There is also

evidence that alcohol can inhibit coagulation

and this might explain why alcohol tends to

directly relate to hemorrhagic stroke

(intracerebral hemorrhage, for example).

Cigarette smoking Cigarettes damage the body--gradually and

insidiously--in a number of different ways.

Cigarette smoking is the leading cause of

preventable death in the United States. It

accounts for almost 500,000 deaths per year,

or one in every five deaths. Cigarette

smoking contributes to a remarkable number

of diseases, including coronary heart

40| P a g e

disease, stroke, chronic obstructive

pulmonary disease, peripheral vascular

disease, peptic ulcer disease, and many

types of cancer.

Cocaine and illicit drug use

Years of research now show that drugs are

significant risk factors for stroke. Some drugs

can cause stroke by directly affecting blood

vessels in the brain while others do it

indirectly by affecting other organs in the

body such as the heart or the liver.

Sedentary lifestyle Lack of physical mobility is an

independent risk factor for both stroke

and heart disease.

DIET

Poor diet A poor diet may increase the risk for stroke in

a few significant ways. Eating too much fat

and cholesterol can lead to arteries that are

narrowed by plaque. Too much salt may

contribute to high blood pressure. And too

many calories can lead to obesity. A diet high

in fruits, vegetables, whole grains, and fish

may help lower stroke risk.

Obesity A person with obesity has an abnormal

amount of fatty tissue in the body so does

increases her chance of suffering from a

stroke,

Dehydration Poor oral intake of fluids can lead to

increased blood viscosity, flow stagnation and

decreased brain perfusion.

HEART DISEASES

Atrial fibrillation Atrial fibrillation causes cardioembolic strokes

41| P a g e

-- those caused by a clot that escapes from

the heart and blocks a blood vessel in the

brain. Blood clots are known to form

whenever blood remains static for prolonged

periods of time, or as a result of turbulent

blood flow, both of which are likely to occur

during the erratic and disorganized heart beat

of atrial fibrillation.

Carotid or Artery Disease

Carotid artery disease occurs when the

major arteries in your neck become

narrowed or blocked. These arteries,

called the carotid arteries, supply your

brain with blood. Your carotid arteries

extend from your aorta in your chest to

the brain inside your skull. Carotid

artery disease is a serious health

problem because it can cause a stroke.

Other heart disease People with coronary heart disease or heart

failure have a higher risk of stroke than those

with hearts that work normally.  Dilated

cardiomyopathy (an enlarged heart), heart

valve disease and some types of congenital

heart defects also raise the risk of stroke

SYMPTOMATOLOGYSymptoms Present Rationale

COMMUNICATION and COGNITIVE SYMPTOMSBroca’s Aphasia Aphasia is a disorder that results from

damage to portions of the brain that are

responsible for language. For most people,

these are areas on the left side

(hemisphere) of the brain. Aphasia usually

42| P a g e

occurs suddenly, often as the result of a

stroke or head injury, but it may also

develop slowly, as in the case of a brain

tumor, an infection, or dementia.

Wernicke’s Aphasia Damage to the temporal lobe (the side

portion) of the brain may result in a fluent

aphasia called Wernicke’s aphasia. In most

people, the damage occurs in the left

temporal lobe, although it can result from

damage to the right lobe as well. People

with Wernicke’s aphasia may speak in long

sentences that have no meaning, add

unnecessary words, and even create made-

up words. As a result, it is often difficult to

follow what the person is trying to say.

People with Wernicke’s aphasia usually

have great difficulty understanding speech,

and they are often unaware of their

mistakes.

Agraphia The loss of writing ability that results from

damage to language areas of the brain.

Often, agraphia is the result of a stroke. The

loss of writing ability after stroke is often

incomplete, as many stroke survivors with

agraphia can rapidly re-learn to write some

words or sentences.

Alexia Hemianopic Alexia (HA) is a condition that

damages one half of a patient’s vision

(ahemianopia), and is usually caused by a stroke.

Alexia is an acquired disturbance in reading.

Alexias that occur after left hemisphere damage

typically result from linguistic deficits and may

occur as isolated symptoms or as part of an

43| P a g e

aphasia syndrome.

Dyslexia Dyslexia is a name for a condition where

people have difficulty with reading and

writing. People with dyslexia have normal

intelligence and are not in any way mentally

retarded or intellectually challenged. The

difficulty with certain tasks is believed to be

related to problems with perception

capability in certain parts of the brain.

According to Margaret Greenwald, PhD, assistant

professor of audiology and speech-language

pathology, stroke patients are commonly

diagnosed with acquired dyslexia as a result of

brain injury, but they rarely receive treatment for

their reading deficits.

Dysarthia Dysarthria is a motor speech disorder. The

muscles of the mouth, face, and respiratory

system may become weak, move slowly, or

not move at all after a stroke or other brain

injury. The type and severity of dysarthria

depend on which area of the nervous

system is affected. Some causes of

dysarthria include stroke, head injury,

cerebral palsy, and muscular dystrophy.

Both children and adults can have

dysarthria.

Short term memory loss

Loss of short term memory is common with

people who have had a stroke. Short term

memory is the type of memory that we use

for daily things, such as remembering why

we went to the kitchen, how to do a simple

44| P a g e

daily task or who you saw an hour ago.

PHYSICAL (SENSORY and MOTOR) SYMPTOMS

Hemiplegia Hemiplegia after stroke is common. It is the

term we use to describe paralysis of one

side of the body. The term can be broken

down into “hemi” which means “half,” and

“plegia,” which means paralysis.

The patient’s complaint was right sided

weakness.

Inability to turn eyes toward affected side

Due to the loss of control on the ocular

muscles.

Hemiattention (denial of paralyzed limb)

Due to impaired sensory and motor activities

in the affected area.

Dysphagia Due to the alterations of physiologic

functions.

Spasticity Spasticity involves an increase in the tone of

affected muscles and usually an element of

weakness. The flexor muscles usually more

strongly affected in the upper extremities and the

extensor muscles more strongly affected in the

lower extremities.

45| P a g e

46| P a g e

Precipitating Factor:

AgeSexFamily historyPrior Stroke (Transient Ischemic Attack)

Predisposing Factors:

HypertensionDiabetes Mellitus IICigarette smokingSedentary lifestylePoor diet

Atherosclerosis

Atheromatous Plaques

Emboli travel throughout the body to the narrow arteries and veins

(Thrombosis)

Occlusion in the narrow arteries and blood vessels in the brain

Sx: Hypertention

47| P a g e

If managed:

Dx: PET scan, MRI, CT scan, cerebral angiography, lumbar puncture, ECG, skull x-ray, carotid ultrasound

Tx: aspirin, thrombolytics, carotid stenting, anti coagulants, antihypertensives

If not managed:

Sx: sudden severe

headache, unconscious

ness, nausea,

vomiting, visual

disturbances

Rapture of the blood vessels in the brain

Increase intracranial pressure

Thrombus will travel into the vessels causing thickening and fragility

Cerebral hemorrhage

Sx: dizziness, confusion, headache

Cerebral ischemia

Cerebral Hypoperfusion / decreased oxygen supply

Impaired distribution of oxygen and glucose

Tissue hypoxia and cellular starvation

Formation of small and large clots

Lodges unto other arteries

Initiation of ischemic cascade

Tx:

BT

48| P a g e

Production of O2 free radicals and other reactive O2 species

Transient Ischemic Attack (TIA)

Sx: unilateral numbness, vision loss in one eye, aphasia, dysarthria Structural integrity loss of brain tissue and

blood vessel

Vascular congestion

Compression of tissue

Increased intracranial pressure

Impaired perfusion and function

Diagnostic exams:

* CT or MRI scans, angiogram. ECG, Carotid duplex (ultrasound), Blood clotting tests Blood chemistry, Complete blood count (CBC), C-reaction protein, ESR (Sedimentation rate) ,Serum lipids.

Treatment:

Surgery (carotid endarterectomy), aspirin, low-fat and low-salt dietIf managed:

Palliative careFrequent VS and NVS takingIntubationMechanical ventilationVasodilatorsOsmotic diureticsICP monitoring

If not managed:

49| P a g e

Continued insufficiency of blood flow

Further compression of tissues

Coma

Cerebral death

Dx: Blood tests, electrocardiogram and CT scan of the head

Sx: Unresponsiveness Absence of cerebral and brain stem function (Pupillary responses, corneal and gag reflex are absent)

Cessation of physiologic functions

Cardiovascular system

Pulmonary system

Loss of cardiac muscle functions

Relaxation of venous valves

50| P a g e

Sx:

Decrease cardiac output

Sx:

Hypotension

Failure of accessory muscle for breathing

Loss of lung movement

apnea

Cardiopulmonary arrest

Systemic failure

DEATH

NARRATIVE:Atherosclerosis is the strongest contributing factor to ischemic stroke. The term

atherogenesis refers to the development of the condition of atherosclerosis. The most

fundamental lesions of atherosclerosis is a fatty steak, located in the intimal layer of large

arteries. As years pass by the fatty steak becomes a fatty plaque. The patient is unaware of the

presence of plaque until the plaque starts to invade the diameter of the artery and interfere with

blood flow. The plaque disrupts the integrity of the arterial lining, there will be an increase

coagulation causing thrombus formation that will make the major vessel or artery occluded. In

some instances, embolus can also arise into cerebrovascular accident because of the different

factors that enables it to form; an embolus may form to some organs such as the heart, aorta

and carotid arteries. The embolus may break off causing it to move up and will flow upstream

going to the brain. Through the formed emboli, it can cause again occlusion resulting to cerebral

hypoperfusion or will tend to increase the effect of high blood pressure.

There will be impairment for the distribution of oxygen and glucose going to the brain

due to the cerebral hypoperfusion which will result to tissue hypoxia and cellular starvation. This

is because of the inadequate nutrients being supplied in to the brain’s cells and tissues.

Cerebral ischemia will happen wherein it is a series of biochemical reactions that take place in

the brain and other aerobic tissues after seconds to minutes of ischemia. On the other side, if

there will be an increase of blood pressure, the thrombus will lyse or move from the vessel

causing thickening and fragility, it will then initiate a rupture of the vessel wall as an outcome of

cerebral hemorrhage or also called hemorrhagic stroke. There will be formation of small and

large clots which then lodge unto other arteries causing cerebral ischemia.

Also after an ischemic cascade, there will be a production of oxygen free radicals and

other reactive oxygen as a consequence of both enzymatic and non-enzymatic reactions.

Through the production of these free radicals, endothelial lining of the blood vessel will be

damage. Both the endothelial damage and diminished energy intake will cause transient

ischemic attacks. A transient ischemic attack (TIA) is a transient stroke that lasts only a few

minutes. It occurs when the blood supply to part of the brain is briefly interrupted. TIA

symptoms, which usually occur suddenly, are similar to those of stroke but do not last as long.

Most symptoms of a TIA disappear within an hour, although they may persist for up to 24 hours.

Symptoms can include: numbness or weakness in the face, arm, or leg, especially on one side

of the body; confusion or difficulty in talking or understanding speech; trouble seeing in one or

both eyes; and difficulty with walking, dizziness, or loss of balance and coordination. If this

51| P a g e

instances remained unmanage, complete stroke will be the effect depending on what type of

stroke whether thrombotic stroke or embolic stroke.

Further compression of the brain tissue due to the continued insufficiency of blood

supply, will now cause comatose state of the patient. A cessation of physiologic functions will

also occur and will initiate multi-organ dysfunction syndrome causing shut off of function of the

different systems of the body. Cardiovascular system will lose its cardiac muscle function

leading to a loss of cardiac contractility and will decrease cardiac output. The respiratory system

will lose also its respiratory muscle function thereby losing breathing reflex. When this will

happen, it will lead to cardiopulmonary arrest then systemic failure leading to death.

52| P a g e

1. Diagnostic Exams1.1. Actual

Laboratory Tests

Date Test Definition and

Normal Range

Result Interpretation/

Significance

Nursing

Responsibilities

January 24, 2011 Cranial Computed

Tomography (CT)

Scan

Computed

tomography

(CT) of the brain is

a noninvasive

procedure used to

assist in diagnosing

abnormalities of the

head, brain tissue,

cerebrospinal fluid,

and blood

circulation. It

becomes invasive if

contrast medium is

used.

Slices or thin

sections of certain

anatomic views of

the brain and

associated vascular

Multiple plain axial

CT images of the

head were obtained.

Minute CSF

isodense change is

noted in the left

periventricular area.

No other abnormal

density changes

seen in the rest of

the brain and

brainstem

parenchyma.

Extra- axial spaces

are wide and deep.

No evident

intracranial bleed.

Midline structures

Abnormal findings in:• Abscess

• Aneurysm

• AVMs

• Cerebral atrophy

• Cerebral edema

• Cerebral infarction

• Congenital

abnormalities

• Craniopharyngioma

• Cysts

• Hematomas (e.g.,

epidural,

subdural,

intracerebral)

• Hemorrhage

Pretest

➧ Inform the patient

that the procedure

assesses the brain.

➧ Note any recent

procedures that can

interfere with test

results, including

examinations using

barium or iodine-

based contrast

medium.

Ensure that barium

studies were

performed more

than 4 days before

the CT scan.

➧ Obtain a list of

the patient’s current 53| P a g e

system are

viewed to allow

differentiations

of solid, cystic,

inflammatory,

or vascular lesions,

as well as

identification of

suspected

hematomas or

aneurysms.

Normal Findings:

Normal size,

position, and shape

of intracranial

structures and

vascular system

are not displaced.

The ventricles are

not dilated.

Sella, orbits,

petromastoids and

visualized paranasal

sinuses are

unremarkable.

Calvarium and

visualized facial

bones are intact.

Impression: OLD

LACUNAR

INFARCT, LEFT

PERIVENTRICULAR

AREA. AGE-

RELATED

CEREBRAL

ATROPHY

• Hydrocephaly

• Increased

intracranial

pressure or

trauma

• Infection

• Sclerotic plaques

suggesting

multiple sclerosis

• Tumor

• Ventricular or

tissue displacement

or enlargement

In the case of our

patient, she has

abnormalities in her

CT scan result:

cerebral atrophy

and cerebral

infarction.

medications

including

anticoagulants,

aspirin and other

salicylates, herbs,

nutritional

supplements, and

nutraceuticals. Note

the last time and

dose of medication

taken.

➧ Review the

procedure with the

patient. Address

concerns about

pain and explain

that there may be

moments of

discomfort and

some pain

experienced during

the test.

Inform the patient

the procedure is 54| P a g e

usually performed

in a radiology suite

by a physician

specializing in this

procedure, with

support staff, and

takes approximately

15 to 30 min.

➧ Explain that an

IV line may be

inserted to allow

infusion of IV fluids,

contrast medium,

dye, or sedatives.

Usually contrast

medium and normal

saline are infused.

➧ Inform the patient

that he or she may

experience nausea,

a feeling of warmth,

a salty or metallic

taste, or a transient

headache after 55| P a g e

injection of contrast

medium.

➧ Instruct the

patient to remove

dentures and

jewelry and other

metallic objects

from the area to be

examined.

Intra test

➧ Ensure the

patient has

complied with

medication

restrictions and pre

testing

preparations.

➧ Ensure the

patient has

removed dentures

and all external

metallic objects

from the area to be 56| P a g e

examined prior to

the procedure.

➧ Instruct the

patient to cooperate

fully and to follow

directions. Instruct

the patient to

remain still

throughout

the procedure

because movement

produces unreliable

results.

➧ Administer an

antianxiety agent,

as ordered, if the

patient has

claustrophobia.

Administer a

sedative

to a child or to an

uncooperative

adult, as ordered.

➧ Place the patient 57| P a g e

in the supine

position on an

exam table.

➧ If contrast media

is used, a rapid

series of images is

taken during and

after injection.

➧ Instruct the

patient to take slow,

deep breaths if

nausea occurs

during the

procedure.

➧ Monitor the

patient for

complications

related to the

procedure (e.g.,

allergic

reaction,

anaphylaxis,

bronchospasm)

58| P a g e

if contrast is used.

Post test

➧ Monitor vital

signs and

neurologic status

every 15 min for 1

hr, then every 2 hr

for 4 hr, and then

as ordered by the

physician. Monitor

temperature every

4 hr for 24 hr.

Compare with

baseline values.

Notify the physician

if temperature is

elevated.

➧ If contrast was

used, observe for

delayed allergic

reactions, such as

rash, urticaria,

tachycardia, 59| P a g e

hyperpnea,

hypertension,

palpitations,

nausea, or

vomiting.

➧ If contrast was

used, advise the

patient

to immediately

report symptoms

such as fast heart

rate, difficulty

breathing, skin

rash, itching, or

decreased urinary

output.

➧ Instruct the

patient to increase

fluid

intake to help

eliminate the

contrast medium, if

used.

60| P a g e

➧ Inform the patient

that diarrhea may

occur after

ingestion of oral

contrast medium.

Date Test Definition and

Normal Range

Result Interpretation/

Significance

Nursing

Responsibilities

January 24, 2011 Chest Radiology Chest X-rays are

taken when a

patient is

suspected of

having problems

with the lungs,

heart, or other

Study taken in AP

projection.

Lung fields are clear.

The heart is

magnified with left

ventricular

Chest X-ray

examination is

done to identify the

presence of

pulmonary infiltrate,

which is fluid

leakage into the

1.) Remove from

the chest area all

jewelry, clothing

with snaps,

electrocardiographic

patches (if not

contraindicated), 61| P a g e

chest structures.

Another way of

looking for other

complications in the

lungs and heart.

X-ray examination

of the chest is done

to diagnose

disease and to

assess the

progress of a

disease.

Normal Values:

Normal anatomy

and no pathologic

changes evident or

no abnormalities

found in the lungs,

heart and other

chest structures.

prominence.

Aortic knob is

calcified.

Mediastinum and

hemidiaphragm are

unremarkable.

Visualized osseous

structures are porotic.

The rest of the

included structures

are unremarkable.

Impression:

SUGGESTIVE LEFT

VENTRICULAR

CARDIOMEGALY.

ATHEROSCLEROTIC

AORTA. SENILE

OSTEOPOROSIS.

alveoli from

inflammation.

It is also use to

evaluate respiratory

status and heart

size.

Abnormalities found

in the lungs

sometimes

indicates

pneumonia,

emphysema,

chronic obstructive

pulmonary disease,

bronchiectasis,

pulmonary edema,

interstitial

pneumonitis, and

others, while in the

heart congestive

heart failure or

pericardial effusion.

In the case of our

and other metal

objects that may

interfere with the

interpretation of the

results.

2.) It is important to

breathe in deeply,

hold your breath,

and remain

motionless while the

radiograph is taken.

4.) A radiograph

takes approximately

15 minutes to

complete and verify

that the images are

properly exposed.

5.) No restrictions

are necessary on

food or fluid intake.

6.) No sedation is

used for this

procedure.

7.) Views are taken 62| P a g e

client, it was found

out that there is

enlargement of the

heart

atherosclerotic

plaque in aorta and

osteoporosis.

in various positions

on the table or

chair.

8.) When taking a

PA view of the

chest, instruct

patient to place

his/her chest

against the

photographic plate

while standing, chin

raised, with both

hands on the hips,

palms out, and the

elbows and

shoulders in a

forward position.

9.) When taking a

lateral view of the

chest, instruct

patient to raise both

hands while

standing and the left

shoulder is lightly 63| P a g e

placed against the

photographic plate.

10.) Instruct patient

to take a deep

breath and hold

while the picture is

being taken.

After the test, give

back clothing,

jewelries that was

removed before the

procedure.

Date Test Definition and Normal

Range

Result Interpretation/ Significance Nursing

Responsibilties

January 25,

2011

Fasting Blood

Sugar (FBS)

This test is taken to

measure blood glucose

level.

Fasting glucose levels

are used to help

diagnose diabetes

mellitus and

hypoglycemia. A

randomly timed test for

7.1 mmol/ L

(HIGH)

Increased in:• Acromegaly, gigantism (GH

stimulates

the release of glucagon, which

in turn inceases glucose levels)

• Diabetes (Glucose intolerance

and elevated glucose levels

define

Pretest

1. Inform the

patient that

the test is

used as a

general

indicator of

nutritional

status, 64| P a g e

glucose is usually

performed for routine

screening and

nonspecific evaluation

of carbohydrate

metabolism.

Normal value:

3.9 - 6.1 mmol/ L

diabetes),

• Myocardial infarction (Related

to stress and/or pre-existing

diabetes)

• Strenuous exercise

(Hyperglycemia

is stimulated by the

release of catecholamines

and glucagon)

Decreased in:• Glucagon deficiency (Glucagon

controls glucose levels;

hypoglycemia

occurs in the absence of

glucagon)

• Hypothyroidism (Thyroid

hormones affect glucose levels;

decreased thyroid hormone

levels result in decreased

glucose levels)

In the case of our client, her FBS

result was high since she had

hydration and

chronic

disease.

2. Obtain a

history of the

patient’s

complaints,

including a list

of known

allergens.

3. Review the

procedure

with the

patient. Inform

the patient

that specimen

collection

takes

approximately

5 to 10

minutes.

Address

concerns

about pain 65| P a g e

been diagnosed of Diabetes

Mellitus.

and explain

that there may

be some

discomfort

during the

venipuncture.

4. There are no

food, fluid or

medication

restriction

unless by

medical

direction.

Intra test

1. If the patient

has a history

of allergic

reaction to

latex, avoid

the use of

equipment

containing

Blood Urea

Nitrogen

(BUN)

Urea is a nonprotein

nitrogen compound

formed in the liver from

ammonia as an end

product of protein

metabolism.

Urea diffuses freely into

extracellular and

intracellular fluid and is

ultimately excreted by

the kidneys.

Blood urea nitrogen

(BUN) levels reflect the

balance between the

production and

excretion of urea.

Normal Range: 2.5- 6.4

mmol/ L

6.4 mmol/ L Increased in:• Acute renal failure (Related to

decreased renal excretion)

• Chronic glomerulonephritis

(Related to decreased renal

excretion)

• Congestive heart failure

(Related

to decreased blood flow to the

kidneys, decreased renal

excretion,

and accumulation in circulating

blood)

• Diabetes (Related to decreased

renal excretion)

• Shock (Related to decreased

blood

flow to the kidneys, decreased

renal excretion, and accumulation

in circulating blood)

• Urinary tract obstruction

66| P a g e

(Related to

decreased renal excretion and

accumulation in circulating blood)

Decreased in:• Inadequate dietary protein (Urea

nitrogen is a by-product of protein

metabolism; less available

protein is reflected in decreased

BUN levels)

• Low-protein/high-carbohydrate

diet

(Urea nitrogen is a by-product of

protein metabolism; less available

protein is reflected in decreased

BUN levels)

In the case of our client, her BUN

result is normal.

latex.

2. Instruct the

patient to

cooperate

fully and to

follow

directions.

Direct the

patient to

breathe

normally and

to avoid

unnecessary

movement.

3. Positively

identify the

patient and

label the

appropriate

container.

Perform the

venipuncture.

4. Remove the

needle and

Creatinine Creatinine is produced

in relatively constant

quantities by the

muscles and is

excreted by the

71.2 umol/L - An increase in creatinine

may indicate congestive

heart failure, dehydration,

renal calculi, renal failure,

acute and chronic renal 67| P a g e

kidneys. Thus, the

amount of creatinine in

the blood relates to

renal excretory

function.

Normal Range: 53.0-

115.0 umol/ L

failure and shock.

- A decrease in creatinine

may indicate

hyperthyroidism, liver

disease and inadequate

protein intake.

The creatinine level of our client is

normal.

apply direct

pressure with

dry gauze to

stop bleeding.

Observe

venipuncture

site for

bleeding or

hematoma

formation and

secure gauze

with adhesive

bandage.

5. Promptly

transport the

specimen to

the laboratory

for processing

and analysis.

Posttest

1. Reinforce

information

given by the

Cholesterol Total cholesterol levels

are used for screening

for

hypercholesterolemia.

Cholesterol is a

lipid needed to form cell

membranes and a

component of the

materials that render

the skin waterproof. It

also helps form bile

salts, adrenal

corticosteroids,

estrogen, and

androgens.

4.3 mmol/ L This test is an important

screening test for heart disease.

Increased: Type II familial

hypercholesterolemia

Biliary cirrhosis

Chronic renal failure

Poorly controlled diabetes

mellitu

Diet high in cholesterol

and fats

Decreased:

68| P a g e

Cholesterol is obtained

from the

diet (exogenous

cholesterol)

and also synthesized in

the

body (endogenous

cholesterol).

Normal Value:

0.0 – 5.2 mmol/L

Hyperthyroidism

Malnutrition

Chronic anemias

Severe burns

In the case of our client, her

cholesterol level is normal.

patient’s

health care

provider

regarding

further testing,

treatment, or

referral to

another health

care provider.

2. Depending on

the results of

this

procedure,

additional

testing may

be performed

to evaluate or

monitor

progression of

the disease

process and

determine the

need for a

LDL-

Cholesterol

Up to 70% of the total

serum cholesterol is

present in the LDL. The

“bad” cholesterol.

Normal value:

0.00 – 3.4 mmol/L

3.1 mmol/ L Increased: Familial type 2

hyperlipidemia

Secondary causes can

include: diet high in

cholesterol and saturated

fat, nephritic syndrome,

multiple myeloma,

diabetes mellitus, chronic

renal failure

Decreased:

69| P a g e

Hypolipoproteinemia

Hyperthyroidism

Chronic anemias

In the case of our client, the result

is normal.

change in

therapy.

3. Evaluate test

results in

relation to the

patient’s

symptoms

and other

tests

performed.

Rev

Triglycerides

(TGL)

Triglycerides are a

combination of three

fatty acids

and one glycerol

molecule.

They are necessary to

provide

energy for various

metabolic

processes.

Triglycerides are also

synthesized in the liver

from fatty acids and

from protein and

glucose above the

body's current needs

and then stored in

adipose tissue. They

1.04 mmol/ L This test evaluates suspected

atherosclerosis and measures the

body’s ability to metabolize fat.

Increased: Hyperlipoproteinemia

Liver disease

Renal disease

Hypothyroidism

Myocardial infarction

Decreased: Malnutrition

Hyperthyroidism

Brain infarction

Chronic obstructive lung

disease

70| P a g e

may be later retrieved

and formed into

glucose through

gluconeogenesis when

needed by the body.

Triglyceride levels are

taken into consideration

with total cholesterol,

high-density lipoprotein

cholesterol, and

chylomicron levels

when categorizing a

client's serum into

lipoprotein phenotypes

that represent genetic

lipoprotein

abnormalities.

Normal Value:

0.0 – 1.70 mmol/ L

In the case of our client, the result

is normal.

HDL-

Cholesterol

(AHDL)

A class of lipoproteins

produced by the liver

and intestines. The

0.75 mmol/ L

(LOW)

Increased: HDL excess

Chronic liver disease

Long term aerobic or 71| P a g e

“good” cholesterol.

Normal Value:

0.90 – 1.55 mmol/L

vigorous exercise

Decreased: Familial

hypolipoproteinemia

Poorly controlled diabetes

mellitus

Chronic heart failure

In the case of our client, the result

is low since our client had been

diagnosed of having diabetes

mellitus.

Serum

Electrolytes

Serum electrolytes are

often routinely ordered

for any client admitted

to a hospital as a

screening test for

electrolyte and acid-

base imbalances.

Serum electrolytes also

are routinely assessed

for clients at risk in the

community, for

Sodium:

144.8 mmol/

L

Potassium:

3.24 mmol/ L

(LOW)

Calcium: 2.

19 mmol/ L

Sodium

- An increase in sodium

may indicate burn,

dehydration, diabetes, and

diarrhea, excessive intake

of sodium, fever and

vomiting.

- A decrease in sodium may

indicate congestive heart

failure, central nervous

system disease, excessive 72| P a g e

example, client who are

being treated with a

diuretic for

hypertension or heart

failure. The most

commonly ordered

serum tests are for

sodium, potassium,

chloride, and

bicarbonate ions.

Normal Values:

a. Sodium: 136-

145 mmol/L

b. Potassium: 3.5-

5.1 mmol/L

c. Calcium: 2.12-

2.52 mmol/L

antidiuretic hormone

production, excessive use

of diuretics, hepatic failure

and nephritic syndrome.

Potassium

- An increase in potassium

may indicate acidosis,

acute renal failure, burns,

dehydration, insulin

deficiency, ketoacidosis,

leukocytosis.

- A decrease in potassium

may indicate alcoholism,

alkalosis, bradycardia,

congestive heart failure,

hypertension,

hypomagnesemia and

renal tubular acidosis.

Calcium

- An increase in calcium

may indicate vitamin D

toxicity and

hyperthyroidism.

- A decrease in calcium 73| P a g e

may indicate burns,

magnesium deficiency,

multiple organ failure and

vitamin D deficiency.

In the case of our client, her

potassium is low since she is

hypertensive.

Date Test Definition and

Normal Range

Result Interpretation/

Significance

Nursing

Responsibilities

January 25, 2011 Glycosylated

Hemoglobin (HBA-

1C)

Glycosylated or

glycated

hemoglobin is a

term used to

describe the

combination of

glucose and

hemoglobin into a

ketamine; the rate

at which this occurs

is proportional to

6.7 % (HIGH) Increased in:• Diabetes (poorly

controlled or

uncontrolled)

(Related to and

reflective of

elevated glucose

levels)

Decreased in:• Chronic blood loss

Pretest

1. Inform the

patient that

the test is

used as a

general

indicator of

nutritional

status,

hydration and

chronic 74| P a g e

glucose

concentration.

The average life

span of a red

blood cell (RBC) is

approximately

120 days;

measurement of

glycated

hemoglobin is a

way to monitor

long-term diabetic

management.

Normal Range:

4.5%- 6.3%

(Blood

loss decreases

concentration

of RBC-bound

glycated

hemoglobin)

• Chronic renal

failure (Low RBC

count associated

with this

condition reflects

corresponding

decrease in RBC

bound

glycated

hemoglobin)

In the case of our

client, the result is

high since she is a

diabetic person.

disease.

2. Obtain a

history of the

patient’s

complaints,

including a list

of known

allergens.

3. Review the

procedure

with the

patient. Inform

the patient

that specimen

collection

takes

approximately

5 to 10

minutes.

Address

concerns

about pain

and explain

that there may 75| P a g e

be some

discomfort

during the

venipuncture.

4. There are no

food, fluid or

medication

restriction

unless by

medical

direction.

Intra test

6. If the patient

has a history

of allergic

reaction to

latex, avoid

the use of

equipment

containing

latex.

7. Instruct the

patient to 76| P a g e

cooperate

fully and to

follow

directions.

Direct the

patient to

breathe

normally and

to avoid

unnecessary

movement.

8. Positively

identify the

patient and

label the

appropriate

container.

Perform the

venipuncture.

9. Remove the

needle and

apply direct

pressure with

dry gauze to 77| P a g e

stop bleeding.

Observe

venipuncture

site for

bleeding or

hematoma

formation and

secure gauze

with adhesive

bandage.

10. Promptly

transport the

specimen to

the laboratory

for processing

and analysis.

Posttest

11. Reinforce

information

given by the

patient’s

health care

provider 78| P a g e

regarding

further testing,

treatment, or

referral to

another health

care provider.

12. Depending on

the results of

this

procedure,

additional

testing may

be performed

to evaluate or

monitor

progression of

the disease

process and

determine the

need for a

change in

therapy.

13. Evaluate test

results in 79| P a g e

relation to the

patient’s

symptoms

and other

tests

performed.

80| P a g e

1.2. Possible

Diagnostic Test

Test Rationale Result Interpretation Nursing Responsibilities

Positron Emission

Tomography (PET)

Positron emission

tomography (PET)

combines

the biochemical

properties of

nuclear medicine with

the

accuracy of computed

tomography

(CT). PET uses positron

emissions from specific

radionuclides (oxygen,

nitrogen, carbon, and

fluorine) to produce

detailed functional

images within the body.

After the radionuclide

becomes concentrated

in the brain, PET

images of blood flow or

metabolic processes at

Normal patterns

of tissue

metabolism,

blood flow, and

radionuclide

distribution

Abnormal findings in:• Alzheimer’s disease

• Aneurysm

• Cerebral metastases

• Cerebrovascular accident

• Creutzfeldt-Jakob disease

• Dementia

• Head trauma

• Huntington’s disease

• Migraine

• Parkinson’s disease

• Schizophrenia

• Seizure disorders

• Tumors

Pretest

➧ Inform the patient that the

procedure assesses blood

flow to the brain and brain

tissue metabolism.

➧ Review the procedure with

the patient. Address

concerns about pain related

to the procedure and explain

to the patient that some pain

may be experienced during

the test, or there may be

moments of discomfort.

Reassure the patient that

radioactive material poses

minimal radioactive hazard

because of its short half-life

and rarely produces side

effects. Inform the patient

that the procedure is

performed in a special 81| P a g e

the cellular level can be

obtained. PET identifies

the amount of tissue

damage following a

CVA. Positron emission

tomography (PET) is a

test that uses a special

type of camera and a

tracer (radioactive

chemical) to look at

organs in the body. The

tracer usually is a

substance (such as

glucose) that can be

used (metabolized) by

cells in the body.

department, usually in a

radiology suite and takes

approximately 60 to 120 min.

➧ Instruct the patient to

remove jewelry and other

metallic objects from the

area to be examined prior to

the procedure.

➧ Instruct the patient to

avoid taking anticoagulant

medication or to reduce

dosage as ordered prior to

the procedure.

➧ Instruct the patient to

restrict food for 4 hr; restrict

alcohol, nicotine, or caffeine-

containing drinks for 24 hr;

and withhold medications for

24 hr before the test.

Intra test

➧ Ensure that the patient

has complied with dietary,

fluid, and medication 82| P a g e

restrictions and pre testing

preparations.

➧ Ensure the patient has

removed all jewelry and

external metallic objects

from the area to be

examined prior to the

procedure.

➧ Instruct the patient to void

prior to the procedure and to

change into the gown, robe,

and foot coverings provided.

➧ Instruct the patient to

cooperate fully and to follow

directions. Ask the patient to

remain still throughout the

procedure because

movement produces

unreliable results.

➧ Record baseline vital

signs and assess

neurological status.

➧ The patient may be asked

to perform different cognitive 83| P a g e

activities (e.g., reading) to

measure changes in brain

activity during reasoning or

remembering.

➧ The patient may be

blindfolded or asked to use

earplugs to decrease

auditory and visual stimuli.

➧ Monitor the patient for

complications

related to the procedure

(e.g., allergic

reaction, anaphylaxis,

bronchospasm).

Posttest

➧ Instruct the patient to

resume pretest diet, fluids,

medications, or activity.

➧ Observe for delayed

allergic reactions,

such as rash, urticaria,

tachycardia,

hyperpnea, hypertension, 84| P a g e

palpitations, nausea, or

vomiting.

➧ Instruct the patient to

immediately report

symptoms such as fast heart

rate, difficulty breathing, skin

rash, itching, or decreased

urinary output.

➧ Instruct the patient to drink

increased amounts of fluids

for 24 to 48 hr to eliminate

the radionuclide from the

body, unless

contraindicated. Educate the

patient that radionuclide is

eliminated from the body

within 6 to 24 hr.

➧ Instruct the patient to flush

the toilet immediately after

each voiding, and

to meticulously wash hands

with soap and water for 24 hr

after the procedure.

85| P a g e

➧ Instruct all caregivers to

wear gloves when discarding

urine for 24 hr after the

procedure. Wash gloved

hands with soap and water

before removing gloves.

Then wash hands after the

gloves are removed.

Test Rationale Result Interpretation/

Significance

Nursing

Responsibilities

Electroencephalogram

(EEG)

Electroencephalography

(EEG) is a noninvasive

study that measures the

• Normal occurrences

of alpha, beta,

theta, and delta waves

Abnormal findings in:• Abscess

Pretest

➧ Inform the patient

that the procedure is 86| P a g e

brain’s electrical activity

and records that activity

on graph paper. These

electrical impulses arise

from the brain cells of

the cerebral cortex.

At one end are action

potentials in a single

axon or currents within a

single dendrite, and at

the other end is the

activity measured by the

scalp EEG.

Indications:

• Confirm suspicion of

increased

intracranial pressure

caused by

trauma or disease

• Detect cerebral

ischemia during

endarterectomy

• Detect intracranial

(rhythms

varying depending on

the patent’s

age)

• Normal frequency,

amplitude, and

characteristics of brain

waves

• Brain death

• Cerebral infarct

• Encephalitis

• Glioblastoma and

other brain

tumors

• Head injury

• Hypocalcemia or

hypoglycemia

• Intracranial

hemorrhage

• Meningitis

• Migraine headaches

• Narcolepsy

• Seizure disorders

(grand mal,

focal, temporal lobe,

myoclonic,

petit mal)

• Sleep apnea

performed to measure

electrical activity of the

brain.

➧ Review the

procedure with the

patient. Address

concerns about pain

related to the

procedure and assure

the patient there is no

discomfort during the

procedure, but that, if

needle electrodes are

used, a slight pinch

may be felt. Explain

that electricity flows

from the patient’s body,

not into the body,

during the procedure.

Explain that the

procedure reveals brain

activity only, not

thoughts, feelings, or

intelligence. Inform the 87| P a g e

cerebrovascular

lesions, such as

hemorrhages and

infarcts

• Detect seizure

disorders and identify

focus of seizure and

seizure activity,

as evidenced by

abnormal spikes

and waves recorded on

the graph

• Determine the

presence of tumors,

abscesses, or infection

patient the procedure is

performed in a

neurodiagnostic

department, usually by

a HCP and support

staff, and takes

approximately 30 to 60

min.

➧ Inform the patient

that he or she may

be asked to alter

breathing pattern; be

asked to follow simple

commands such

as opening or closing

eyes, blinking, or

swallowing; be

stimulated with bright

light; or be given a drug

to induce sleep

during the study.

➧ Instruct the patient to

clean the hair

and to refrain from 88| P a g e

using hair sprays,

creams, or solutions

before the test.

➧ Instruct the patient to

eat a meal

before the study and to

avoid stimulants

such as caffeine and

nicotine for

8 hr prior to the

procedure.

Intra test

➧ Ensure the patient

has complied with

pretesting preparations.

Ensure that

caffeine-containing

beverages were

withheld for 8 hr before

the procedure,

and that a meal was

ingested before

89| P a g e

the study.

➧ Ensure that the

patient is able to

relax; report any

extreme anxiety or

restlessness.

➧ Ensure that hair is

clean and free of

hair sprays, creams, or

solutions.

➧ Remind the patient

to relax and not to

move any muscles or

parts of the face

or head.

Posttest

➧ When the procedure

is complete,

remove electrodes from

the hair and

remove paste by

cleansing with oil or

90| P a g e

witch hazel.

➧ If a sedative was

given during the test,

allow the patient to

recover. Bedside

rails are put in the

raised position for

safety.

Test Rationale Result Interpretation/

Significance

Nursing Responsibilities

Magnetic Resonance

Imaging (MRI)- Brain

Magnetic resonance

imaging (MRI) uses a

magnet

and radio waves to

produce an

energy field that can be

Normal anatomic

structures, soft

tissue density, blood

flow rate,

face, nasopharynx,

Abnormal findings in:• Abscess

• Acoustic neuroma

• Alzheimer’s disease

• Aneurysm

• Arteriovenous

Pretest

➧ Inform the patient that

the procedure

assesses the brain.

➧ Review the procedure

91| P a g e

displayed

as an image.

Brain MRI can

distinguish

solid, cystic, and

hemorrhagic

components of lesions.

This procedure

is done to aid in the

diagnosis

of intracranial

abnormalities,

including tumors,

ischemia, infection,

and multiple sclerosis,

and

in assessment of brain

maturation

in pediatric patients.

Indications:

• Detect and locate

brain tumors

• Detect cause of

neck, tongue,

and brain

malformation

• Benign meningioma

• Cerebral aneurysm

• Cerebral infarction

• Craniopharyngioma or

meningioma

• Granuloma

• Intraparenchymal

hematoma or

hemorrhage

• Lipoma

• Metastasis

• Multiple sclerosis

• Optic nerve tumor

• Parkinson’s disease

• Pituitary

microadenoma

• Subdural empyema

• Ventriculitis

with the patient.

Address concerns about

pain related

to the procedure and

explain to the patient

that no pain will be

experienced

during the test, but there

may be

moments of discomfort.

Reassure the

patient that if contrast is

used, it poses

no radioactive hazard

and rarely

produces side effects.

Inform the

patient the procedure is

performed in

an MRI department,

usually by a health

care provider (HCP)

who specializes in

this procedures, with 92| P a g e

cerebrovascular

accident, cerebral

infarct, or

hemorrhage

• Detect cranial bone,

face, throat,

and neck soft tissue

lesions

• Evaluate the cause of

seizures, such

as intracranial infection,

edema, or

increased intracranial

pressure

• Evaluate cerebral

changes associated

with dementia

• Evaluate

demyelinating disorders

• Evaluate intracranial

infections

• Evaluate optic and

auditory nerves

support staff, and

takes approximately 30

to 60 min.

➧ Inform the patient that

the technologist

will place him or her in a

supine

position on a flat table in

a large

cylindrical scanner.

➧ Tell the patient to

expect to hear loud

banging from the

scanner and possibly

to see

magnetophosphenes

(flickering

lights in the visual field);

these will stop

when the procedure is

over.

➧ Explain that an IV line

may be inserted

to allow infusion of IV 93| P a g e

fluids, contrast

medium, or sedatives.

➧ Instruct the patient to

remove jewelry

and all other metallic

objects from the

area to be examined

prior to the

procedure.

➧ There are no food,

fluid, or medication

restrictions, unless by

medical direction.

Intratest

➧ Ensure that the

patient has removed all

external metallic objects

from the area

to be examined prior to

the procedure.

➧ Instruct the patient to

void prior to the

procedure and to 94| P a g e

change into the

gown, robe, and foot

coverings

provided.

➧ Instruct the patient to

cooperate

fully and to follow

directions. Instruct

the patient to remain still

throughout

the procedure because

movement produces

unreliable results.

➧ Supply earplugs to

the patient to block

out the loud, banging

sounds that

occur during the test.

Instruct the

patient to communicate

with the

technologist during the

examination

via a microphone within 95| P a g e

the scanner.

➧ Place the patient in

the supine position

on an exam table.

➧ If contrast is used,

imaging can begin

shortly after the

injection.

➧ Ask the patient to

inhale deeply and

hold his or her breathe

while the

images are taken, and

then to exhale

after the images are

taken.

➧ Instruct the patient to

take slow, deep

breaths if nausea

occurs during the

procedure.

➧ Monitor the patient for

complications

related to the procedure 96| P a g e

(e.g., allergic

reaction, anaphylaxis,

bronchospasm)

Posttest

➧ Observe for delayed

allergic reactions,

such as rash, urticaria,

tachycardia,

hyperpnea,

hypertension,

palpitations, nausea, or

vomiting, if contrast

medium

was used.

➧ Instruct the patient to

immediately

report symptoms such

as fast heart

rate, difficulty breathing,

skin rash,

itching, or decreased

urinary output.

97| P a g e

Test Rationale Result Interpretation/

Significance

Nursing Responsibilities

Carotid

Ultrasound

Using the duplex

scanning method,

carotid US

records sound waves

to obtain

information about the

carotid

arteries. The amplitude

and

waveform of the

carotid pulse

are measured,

Normal blood flow

through the

carotid arteries with

no evidence

of occlusion or

narrowing

Abnormal findings in:• Carotid artery

occlusive disease

(atherosclerosis)

• Plaque or stenosis

of carotid artery

• Reduction in

vessel diameter of

more than 16%,

indicating stenosis

Pretest

➧ Review the procedure with the

patient.

Address concerns about pain

related

to the procedure and explain that

some pain may be experienced

during

the test, and there may be

moments of

discomfort. Inform the patient that

98| P a g e

resulting in a

two-dimensional image

of the

artery. Carotid arterial

sites

used for the studies

include

the common carotid,

external

carotid, and internal

carotid.

the

procedure is performed in a US

department by a health care

provider

(HCP) who specializes in this

procedure,

with support staff, and takes

approximately 30 to 60 min.

➧ Instruct the patient to remove

jewelry

and other metallic objects from the

area to be examined.

➧ There are no food, fluid, or

medication

restrictions, unless by medical

direction.

Intratest

➧ Ensure that the patient has

removed all

external metallic objects from the

area

to be examined prior to the

procedure.

➧ Instruct the patient to void and 99| P a g e

change

into the gown, robe, and foot

coverings

provided.

➧ Instruct the patient to cooperate

fully

and to follow directions. Ask the

patient to remain still throughout

the procedure because movement

produces unreliable results.

➧ Place the patient in the supine

position

on an exam table; other positions

may

be used during the examination.

➧ Expose the neck and drape the

patient.

➧ Conductive gel is applied to the

skin

and a Doppler transducer is

moved

over the skin to obtain images of

the

100| P a g e

area of interest.

➧ Ask the patient to breathe

normally

during the examination. If

necessary

for better organ visualization, ask

the

patient to inhale deeply and hold

his

or her breath.

Post test

➧ When the study is completed,

remove

the gel from the skin.

➧ Instruct the patient to continue

with

diet, fluids, and medications, as

directed by the HCP.

➧ Instruct the patient in the use of

any

ordered medications. Explain the

importance of adhering to the

therapy

regimen. As appropriate, instruct 101| P a g e

the

patient in significant side effects

and

systemic reactions associated with

the

prescribed medication. Encourage

him or her to review

corresponding

literature provided by a

pharmacist.

Test Rationale Result Interpretation/

Significance

Nursing Responsibilities

Echocardiography Echocardiography,

a noninvasive

ultrasound (US)

procedure, uses high-

frequency

sound waves of various

intensities

to assist in diagnosing

cardiovascular

• Normal appearance in

the size,

position, structure, and

movements

of the heart valves

visualized and

recorded in a

combination of

ultrasound modes; and

Abnormal findings in:• Aneurysm

• Aortic valve

abnormalities

• Cardiac neoplasm

• Cardiomyopathy

• Congenital heart defect

• Congestive heart

Pretest

➧ Inform the patient that

the procedure assess

cardiac function.

➧ Review the procedure

with the patient.

Address concerns about

pain related to the

procedure and explain 102| P a g e

disorders. The

procedure records the

echoes

created by the deflection

of an

ultrasonic beam off the

cardiac

structures and allows

visualization

of the size, shape,

position,

thickness, and

movement of all

four valves, atria,

ventricular and

atria septa, papillary

muscles,

chordae tendineae, and

ventricles.

This study can also

determine

blood-flow velocity and

direction

and the presence of

normal

heart muscle walls of

both ventricles

and left atrium, with

adequate

blood filling.

failure

• Coronary artery

disease

• Endocarditis

• Mitral valve

abnormalities

• Myxoma

• Pericardial effusion,

tamponade,

and pericarditis

• Pulmonary

hypertension

• Pulmonary valve

abnormalities

• Septal defects

• Ventricular hypertrophy

• Ventricular or atrial

mural thrombi

that there should be no

discomfort during the

procedure. Inform the

patient the

procedure is performed

in an US or

cardiology department,

and takes approximately

30 to

60 min.

➧ Instruct the patient to

remove jewelry, and

other metallic objects

from the area to be

examined.

➧ There are no food or

fluid restrictions, unless

by medical direction.

Intra test

➧ Ensure the patient

has removed all external

metallic objects from the

area to be examined 103| P a g e

pericardial

effusion during the

movement of

the transducer over

areas of the

chest.

Indications:

• Detect ventricular or

atrial mural

thrombi and evaluate

cardiac wall

motion after myocardial

infarction

• Detect subaortic

stenosis as evidenced

either by displacement

of

the anterior atrial leaflet

or by a

reduction in aortic valve

flow,

depending on the

obstruction

prior to the procedure.

➧ Instruct the patient to

cooperate fully and to

follow directions. Instruct

the patient to remain still

throughout the

procedure because

movement produces

unreliable results.

➧ Place the patient in a

supine position on a flat

table with foam wedges

to help maintain position

and immobilization.

➧ Expose the chest,

and attach

electrocardiogram leads

for simultaneous

tracings, if desired.

➧ Apply conductive gel

to the chest.

Place the transducer on

the chest

surface along the left 104| P a g e

• Evaluate ventricular

aneurysms

and/or thrombus

sternal border,

the subxiphoid area,

suprasternal notch, and

supraclavicular areas to

obtain views and

tracings of the portions

of the heart. Scan the

areas

by systematically

moving the probe in a

perpendicular position to

direct the ultrasound

waves to each part of

the heart.

➧ To obtain different

views or information

about heart function,

position the

patient on the left side

and/or sitting up, or

request that the patient

breathe slowly or hold

the breathe during the

procedure. To evaluate 105| P a g e

heart function changes,

the patient may be

asked to inhale amyl

nitrate (vasodilator).

➧ Administer contrast

medium, if ordered. A

second series of images

is obtained.

Post test

➧ When the study is

completed, remove the

gel from the skin.

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Test Rationale Result Interpretation/

Significance

Nursing Responsibilities

Electrocardiogram The electrocardiogram

(ECG), a noninvasive

study, measures the

electrical currents or

impulses that the heart

generates during a

cardiac cycle. The ECG

is a graphic display of

the electrical activity of

the heart, which is

analyzed by time

intervals and segments.

Continuous tracing of

the cardiac cycle

activities is captured as

heart cells are

electrically stimulated,

causing depolarization

• Normal heart rate

according to age:

range of 60 to 100

beats/min in

adults

• Normal, regular rhythm

and wave

deflections with normal

measurement

of ranges of cycle

components

and height, depth, and

duration of complexes

as follows:

P wave: 0.12 sec or 3

small blocks with

amplitude of 2.5 mm

Q wave: less than 0.04

• Arrhythmias.

• Atrial or ventricular

hypertrophy.

• Bundle branch block.

• Electrolyte imbalances.

• MI or ischemia.

• Pericarditis.

• Pulmonary infarction.

• P wave: An enlarged P

wave

deflection could indicate

atrial

enlargement. An absent

or altered

P wave could suggest

that the electrical

impulse did not come

Pretest

➧ Review the procedure

with the patient.

Address concerns about

pain related to the

procedure and explain

that there should be no

discomfort related to the

procedure. Inform the

patient that the

procedure is performed

by a health

care provider (HCP) and

takes approximately 15

min.

➧ Review the procedure

with the patient.

Address concerns about 107| P a g e

and movement of the

activity through the cells

of the myocardium.

Indications:

• Assess the extent of

myocardial infarction

(MI) or ischemia, as

indicated by abnormal

ST segment, interval

times, and amplitudes

• Assess the function of

heart valves

• Monitor rhythm

changes during

the recovery phase after

an MI.

mm

R wave: 5 to 27 mm

amplitude,

depending on lead

T wave: 1 to 13 mm

amplitude,

depending on lead

QRS complex: 0.12 sec

or 3 small blocks

ST segment: 1 mm

from the SA node.

• P-R interval: An

increased interval

could imply a conduction

delay in

the AV node.

• QRS complex: An

enlarged Q wave

may indicate an old

infarction; an

enlarged deflection

could indicate

ventricular hypertrophy.

Increased

time duration may

indicate a bundle

branch block.

• ST segment: A

depressed ST

segment indicates

myocardial

ischemia. An elevated

ST segment

may indicate an acute

pain related to

the procedure and

explain that there should

be no discomfort related

to the procedure. Inform

the patient that the

procedure takes

approximately

15 min.

➧ Instruct the patient to

remove jewelry

and other metallic

objects from the area to

be examined.

➧ No food, fluid, or

medication restrictions

exist, unless by medical

direction.

Intra test

➧ Ensure the patient

has complied with

pretesting preparations.

➧ Ensure the patient 108| P a g e

MI or pericarditis.

A prolonged ST

segment

may indicate

hypocalcemia or

hypokalemia (short

segment).

• T wave: A flat or

inverted T wave

may indicate myocardial

ischemia,

infarction, or

hypokalemia. A tall

T wave may indicate

hyperkalemia.

has removed all

external metallic objects

from the area

to be examined prior to

the procedure.

➧ Instruct the patient to

void prior to the

procedure and to

change into the gown,

robe, and foot coverings

provided.

➧ Instruct the patient to

cooperate

fully and to follow

directions. Instruct

the patient to remain still

throughout

the procedure because

movement

produces unreliable

results.

➧ Record baseline

values.

➧ Place patient in a 109| P a g e

supine position.

Expose and

appropriately drape the

chest, arms, and legs.

➧ Prepare the skin

surface with alcohol

and remove excess hair.

Shaving may

be necessary. Dry skin

sites.

➧ Apply the electrodes

in the proper position.

Post test

➧ When the procedure

is complete,

remove the electrodes

and clean the

skin where the electrode

pads were

applied.

➧ Monitor vital signs

and compare with

110| P a g e

baseline values.

2. Therapeutics

Date Order Rationale

January 24, 2011 Diet as tolerated Diet as tolerated is ordered when the

client’s appetite, ability to eat, and

tolerance for certain foods may change.

PNSSτL @ 80cc/ hour; regulated Intravenous fluid therapy is essential when

client is unable to take foods and fluids

orally prior to a procedure or surgery. This

was ordered to maintain fluids and

electrolytes in the body and base on the

body weight of the patient. Isotonic

Solutions initially remain in the vascular

compartment, expanding vascular volume.

11:10 am- HGT monitoring every 6 hours It is done to monitor blood glucose level.

Monitor VS every 4 hours and record This was ordered to check and monitor the

functions of the body. These signs reflect

changes in function that otherwise might

not be observed.

Monitor NVS every 4 hours This was ordered to know the mental

status, level of consciousness, motor

function and sensory function of the client.

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Deterioration in a client’s level of

consciousness may indicate that

intracranial pressure is increasing. This is

a life threatening condition that requires

immediate intervention because it

depresses respiration.

Monitor Intake and Output every shift This was ordered to provide important

data about the client’s fluid and electrolyte

balance.

11:35 am- Low Salt, Low Fat, Diabetic Diet

1000kcal, Carbohydrates- 200g, Protein-

80g, Fat- 53g

This was ordered to control the total

caloric intake to attain or maintain a

reasonable body weight, control of blood

glucose level, and normalization of lipids

and blood pressure to prevent heart

disease.

2:35pm- HGT every 6 hours with sliding

scale SQ RI

<140 md/dl: none

141- 160 mg/dl: 2 “U”

161- 200 mg/dl: 4 “U”

201- 300 mg/dl: 6 “U”

301- 400 mg/dl: 8 “U”

>400 mg/dl: refer

It is done to monitor blood glucose level.

Indicated for diabetes mellitus and to

evaluate the effectiveness of insulin

administration.

January 25, 2011 8: 25 am- May go to bathroom with To promote good circulation of blood in the 112| P a g e

assistance body, maintain good body alignment and

to prevent further problems such as

weakness and difficulty of walking.

11:00 am- Plan: 1. D/C Sliding scale

2.Decrease HGT every 12 hours

It is done to monitor blood glucose level.

Indicated for diabetes mellitus and to

evaluate the effectiveness of insulin

administration.

Rehabilitation Program

- For PT session this afternoon then

BID

- Kindly secure 5 PT sessions

To develop, maintain and restore

maximum movement and functional ability.

To treat musculoskeletal problems.

January 26, 2011 May have fresh fruits on diet Fruits provide the body with so many

nutrients. These include numerous forms

of vitamins and energy.

1: 40pm- MGH after PT session

- With home medications:

Minidiab 9mg 1 tab OD pre-

breakfast

Neuroaide 4 tabs 3x a day

Aspiring 80mg/ tab 1 tab

OD

Lipitor 40mg 1 tab OD

This to ensure continuity of care and for

better outcome in the treatment

To comply on treatment regimen and

maintenance medications and to prevent

reoccurrence of the disease.

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3. Drug StudiesGeneric : Amlodipine

Brand : Amvaz® , Norvasc® 

Classification : Calcium Channel Blocker

Date Ordered : 1/24/11

Ordered Dose : 10mg/1tab (1 tab, once a day)

Suggested Dose : 2.5mg, 5.0mg, 10mg

Action : Inhibits influx of calcium through the cell membrane, resulting in a

depression of automaticity and conduction velocity in cardiac muscle.

Decreases SA and AV conduction and prolongs AV nod effective and

functional refractory periods.

Indications : Hypertension and Chronic angina

Contraindications : Clients with impaired hepatic function

: Clients with CHF

Side Effects : Edema, palpitations, dizziness, headache, fatigue, muscle

cramps, nasal or Chest congestion, polyuria, dysuria

Drug Interactions :Diltiazem (increase plasma levels of Amlodipine and further decrease

Blood Pressure)

: Grapefruit juice (increase plasma levels of Amlodipine)

Nursing Responsibilities:

Instruct that taking with or without food does not affect the bioavailability of amlodipine.

Patients with hepatic insufficiency may be started on 2.5mg/day.

Can safely be taken with beta-blockers, nitrates, nitroglycerin (sublingual).

Take as directed, once daily.

Report unusualities felt such as (dizziness, chest pain, swelling of extremities, irregular

pulse).

Instruct to ask for generic for cost saving purposes.

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Generic : aspirin (Acetylsalicylic acid)

Brand : Bayer® 

Classification : NSAIDS, antipyretic and analgesic

Date Ordered : 1/24/11

Ordered Dose : 80mg/tab (1 tab, once a day)

Suggested Dose : tablets (325mg), enteric-coated (80mg, 165mg, 325mg, 500mg)

Action : Exhibits antipyretic, anti-inflammatory, and analgesic effects.

: The antipyretic effect is due to an action on the hypothalamus, resulting

in heat loss by vasodilation of peripheral blood vessels.

: The anti-inflammatory effects are probably mediated through inhibition of

cyclo-oxygenase, which results in a decrease in prostaglandin (implicated

in the inflammatory response).

Indications : Analgesic ( pain from integumentary, myalgia, neuralgia,

arthralgia, headache, dysmenorrhea, pain secondary to trauma)

: Reduces risk of death, nonfatal stroke, and recurrent myocardial

infarction.

Contraindications : Hypersensitivity to salicylates

: Clients who have asthma , Hay fever, Nasal polyps

Side Effects :G.I.: Dyspepsia, nausea, epigastric discomfort, heartburn,

anorexia

: Hematologic: Prolongation if bleeding time, thrombocytopenia,

leukopenia, shortened erythrocyte survival time

Drug Interactions : ACE inhibitors (decreases effect of ACE inhibitors)

: Acetazolamide (increases CNS toxicity of salicylates and increases

secretion of salicylic acid in alkaline urine)

: Ethyl Alcohol (increases chance of GI bleeding caused by salicylates)

: Antacids (decreases salicylate levels in plasma due to increased rate of

renal excretion)

: Ammonium Chloride (increases effect of salicylates by increased renal

tubular reabsorption)

Nursing Responsibilities:

Take as directed. To reduce gastric irritation administer with meals and a full glass of

water.

115| P a g e

Instruct to avoid taking antacids within 1 to 2 hours after ingestion of enteric-coated

tablets this is because Sodium Bicarbonate may decrease serum level of aspirin thus

reducing its effectiveness.

Instruct to note expiration date and color of product before taking.

Report toxic effects immediately such as: (hearing, dizziness or unusual increase in

sweating and severe abdominal pain)

Avoid high alcohol ingestion; may cause GI bleeding.

Generic : Atorvastatin Calcium116| P a g e

Brand : Lipitor® 

Classification : Antihyperlipidemic

Date Ordered : 1/24/11

Ordered Dose : 40mg/tab (1 tab at hour of sleep)

Suggested Dose : 10mg, 20mg, 40mg, 80mg

Action : Competitively inhibits HMG-CoA reductase; this enzyme catalyzes

the early rate-limiting step in the synthesis of cholesterol. Thus,

cholesterol synthesis is inhibited/decreased. Decreases cholesterol,

triglycerides, LDL, and increases HDL.

Indications : Hypercholesterolemia, Dyslipidemia, Adjunct to diet to decrease

elevated total LDL cholesterol.

Contraindications : Active liver disease, Pregnancy, Lactation

Side Effects : Headache, asthenia, abdominal pain, cramps

Drug Interactions : Antacids (decrease atorvastatin levels)

: Clarithromycin (increase atorvastatin plasma levels)

: Colestipol (decreases atorvastatin levels)

: Digoxin (increases digoxin levels)

: Erythromycin (increases atorvastatin levels)

Nursing Responsibilities:

Instruct to take as single dose at any time of the day, with or without food.

Determine lipid levels within 2-4 weeks; adjust dosage accordingly

Instruct to continue dietary restrictions of saturated fat and cholesterol.

Encourage to have regular exercise and weight loss in the overall goal of lowering

cholesterol levels.

Report unexplained muscle pain, weakness, or tenderness, especially if accompanied by

fever or malaise.

Generic : citicoline

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Brand : Zynpase® 

Classification : Psychostimulant

Date Ordered : 1/24/11

Ordered Dose : 2gms IVTT q 12 hours

Suggested Dose : Zynapse 500 - 125mg/mL Injection: 1 to 2 injections daily 

: Zynapse 1000 - 250mg/mL Injection: 1 Injection daily

: Dosage may be adjusted based on the seriousness of the disease. It can

be administered intravenously, (3 to 5 minute) injection and in intravenous

drop perfusion (dripping speed 40-60 drops/minute). Zynapse is

compatible with all intravenous isotonic solutions. 

Action : Activates the bio-synthesis of structural phospholipids in the

neuronal membrane. Increases cerebral metabolism and the levels of

various neurotransmitters, including acetylcholine and dopamine.

Restores the activity of mitochondrial ATPase and of membranal

Na+/K+ATPase and inhibits the activation of phospholipase A2 and

accelerates the re-absorption of cerebral edema in various experimental

models.

Indications : Cerebrovascular diseases - e.g. from ischemia due to stroke

: Head Trauma of varying severity

: Cognitive disorders

: Parkinson's disease

Contraindications : Pregnancy, lactating patients, persistent Intracranial Hemorrhage

Side Effects : Hypotensive Effect, sleeplessness

Drug Interactions : L-DOPA (potentiates effects of L-DOPA)

Nursing Responsibilities:

Instruct to take drug during day time.

Monitor Pulse and Blood Pressure before and after giving citicoline.

Generic : Potassium Chloride

Brand : Kalium Durule®118| P a g e

Classification : Electrolyte

Date Ordered : 1/25/11

Ordered Dose : 750mg/1tab (3 times a day)

Suggested Dose : 750mg, 3 to 4 tablets, not exceeding 12 tablets a day.

Action : Replaces potassium loss and maintains potassium level.

Indications : To prevent hypokalemia, Prophylaxis during treatment with

diuretics.

Contraindications : Patients with oliguria, anuria, untreated Addison’s disease, acute

dehydration, heat cramps

: Use cautiously with patient with cardiac disease and renal impairment

Side Effects : Arrhythmias, Heart block, Hypotension, Cardiac arrest,

Hyperkalemia, Respiratory paralysis, Nausea, Vomiting, Abdominal pain

Drug Interactions : Angiotensin converting enzyme (ACE) inhibitors [enalapril (Vasotec)]

: Angiotensin receptor blockers (ARB) drugs [valsartan(Diovan)]

: Spironolactone (Aldactone)

: Triamterene(Dyrenium)]

: NSAIDS

: (Concurrent use with potassium supplements may increase serum

potassium concentrations, which may cause severe hyperkalemia and

lead to cardiac arrest, especially in renal insufficiency).

: (NSAIDs in combination with potassium supplements may increase the

risk of gastrointestinal side effects)

Nursing Responsibilities:

Monitor potassium levels

Instruct to take with food to avoid GI irritation.

Instruct to report any unusualities felt such as difficulty of breathing, abdominal pain and

dizziness.

Check blood pressure before and after giving of potassium chloride.

Instruct to increase oral fluid intake.

Monitor pulse, blood pressure and ECG periodically during IV therapy.

Monitor serum potassium levels before and after therapy.

Generic : Glipizide

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Brand : MINIDIAB®

Classification : Sulfonylurea hypoglycaemic agent

Date Ordered : 1/25/11

Ordered Dose : 5mg/1tab (once a day, before meals)

Suggested Dose : starting dose (5mg), for geriatric patients with live disease (2.5mg)

Action : Lowers down blood glucose acutely by stimulating the release of

insulin from the pancreas, an effect dependent upon functioning beta cells

in the pancreatic islets.

Indications : For control of hyperglycaemia and treatment for non-insulin

dependent diabetes

Contraindications : Hypersensitivity to MINIDIAB or other sulphonylurea derivatives

: Patients with diabetic ketoacidosis, with or without coma (this condition

must be treated with insulin)

: Severe renal and hepatic insufficiency

: Pregnancy

Side Effects : Hypoglycaemia, Nausea, Abdominal Pain, Allergic reaction (skin

rash), Dizziness, Drowsiness, Blurred Vision

Drug Interactions : Fluconazole (increase chance of hypoglycaemia and increase half-life of

glipizide)

: Alcohol (increases hypoglycaemic effect of MINIDIAB which can lead to

hypoglycaemic coma)

: ACE inhibitors ( may lead to increased hypoglycaemic effect in diabetic

patients treated with MINIDIAB)

: H2 Receptor Antagonists(i.e. cimetidine) (may potentiate

hypoglycaemic effects of sulphonylureas including MINIDIAB

Nursing Responsibilities:

Instruct to take blood glucose level before and after giving of hypoglycaemic drug.

Enquire for any history of hypersensitivity to sulphonylurea derivative drugs.

Instruct to take during meal time.

Intruct to take drug as ordered specifically the dosage prescribed and the frequency.

Watch out for unusualities such as allergic reaction and signs of hypoglycaemia

such as (drowsiness, blurred vision and weakness)

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Generic : MLC 601

Brand : NeuroAid

Classification : Neuroprotective Agent

Ordered Dose : 3 capsules (3 times a day)

Suggested Dose : 3 capsules daily for 3 months.

Action : Potential role in neuroplasticity and neurogenesis. Stimulates the

secretion of BDNF and makes cells more resistant against glutamate

aggression. Increases neurite outgrowth and connectivity as well as

reduces the infarct volume which results in better neurological function.

Indications : Cerebral Stroke

: Heart Stroke

: Neurodegenerative diseases

: Brain Trauma

: Nervous System trauma

: Stroke disabilities such as: hemi paralysis or aphasia

Contraindications : No known contraindications

Side Effects : Nausea, Vomiting, Mild Headache, Thirst

Drug Interactions : No known drug interactions

Nursing Responsibilities:

Instruct to increase oral fluid intake.

Instruct to take analgesics as ordered to relieve headache.

Provide snacks of preferred bland food when available.

Encourage slow deep breathing to promote relaxation to avoid nausea.

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2. Discharge Plan

RATIONALE

MEDICATIONS

Advice patient to take medications at

home on time and as prescribed by the

physician.

Instruct patient and watcher not to

crush tablets and not to skip

medications.

Discuss with the patient and watcher

the name of the drug, its side effects,

its use and guidelines on when to

contact physician.

Instruct patient not to take any

medicines that are contraindicated to

the prescribed drugs.

Warn not to change brands of a drug

without consulting the doctor first.

Instruct patient not to stop taking the

prescribed drugs without notifying their

® Alterations in doses or timing may alter the

effect of the drug. Strict compliance to

medication facilitates relief of any signs and

symptoms or even faster recovery from the

illness or disease.

® Crush tablets have a strong, persistent bitter

taste. Skipping medications can alter the effect

of the drug and may build up to the

vulnerability of the microorganisms to the

drugs.

® This gives patient enough knowledge about

the drugs and to know what to expect and to

encourage compliance to it.

® Some drugs may have synergistic or

additive effect to certain drugs.

® They must also be well educated about the

proper time to take the medications since each

medication has prescribed time depending on

its possible side effects and pharmacokinetics.

® The amount of medicine that a person takes

depends on the strength of the medicine.

144| P a g e

health care provider.

Exercise

Instruct patient to have an adequate

rest and sleep.

Instruct patient to do range of motion if

tolerated such as stretching of

extremities.

Advise patient to consult a physical

therapist to determined appropriate

exercise plan.

Advise patient to join occupational

therapy.

® This lessens the strain to the body and to

allow relaxation.

® This helps loosen the joint structures,

promote wellness and improve

circulation. It would prevent aggravation and

exhaustion of the

muscles and joints.

® To involve re-learning functions as

transferring, walking and other gross motor

functions.

® Focuses on exercises and training to help

relearn everyday activities known as the

Activities of daily living (ADLs) such as eating,

drinking, dressing, bathing, cooking, reading

and writing, and toileting.

Treatment

Stress the importance of follow-up

examinations and treatment because of

changing physical status.

Stress also the importance of stroke

rehabilitation

® Allows adjustments of therapies or

medications appropriate for the current health

status of the client to minimize fatal side

effects of the medications, in cases there

maybe.

® To help them return to normal life as much

as possible by regaining and relearning the

skills of everyday living. It also aims to help

the survivor understand and adapt to

difficulties, prevent secondary complications

and educate family members to play a

supporting role.

145| P a g e

Hygiene

Instruct patient to take a bath daily.

Avoid using any product that has an

alcohol.

Encourage patient to do activities of

daily living

® This is one way to help in maintaining skin

care.

® This is to prevent dry skin that may cause

impairment of the skin integrity

® To promote good health. It also increases

the sense of wellness, which is very much

needed in the therapeutic process.

Out patient

Advise patient that to consult her

health care providers immediately if

there are any complications arising.

Advise patient to have a regular check

up with their health care provider.

Advise patient and significant others to

carry out follow up diagnostic regimen

® Immediate action helps in the client’s

improvement.

®This will help in the prevention of recurrence

and it allows monitoring of the client’s health

status.

® To evaluate worsening condition of the

client that needs medical attention.

Diet

Encourage patient to eat low salt and

low fat foods

Instructed patient to avoid sweet foods

Encourage patient to eat nutritious

foods such as fruits and green leafy

vegetables

® This may contribute to increasing risk of

having stroke and hypertension

®This may contribute to the viscosity of the

blood that may cause complications.

® This is to maintain a balance diet and to

prevent complications that may occur.

146| P a g e

The prognosis following a stroke is related to the severity of the stroke and how much of

the brain has been damaged. Some patients return to a near-normal condition with minimal

awkwardness or speech defects. Many stroke patients are left with permanent problems such

as hemiplegia (weakness on one side of the body), aphasia (difficulty or the inability to speak),

or incontinence of the bowel and/or bladder. A significant number of persons become

unconscious and die following a major stroke.

Disability affects 75% of stroke survivors enough to decrease their employability. Stroke

can affect patients physically, mentally, emotionally, or a combination of the three. The results of

stroke vary widely depending on size and location of the lesion. Dysfunctions correspond to

areas in the brain that have been damaged.

30 to 50% of stroke survivors suffer post stroke depression, which is characterized by

lethargy, irritability, sleep disturbances, lowered self esteem, and withdrawal. Depression can

reduce motivation and worsen outcome, but can be treated with antidepressants.

Emotional lability, another consequence of stroke, causes the patient to switch quickly

between emotional highs and lows and to express emotions inappropriately, for instance with an

excess of laughing or crying with little or no provocation. While these expressions of emotion

usually correspond to the patient's actual emotions, a more severe form of emotional lability

causes patients to laugh and cry pathologically, without regard to context or emotion. Some

patients show the opposite of what they feel, for example crying when they are happy.

Emotional lability occurs in about 20% of stroke patients.

Cognitive deficits resulting from stroke include perceptual disorders, speech problems,

dementia, and problems with attention and memory. A stroke sufferer may be unaware of his or

her own disabilities, a condition called anosognosia. In a condition called hemispatial neglect, a

patient is unable to attend to anything on the side of space opposite to the damaged

hemisphere. Up to 10% of all stroke patients develop seizures, most commonly in the week

subsequent to the event; the severity of the stroke increases the likelihood of a seizure.

So as to our patient’s condition, she was last admitted at the hospital due to right sided

weakness, couldn’t talk clearly and her face was quite deformed where it was then the start of

her Cerebrovascular accident. She underwent some treatments but unfortunately due to some

147| P a g e

reasons it happened that she had an attacked again. That is why she was prompted again to

seek medical treatment at the hospital because of her condition that it happened to become

severe and as of now she’s undergoing treatment to at least lessen or minimize attacks of her

situation. Overall, our patient’s condition is poor since it will be a lifetime state of her and

because of the severity of her condition. She has now complications that arise where the only

treatment is to maintain a good health of her to continue living life normally.

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BibliographyBurke,K., LeMone,P., Eby,L.(2007). Medical Surgical Nurisng Care. (2nd ed.).Upper

Saddle River, New Jersey: Pearson Education.

DiGuilio,M., Jackson,D.(2007).Medical-Surgical Nursing Demystified.United States of

America: McGraw-Hill Companies.

Doenges, M.E. , Moorhouse, M.F. and Murr, A.C. (2008). Nursing Care Plans (7th ed).

Philadephia: F.A. Davis Company.

Gulanick, M. and Myers, J.L. (2007). Nursing Care Plans. (6th edition). Singapore:

Elsevier, Mosby, Inc.

Karch, A. (2009). Lippincott’s Nursing Drug Guide. New York: Lippincott Williams and Wilkins.

Kozier, B., Erb, G., Berman, A. et al. (2008). Kozier and Erb’s Fundamentals of Nursing. (8 th ed).

Singapore: Pearson Education South Asia Pte Ltd.

Marieb, E.. (2006). Essentials of Human Anatomy and Physiology. ( 8th edition). San Fransisco,

California: Pearson Education.

MIMS Annual (113th ed.). (2007). Manila: CMP Medica.

Osborn, K., Watson, A., Wraa, C. (2010). Medical – Surgical Nursing: Preparation for

Practice. Upper Saddle River, New Jersey: Pearson Education, Inc.

Porth, C., Matfin, G. (2009). Pathophysiology: Concepts of altered Health States. (8th ed.).

China: Lippincott Williams and Wilkins.

Smeltzer, S., Bare, B., Hinkle, J., Cheever, K. (2010). Brunner & Suddarth’s Textbook of

Medical- Surgical Nursing (12th Ed.). Philadelphia: Lippincott Williams & Wilkins.

Timbu,B., Smith,N.(2010).Introductory Medical Surgical Nursing.(10th

ed.).China:Wolters Kluwer Health/Lippincott Williams & Wilkins.

Van Leeuwen, A.M. and Poelhuis- Leth, D.J. (2009). Davis’s Comprehensive Handbook

of Laboratory and Diagnostic Tests with Nursing Implications. (3rd edition).

Philadephia: F.A. Davis Company.

Weber, Janet. (2008). Nurse's Handbook of Health Assessment. (6th ed). Philadephia: Lippincott

Williams & Wilkins.

William, L. (2007). Medical Surgical Nursing. (3rd edition). F.A Davis Company

Philadelphia.

Webliographyhttp://en.wikipedia.org/wiki/Stroke

149| P a g e

http://nurseslabs.com/nursing-care-plan/cerebrovascular-accident-nursing-care-plans/

http://sickle.bwh.harvard.edu/stroke.html

http://www.accessmylibrary.com/article-1G1-114168257/aphasia-alexia-and

oral.html

http://www.asha.org/public/speech/disorders/dysarthria.htm

http://www.ehow.com/facts_6179253_short-memory-loss-due-stroke.html

http://www.ehow.com/how-does_4926641_how-hypertension-causes-strokes.html

http://www.health.com/health/condition-article/0,,20229159,00.html

http://www.healthline.com/galecontent/cerebral-circulation

http://www.medicinenet.com/stroke/page7.htm

http://www.medterms.com/script/main/art.asp?articlekey=2676

http://www.slideshare.net/kjedz/schematic-pathophysiology-cva

http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=48

150| P a g e