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I. INTRODUCTIONThe nervoussystem is an organ system containing a networkofspecialized

cells called neuronsthat coordinate the actions of an animal and transmit

signals between differentpartsof its body. In most animals the nervous system

consists of two parts, central and peripheral. The central nervous

systemofvertebrates (such as humans) contains the brain,spinal cord,

andretina.Theperipheral nervoussystem consistsofsensory neurons, clustersof

neurons calledganglia, and nerves connectingthemtoeachotherandtothe

central nervous system. These regions are all interconnected by means of

complex neural pathways. Theenteric nervous system, a subsystem of the

peripheral nervoussystem,hasthe capacity,even when severed fromthe rest

of the nervous system through itsprimary connection by the vagus erve, to

function independently in controlling thegastrointestinal system. (Accessed at:

http://www.merck.com/mmhe/sec06/ch086/ch086a.html on August 12, 2010)

The autonomic nervoussystemregulates certain bodyprocesses,such as

blood pressure and the rate of breathing. This system works automatically

(autonomously), without a person's conscious effort. The autonomic nervous

systemhastwomain divisions:thesympathetic andtheparasympathetic. After

the autonomic nervous system receives information about the body and

external environment, itresponds bystimulating bodyprocesses,usuallythrough

thesympathetic division,or inhibitingthem,usuallythroughtheparasympathetic

division.(Giraldo, Elias A., 2007)

An autonomic nervepathway involvestwo nerve cells.One cell is located

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bothsidesof it.Theganglia fortheparasympathetic division are located nearor

in the internal organs.(Giraldo, Elias A., 2007)

Generally, the sympathetic division prepares the body for stressful or

emergencysituationsfightor flight.Thus, it increasesheart rate andthe force

ofheart contractions andwidens (dilates)the airwaystomake breathingeasier.

It causesthe bodytoreleasestoredenergy. Muscularstrength is increased.This

division also causespalmstosweat,pupilstodilate, andhairtostandon end.It

slows bodyprocesses that are less important in emergencies,such asdigestion

andurination.

The parasympathetic division controls body process during ordinary

situations. Generally, it conserves and restores. It slows the heart rate and

decreases bloodpressure.Itstimulatesthegastrointestinal tracttoprocessfood

and eliminatewaste. Energy from theprocessed food is used to restore and

buildtissues.

Two chemical messengers (neurotransmitters), acetylcholine and

norepinephrine, are used to communicate within the autonomic nervous

system. Nerve fibers that secrete acetylcholine are called cholinergic fibers.

Fibers that secrete norepinephrine are called adrenergic fibers. Generally,

acetylcholinehasparasympathetic (inhibiting)effects and norepinephrinehas

sympathetic (stimulating)effects. However, acetylcholinehassomesympathetic

effects. Forexample, it sometimes stimulates sweatingormakes thehair stand

on end.(Giraldo, Elias A., 2007)

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basal ganglia and anterior limb ofthe internal capsule.Thevertebral and basilar

arteriessupplythe brain stem, cerebellum,posteriorcerebral cortex, andmedialtemporal lobe.Theposteriorcerebral arteries bifurcatefromthe basilararteryto

supply themedial temporal (including thehippocampus) andoccipital lobes,

thalamus, andmammillary andgeniculate bodies. The anterior andposterior

circulations communicate in the circleof Williswhich is atthe baseofthe brain.

(Accessed at: http://www.merck.com/mmhe/sec06/ch086/ch086a.html onAugust 12, 2010)

When an artery that carries blood to the brain becomes clogged or

blocked, an ischemic stroke can occur. Arteries may be blocked by fatty

deposits (atheromas, or plaques) due to atherosclerosis. Arteries in the neck,

particularly the internal carotid arteries, are a common site for atheromas.

Arteriesmay also be blocked by a blood clot (thrombus). Blood clotsmayform

on an atheroma in an artery.Clotsmay alsoform in theheartofpeoplewith a

heartdisorder. Partof a clotmay breakoff andtravel throughthe bloodstream

(becoming an embolus). Itmaythen blockan arterythatsupplies bloodtothebrain,such asoneofthe cerebral arteries. (Giraldo, Elias A., 2007)

Cerebrovascular accident (CVA) is the medical term for what are

commonlytermed asCVA, brain attack, cerebral infarction orstroke. Itrefersto

the acute neurological injury to the brain that occurswhen flow of blood to

brain tissue is interrupted by a cloggedor ruptured artery.The brain requires a

steadysupplyofoxygen in ordertopump bloodeffectively to all ofthe body.

Oxygen is supplied to the brain in the blood that flows through arteries. Total

ti f bl d fl d i ibl b i i f ti ithi 3 i t

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because of lack of nutrients andoxygen. (Lippincott Williams & Wilkins, 2003,

HandbookofDiseases)

CVA orStrokes can be classified intotwomajorcategories: ischemic and

hemorrhagic. Ischemic strokes arethosethat are caused by interruption ofthe

bloodsupply,whilehemorrhagic strokes are theoneswhich result from rupture

of a bloodvessel oran abnormal vascularstructure. 87% ofstrokes are caused

by ischemia and the remainder byhemorrhage. Somehemorrhagesdevelop

inside areasof ischemia ("hemorrhagic transformation").It isunknown howmany

hemorrhages actuallystartoff as ischemic stroke. Strokesymptoms lasting < 1 h

are termed a transient ischemic attack (TIA). Strokesdamage brain tissue; TIAs

often do not, andwhen damageoccurs, it is lessextensive than thatdue to

strokes. (Accessed on: http://www.eurekalert.org/pub_releases/2008-03/arrs-

wbm032808.php at August 2, 2010)

Risk factors for a cerebrovascularaccident includehavinghypertension,

heartdisease,diabetes,high cholesterol andobesity.Other risk factors include

beingof African-American ancestry, beingmale,drinkingexcessive amountsof

alcohol,smoking andhaving a familyhistoryofheartdiseaseorcerebrovascular

accident. Having a brain aneurysm puts a person at an extreme risk for a

hemorrhagic cerebrovascular accident. (Accessed

on:http://www.wrongdiagnosis.com/s/stroke/12153454636=xy.090970952075 at

July 29, 2010)

Another common cause of ischemic strokes is a lacunar infarction. In

lacunar infarction,oneofthesmall arteriesdeep in the brain becomes blocked

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partofthe brain isdamaged in lacunar infarction. (Lippincott Williams & Wilkins,

2003, HandbookofDiseases)

Rarely,small piecesoffatfromthemarrowof a broken long bone,such as

a leg bone, are released into the bloodstream. These pieces can clump

together and block an artery. The resulting disorder, called fat embolism

syndrome,mayresemble a stroke.

The incidenceofstroke increasesexponentiallyfrom 30 yearsof age, and

etiologyvaries by age. Advanced age isoneof themost significant stroke risk

factors. 95% of strokes occur in people age 45 and older, and two-thirds of

strokesoccur in thoseover the ageof 65. A person's riskofdying ifheor she

doeshave a stroke also increaseswith age. However,stroke can occurat any

age, including in fetuses. Mens stroke incidence rates are 1.25 timesgreater

thanwomens.Thedifference in incidencerates betweenthesexes issomewhat

higher at younger ages but nonexistent at older ages. The male/female

incidencewas 1.59 forages 6569;1.46 forages 7074; 1.35 forages 7579 and

0.74forage 80 andolder. (Barnett, H. J. M.; Mohr, J. P.; Stein, B.; and Yatsu, F. M.,

eds. (1998). Stroke: Pathophysiology, Diagnosis & Management. Philadelphia,

PA:Churchill-Livingstone.)

Hypertension accounts for 35-50% of stroke risk. Epidemiological studies

suggestthateven a small bloodpressurereduction (5 to 6 mmHgsystolic, 2 to 3

mmHgdiastolic)wouldresult in 40% fewerstrokes. Lowering bloodpressurehas

been conclusivelyshown toprevent both ischemic andhemorrhagic strokes.It is

equally important in secondary prevention. Even patients older than 80 years

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protection againstother formsof cardiovasculardiseaseshould be considered

and cost. (US Census Bureau,International Data Base, 2004)

An ischemic stroke can also result from any disorder that reduces the

amountof bloodoroxygen supplied to the brain,such assevere blood lossor

very low bloodpressure.Occasionally, an ischemic strokeoccurswhen blood

flow to the brain is normal but the blood does not contain enough oxygen.

Disordersthatreducetheoxygen contentof blood include a severedeficiency

of red blood cells (anemia), suffocation, and carbon monoxide poisoning.

Usually, brain damage in such cases iswidespread (diffuse), and coma results.

(Lippincott Williams & Wilkins, 2003, HandbookofDiseases)

An ischemic stroke can occur if inflammation of bloodvessels (vasculitis)

or infection (such asherpessimplex) narrows bloodvesselsthatsupplythe brain.

Migraineheadachesordrugssuch as cocaine and amphetamines can cause

spasmof the arteries,which can narrow the arteries supplying the brain and

cause a stroke. (Lippincott Williams & Wilkins, 2003, HandbookofDiseases)

ThegroupfoundCerebrovascularAccident as an interesting caseforthe

casestudy.Utilizingthe availableresources atthe library aswell asthe internet

toprovide accurate information about the saiddisease.Thegroup also chose

this case so thatexpand the familiarity andunderstanding thatwill also beof

assistance in thefuture.

A. ObjectivesAfter the completion of the study the student nurses shall be able to:

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y Enumeratethedifferentsigns andsymptomsofCerebrovascularaccidenty List down the different diagnostic procedures that would help in the

diagnosisofCerebrovascularaccident.

y Identify andunderstanddifferent typesofmedical treatment necessaryforthetreatmentofCerebrovascularaccident.

y Formulate nursing careplansutilizingthe nursingprocessy Formulate conclusions based on the findings and enumerated a

recommendations concerningCerebrovascularaccident.

Nurse Centered Objectives:

Attheendofthestudy,thestudent nurses:

y Shall have critical thinkingskills necessaryforprovidingsafe andeffectivenursing care.

y Shall have a comprehensive assessment and implement care baseon ourknowledge andskillsofthe condition

y Shall havefamiliarizeduswitheffective inter-personal skillstoemphasizedhealthpromotion and illnessprevention.

y Shall have impartedthe learningexperiencefromdirectpatient care.

Patient Centered Objectives:

Attheendofthisstudy,thepatient/familywill be ableto:

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3. Increase awarenesson theriskfactorsofCerebrovascularaccident.4. Developthefamilyssupportsystem anddistinguishtheirrespectiveroles

in improvingpatientshealthstatus.

5. Involvethem in promotingthehealth careofthepatient.

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II. NURSINGASSESSMENT

A. Personal HistoryTatay Stroke, isthefatherofseven children withhisfirstmarriage and

threestep-children fromhisfirstwife. He isthesecondeldest amongseven

children. He is currently living with his secondwife whom is his primary

caregiver. Hewas a overseasworker for 25 years at Saudi Arabia as a

Engineeringforan air-conditioning companyto be abletosupporthiswife

and children.

After all of his children graduated, he stopped working and

receiving support from his children who are currently overseas, three ofwhich areworking as nurses.Otherthatthesupporthe isreceivingfromhis

children,he also receivesmoney fromhispension whichhe andhiswife

are consumingfortheirexpenses like in hishospitalization.

A collegegraduate,hemethis firstwife at a churchwhilehearing

mass.Theyeloped aftergetting a stable job at a softdrinks company to

be abletosupporttheirfamily.Duringthetimethathewasmarriedwithhis

firstwifehewasworkingoverseas andwould comehome backonceor

twice a yeartoseehisfamily.Oncehestoppedworking and camehome

tothe countryhe andhisfirstwifehaveseparated andgot annulled.Thenhemethissecondwife,whowas a common friendofhim andoneofhis

friends, aftermeeting andgettingtoknoweachother,hemarriedherwho

he is livingwith now andtheonewho istaking careofhim. Hehas been a

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headaches, nape pain and dizziness. His blood pressurewasmonitored

andfinal diagnosedwith Hypertension.

B. Pertinent family history

Sister

(63y/o)

Brother

59(y/o)

Brother

72(y/0)

Brother

69(y/o)

Sister

66(y/o)

Brother

(78y/o)Tatay stroke

(75y/o)

Father

Mother

Grandfather

Grandmother

Grandfather

Grandmother

Male Female MarriedLegend:

HypertensionNo Known DeceasedDiabetes

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Tataystroke comesfrom a bigfamily. He isthesecondeldest amongthe

seven children. Four of them are males while two are females. Both his

grandfather in hisfatherandmotherssidedied becauseof Hypertension. While

one of her grandmother died due to Diabetes Mellitus and the other one

becauseofold age. His father suffered from asthma andunfortunately, ituntil

hegotdiagnosedwith Bronchitis anddied. Hismotherwas a smoker,with a lot

of vices such as excessive alcohol intake that brought up her condition andreason forherdeath. Therewere noother familymemberswho suffered from

CVA.

C.History of

Past i

llness

Thepatienthad noprevious hospital confinement. Though hiswife said

that, Tatay Stroke suffers from productive cough and colds whenever cold

weathersets in,medicinesforcommon cough and colds aregiven and if itwas

accompanied by fever, she would give him antipyretics. She assumed that

maybe, concurrent coughepisode is caused byherhusbandsdeadlypractice,

which is smoking. During his childhood days, Tatay stroke, have experienced

having Measles,Chicken Pox, Mumps andTonsillitis.

D. History of Present illnessTatay Stroke suffers from headache, right body weakness and has

difficulty in speaking brought about mainly by his current diagnosis which is

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Tatay Stroketo comewithherto local hospital nearbywherehewas admitted

with a chief complaintofrightsided bodyweakness.

CranialNerve

Type

andFunction

Assessm

entTechnique Normal

Response Clients Response

I.Olfactory Type:

Sensory

Function:

Senseof

smell

Ask the client to

smell and identify

the smell of

garlic/coffee

with each nostril

separately and

with the eyes

closed.

Client is able

to identify

different

smell with

each nostril

separately

and with

eyes closed

unless such

conditionlike colds is

present.

Tatay Stroke was

ableto identifythe

different scents

(garlic and coffee)

that he had

smelled.

II.Optic Type:

Sensory

The client is

instructed to

cover an eye

The client

should spot

the moving

Tatay Stroke was

able to spot the

moving object in

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clients nose). An

object is move

intovisual fields in

the periphery.

The client is

informed to tell

the examiner

when themoving

object isspotted.

III.Oculomotor Motor

Pupil

constriction,

movement

of eye up

anddown

Reaction to light:

Using a penlightand

approaching

from the side,

shine a light on

the pupil.

Observe theresponse of the

illuminated pupil.

Shine the lighton

the pupil again,

and observe the

response of the

otherpupil.

Reaction to

Illuminated

and non-

illuminated

pupil should

constrict.

Pupils

constrict

when

The illuminated

and non-

illuminatedpupil of

Tatay Stroke

constricted.

Tatay Strokepupils

constricted when

asked to look at a

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Alternate the

gaze from the

near to the far

object. Next,

move an object

towards the

clients nose.

object,

converge

when near

object is

moved

towards the

nose.

the nose, the iris

converged.

IV.Trochlear Motor

Downward,superior

and inferior

oblique,

lateral

Hold a penlight 1

ft. in front of the

clients eyes. Ask

the client to

follow the

movements of

the penlightwith

the eyes only.

Move the

penlight upward,

downward,sideward and

diagonally.

Clients eyes

should be

able to

follow the

penlight as it

moves.

BotheyesofTatay

Stroke are able to

move as

necessary.

V.Trigeminal Motor The patient is

asked to swallow

as being

observed by the

examiner

Client should

be able to

movehis jaw

and swallow

without

There is the

affectation of his

jaw movement

and has difficulty

in mastication

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Lateral

movementofeyes

clients eyes. Ask

the client to

follow the

movements of

the penlightwith

the eyes only.

Move the

penlight through

the six cardinalfieldsofgaze.

move in

unison with

parallel

alignment.

coordination.

VII. Facial Motorand

Sensory

Movement

of muscles

of the

faces.

Ask client to

smile, raise the

eyebrows, frown,

and puff out

cheeks, close

eyestightly.

Client should

be able to

smile, raise

eyebrows,

andpuffout

cheeks and

close eyes

without anydifficulty.

Tatay Stroke

wasnt able to

raise eyebrows,

and puff out his

cheek at the left

sideoftheface.

VIII.

Vestibulocochlear

Sensory

andmotor

Sense of

hearing

Have the client

occludeoneear.

Outofthe clients

sight, place a

tickling watch 2

to 3 cm. askwhat

the client can

hear and repeat

Client should

be able to

hear the

tickling of

thewatch in

bothears.

Tatay Stroke was

able to hear

tickling in both

ears.

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Glossopharyngeal andmotor

Sense oftasteon the

posterior

1/3 of the

tongue

Gagreflex

say ah and

have the patient

yawn to observe

upward

movementofthe

softpalate.

Elicit gag

response.

Note ability to

swallow.

be able to

elicit gag

reflex and

swallow

without any

difficulty.

able to elicit gag

reflex and able to

swallow with

difficulty.

X.Vagus Motor

Swallowing

and

speaking

and gag

reflex

Askthepatienttoswallow and

speak (note

hoarseness)

The clientshould be

able to

swallow

without

difficulty and

speak

audibly.

Tatay Stroke wasable to swallow

with difficulty and

has slurred

speech..

XI. Accessory Motor

Movement

of shoulder

muscle

Ask client to

shrug shoulders

against

resistance from

your hands and

turn head to side

against

i t f

Client should

be able to

shrug

shoulders

and turn

head from

sidetoside.

Tatay Stroke was

able to shrugonly

his left shoulders

and turn his head

fromoneside.

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XII. Hypoglossal Motor

Movement

oftongue.

Ask client toprotrude tongue

at midline and

then move itside

toside.

The clientshould be

able to

move

tongue

without any

difficulty.

Tatay Stroke hasrestricted

movement of the

tongue.

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Page | 17

DIAGNOSTIC AND LABORATORYPROCEDURES

DIAGNOSTIC OR

LABORATORY

PROCEDURES

DATE

OREDERED

DATE

RESULTSIN

INDICATIONS OR

PURPOSESRESULTS

NORMAL

VALUES

ANALYSIS AND

INTERPRETATION

COMPLETEBLOOD

COUNT (CBC) OR

HEMATOLOGY

> consistsofseveral

teststhat allowforthe

evaluation ofdifferent

cellularcomponentsof

the bloodon a broad

rangeof clients.The

items commonlyevaluated includehgb,

hct,RBC,RBC indices,

WBC, WBCdifferential,

platelets and

microscopic

examination ofstained

D.O:

7/22/10

D.R:

7/22/10

HEMOGLOBIN (HGB)

-tomonitorHgb

value in theRBC

-Iron status and

oxygen carrying

capacityoftheRBCs.

-tosuggestthe

presenceof body

fluiddeficitdueto

elevated Hgb level.

150g/dL

120-170g/dL

Thepatients Hgb is in

the normal rangewhich

meansthatthere is no

presenceof anemia and

there is adequate

oxygenation.There is

sufficientoxygen carried

bythe blood.

RBC COUNT

-itmeasuresthe

numberofRBCto

5.25 x 10 4.0-5.0 x 10 ThepatientsRBC count

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Page | 18

bloodsmears.

WBC DIFFERENTIAL

COUNT

determinesthe

percentageofeach

kindsofwhite blood

cells in thewhite blood

cell count

detecttheoxygen

carrying capacitythe

cells.

-itusedto assess

further ifthepatient

hadepisodesof

bleeding

ismoderatelyelevated

whichmeanspresence

of inflammation.

HEMATOCRIT (HCT)

- to aiddiagnosisof

abnormal statesof

hydration,

polycythemia and

anemia.

-Itmeasuresthe

concentration ofRBC

within the blood

volume and is

expressed as a

percentage.

0.45 % 0.37-0.54 %

Thepatients Hct count is

within the normal range

whichmeansthatthe

percentageofRBC in

blood iswithin the

normal range indicatingabsenceof conditions

which contributesto

hemoconcentration and

hemodilution of blood.

WBC COUNT

-todetect infection

8.2 x 10

g/L

5-10 x

10g/LThe WBC count iswithin

the normal range. WBCs

are cellsofthe immune

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Page | 19

or inflammation

-this bloodtestevaluatesthe

numberof condition

anddifferentiates

causesof alteration

in thetotal WBC

count including

inflammation,

infection andtissue

necrosis.

system involved in

defendingthe body

against both infectiousdisease andforeign

materials.

The bodyhasthe

adequate abilityto

defendthe body against

invadingmicroorganism

whichmeansthatthe

patients immune

defensespatients body.

LYMPHOCYTES

-todetermineviral

infection

-produces antibodies

andotherchemicals

responsiblefor

destroying

microorganisms;

contributesto allergic

reactions,graft

rejection,tumor

0.27 % 0.20-0.40 %

Thevalue iswithin the

normal rangewhich

meansthatthere is an

absenceofviral

infections.The bodyhas

the abilityproduce

antibodies andotherchemicalsresponsiblefor

destroying

microorganisms.

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Page | 20

control, and

regulation ofthe

immunesystem.

SEGMENTERS

-aremature

neutrophilswhich act

asphagocytes and

defendthe body and

if levels areelevated

it indicates

inflammation.

0.73 % 0.50-0.70 %

Segmenters areelevated

indicatingexistenceof

inflammation.

PLATELETS

-arespecial cell

fragmentsthatplay

an importantrole in

blood clotting.If a

patientdoes not

haveenoughplatelets,hewill be at

an increasedriskof

excessive bleeding

and bruising.

-theCBCmeasures

450 x

10/L

150 400 x

10/L

Platelets areelevated in

which causes

aggregation of clotting

andthrombusformation.

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Page | 21

NURSINGRESPONSIBILITIES:

Prior

1. Explain theproceduretothepatientssignificantother.2. Explain tothepatientthatthistestwill help in thepatientsresponsetotreatment.3. Tell thepatientssignificantotherthat nofasting isrequired.4. Explain tothepatientthatthetestrequires bloodsample andvenipuncturewill beperformed.5. Informthepatientthatthepatientwill experiencediscomfortfromthe needlepuncture andpressureof

thetourniquet.

6. Informthatshewill beexperiencingmildpain on sitewherethe needlewaspricked.7. Assurethat collectingthe bloodsampletake lessthan 3 minutes.

During:1. Maintain steriletechnique.2. Collect 5-7 ml ofvenous blood in a vacum.

andsizeofplatelets

present.

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Page | 22

After:1. Applypressureorpressuredressingtothevenipuncturesite.2. Checkthevenipuncturesiteforbleeding.3. Fill-upthe laboratoryformproperly andsend ittothe laboratorytechnician duringthe collection ofthe

sampleofthespecimen.

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Page | 23

DIAGNOSTIC

OR

LABORATORY

PROCEDURES

DATE

OREDERED

DATERESULTS

IN

INDICATIONS

ORPURPOSES RESULTS NORMAL VALUESANALYSIS AND

INTERPRETATION

COMPUTED

TOMOGRAPHY

SCAN (CT-scan,

Non-contrast)

- Anx-ray

procedurethat

combines

manyx-rayimageswiththe

aidof a

computerto

generate cross-

sectional views

and, if needed,

three-

dimensional

imagesofthe

internal organs

andstructures

ofthe body.

D.O: 7/22/10

D.R: 7/22/10

To identify

theextent

theextentof

the brain

injuryor

damage and

the areas

involvethat

are affected.

Lacunar infarct,

left

capsuloganglionic

region.

Microvascular

ischemic

changes, both

periventricular

whitematterandleftparietal white

matter,

agerelated

cerebral atrophy

changes,

atheromatousinternal carotid

arteries

Noevidenceof

mass lesion or

acute

parenchymal

hemorrhage,

hypodensefoci

areseen atthe left

capsuloganglionic

region, bothperiventritcular

whitematterand,

noevidenceof

subfalaine

herniation,

hydrocephalusorcerebral edema.

Noextraaxial fluid

collection orblood

isseen.The internal

carotid arteries are

TheresultoftheCT

scan dated 7/22/10

shows lacunar

infarct atthe left

capsuloganglionic

region.The

infarction may be

duetodecrease

cerebraloxygenation

becauseofthe

presenceofemboli

that impedes blood

supply in the brain.

TheresultoftheCTscan alsoshowsthe

affectation ofthe

leftsideofthe

brain,which iswhy

Tatay Stroke

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Page | 24

atheromatous.

Noteorage

related cerebralatrophy changes.

Orbits

petromastoids,

sella turnica,

includedsinuses

and bonycalvarium are

intact,

manifested

Contralateral

Hemiparesisorrightsidedweakness.

TheCTscan also

shows affectation

ofthe Frontal and

Parietal Lobe

wherein thepatientmanifestedslurred

speech and

change in mental

statuswith a GCS

scoreof 12 at July

26, 2010.

NURSINGRESPONSIBILITIES:

Prior:1.

Informthepatientthattheprocedure assessesthe brain.

2. Obtain a listofmedication thepatient istaking.3. Explain theprocedure to thepatient. Thepatients cooperation is necessary, becausehemust lie still

duringtheprocedure.

4. Obtain information consent ifrequired bythe institution.

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Page | 25

5. Tell thepatientthatfasting is notusuallyrequired.6. Review the procedurewith the patient. Explain the purpose of the test and how the procedure is

performed.

7. Shoe thepatient a pictureof theCTmachine andencourage thepatient to verbalize his concerns,becausesomepatientsmayhave claustrophobia. Mostpatientswho aremildly claustrophobic can be

scanned afterappropriatepremedication with anti-anxietydrugs.

8. Instruct the patients that wigs, hairpins, clips or partial dental plates cannot be worn during theprocedure becausetheyhampervisualization ofthe brain.

9. Tell thepatientthathemayheara clicking noise asthescanningmachinemoves aroundthehead. During:

1. Ensure that thepatienthas compliedwithmedications restrictions andpretestingpreparations. Ensurethatthepatienthasremoved all external metallic objectspriortoprocedure.

2. Haveemergencyequipmentreadily available.3. Instruct the patient to cooperate fully and to follow directions. Instruct the patient to remain still

throughouttheprocedure becausemovementproducesunreliableresults.

4. Administeran anti-anxiety agent, asordered, ifthepatienthas claustrophobia.5. Ask thepatient to inhaledeeply andholdhis breathwhile thex-ray images are taken, and then to

exhale afterthe images aretaken.

6. Instruct the patient to take slow deep breaths if nausea occurs during the procedure. Monitor andadministeran antiemetic agent ifordered.

7. Notethefollowingprocedureforthe brain CT-scan:

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Page | 26

y Thepatient lies in a supineposition on an examining tablewith the head restingon a snug-fittingrubbercapwithin a water-filled box.Thepatientshead isenclosedonlytothehairline.Theface is not

covered, andthepatient can seeoutofthemachine at all times. Sponges areplaced alongtheside

oftheheadtoensurethatthepatientsheaddoes notmoveduringthestudy.

8. The scanner passes an x-ray beam through the brain fromone side to theother. Themachine thenrotates 1 degree, andtheprocedure isrepeated ateachdegreethrough a 180-degree arc.

After:1. Instructthepatienttoresumemedications and activity, asdirected bythehealth carepractitioner.2. Monitorvital signs and neurologic statusevery 15 minutesfor30 minutes.

Documenttheproceduredone.

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III. ANATOMY ANDPHYSIOLOGY

CENTRAL NERVOUSSYSTEM

The central nervous system consists of the brain and spinal cord:

The brain plays a central role in the control of most bodily functions,

including awareness,movements, sensations, thoughts, speech, andmemory.

Some reflex movements can occur via spinal cord pathways without theparticipation of brain structures.

The spinal cord is connected to a section of the brain called the

*FIGURENO. 1: Lateral surface of the cerebral cortex

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Cerebrospinal fluid surrounds the brain and the spinal cord and also

circulateswithin the cavities (called ventricles)of the central nervous system.

The leptomeninges surround the brain and the spinal cord. The cerebrospinal

fluid circulates between 2 meningeal layers called the pia matter and the

arachnoid (or pia-arachnoidmembranes). The outer, thicker layer serves the

roleof a protective shield and is called thedura matter. The basic unitof the

central nervous system is the neuron (nerve cell). Billionsof neurons allow the

differentpartsof the bodyto communicatewitheachothervia the brain and

thespinal cord. A fattymaterial calledmyelin coats nerve cellsto insulatethem

andto allow nervesto communicate quickly.

Anatomy of the Brain

The Cerebrum

*FIGURENO. 2: Medial surface of the cerebral cortex

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Thesurfaceofthe cerebral cortexhasgroovesor infoldings (calledsulci),

the largestofwhich aretermedfissures. Somefissuresseparate lobes.

The convolutions of the cortex give it a wormy appearance. Each

convolution isdelimited by 2 sulci and is also called a gyrus (gyri in plural).The

cerebrum isdivided into 2 halves, known as the right and lefthemispheres. A

mass of fibers called the corpus callosum links the hemispheres. The right

hemisphere controlsvoluntary limb movementson the leftsideofthe body, and

the lefthemisphere controlsvoluntary limb movementson the right sideof the

body. Almosteveryperson hasonedominanthemisphere. Eachhemisphere is

divided into 4 lobes,orareas,which are interconnected.

y Thefrontal lobes are located in thefrontofthe brain and areresponsiblefor voluntary movement and, via their connections with other lobes,

participate in the execution of sequential tasks; speech output;

organizational skills; and certain aspectsof behavior,mood, andmemory.

y Theparietal lobes are located behindthefrontal lobes and in frontoftheoccipital lobes. They process sensory information such as temperature,

pain, taste, and touch. In addition, the processing includes information

about numbers, attentiveness to the position of ones body parts, the

space aroundones body, andone'srelationshiptothisspace.

y The temporal lobes are locatedon each sideof the brain.Theyprocessmemory and auditory (hearing) information and speech and language

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The cortex, also calledgraymatter, isthemostexternal layerofthe brain

andpredominantly contains neuronal bodies (thepartofthe neuronswherethe

DNA-containing cell nucleus is located).Thegraymatterparticipates actively in

the storage and processing of information. An isolated clump of nerve cell

bodies in thegraymatter istermed a nucleus (to bedifferentiated from a cell

nucleus).The cells in thegraymatterextend theirprojections, called axons, to

otherareasofthe brain.

Fibers that leave the cortex to conduct impulses towardotherareas are

termedefferent, and fibers that approach the cortex fromother areasof the

nervous system are termed afferent (nervesorpathways). Fibers thatgo from

themotorcortextothe brainstem (forexample,pons)orthespinal cordreceive

a namethatgenerallyreflectsthe connections (that is, corticopontinetractfor

the formerand corticospinal tract for the latter). Axons are surrounded in their

course outside the gray matter by myelin, which has a glistening whitish

appearance andthusgivesrisetothetermwhitematter.

Cortical areasreceivetheirnames accordingtotheirgeneral function or

lobe name.If in chargeofmotorfunction,the area is calledmotorcortex.If in

chargeof sensory function, the area is called a sensoryor somesthetic cortex.

The calcarine or visual cortex is located in the occipital lobe (also termed

occipital cortex) and receivesvisual input.The auditory cortex, localized in the

temporal lobe,processessoundsorverbal input. Knowledgeofthe anatomical

j ti f fib f th diff t t t d th l ti t ti f b d

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CentralStructures of the Brain

The central structures of the brain include the thalamus,hypothalamus,

andpituitary gland. The hippocampus is located in the temporal lobe but

participates in memory and emotions and is interconnected with central

structures.Other structures are the basal ganglia,which aremadeupofgraymatterand includethe amygdala (localized in thetemporal lobe),the caudate

nucleus, andthe lenticularnucleus (putamen andglobuspallidus). Becausethe

caudate andputamen are structurally similar, neuropathologistshave coined

forthemthe collectivetermstriatum.

The thalamus integrates and relays sensory information to the cortexof

theparietal,temporal, andoccipital lobes.Thethalamus is located in the lower

central partof the brain (that is,upperpartof the brainstem) and is located

mediallytothe basal ganglia.The brain hemispheres lieon thethalamus.Other

rolesofthethalamus includemotorandmemory control.

The hypothalamus, located below the thalamus, regulates automaticfunctions such as appetite, thirst, and body temperature. It also secretes

hormones that stimulate or suppress the release of hormones (for example,

growthhormones) in thepituitarygland.

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regulates the production of many hormones that have a role in growth,

metabolism,sexual response,fluid andmineral balance, andstressresponse.

The ventricles are cerebrospinal-fluidfilled cavities in the interior of the

cerebral hemispheres.

The Base of the Brain

The baseofthe brain containsthe cerebellum andthe brainstem.These

structures serve complex functions. Below is a simplifiedversion of these roles:

Traditionally,the cerebellum has been known to control equilibrium

and coordination and contributes to the generation of muscle tone. It has

recently become evident, however, that the cerebellum plays more diverse

roles such asparticipating in some typesofmemory andexerting a complex

influenceon musical andmathematical skills.

The brainstem connects the brain with the spinal cord. It includes the

midbrain, the pons, and themedulla oblongata. It is a compact structure in

whichmultiple pathways traverse from the brain to the spinal cord and vice

versa. For instance, nervesthat arisefrom cranial nerve nuclei are involvedwith

eye movements and exit the brainstem at several levels. Damage to the

brainstem can therefore affect a numberof bodilyfunctions. For instance, ifthe

corticospinal tract is injured, a lossofmotor function (paralysis)occurs, and it

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Themidbrain is located belowthehypothalamus. Some cranial nervesthat are

alsoresponsibleforeyemuscle control exitthemidbrain.

The pons serves as a bridge between the midbrain and the medulla

oblongata.Thepons also containsthe nuclei andfibersof nervesthatserveeye

muscle control,facial musclestrength, andotherfunctions.

The medulla oblogata is the lowest part of the brainstem and is

interconnectedwiththe cervical spinal cord.Themedulla oblongata alsohelps

control involuntary actions, includingvital processes, such asheart rate, blood

pressure, andrespiration, and it carriesthe corticospinal (that is,motorfunction)

tracttowardthespinal cord.

The Spinal Cord

The spinal cord is an extension of the

brain and issurrounded bythevertebral bodies

that form the spinal column (see Multimedia

File 3).The central structuresof thespinal cord

are made up of gray matter (nerve cell

bodies), andtheexternal orsurroundingtissues

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Within thespinal cord are 30 segmentsthat belongto 4 sections (cervical,

thoracic, lumbar,sacral), basedon their location:

y Eight cervical segments: These control signals from or to areas of thehead, neck,shoulders, arms, andhands.

yTwelvethoracic segments:These control signalsfromortopartofthe armsandthe anteriorandposteriorchest and abdominal areas.

y Five lumbar segments:These control signals fromor to the legs and feetandsomepelvic organs.

y Fivesacral segments:These control signalsfromortothe lowerbackandbuttocks,pelvic organs andgenital areas, andsome areas in the legs andfeet.

y A coccygeal remnant is located atthe bottomofthespinal cord

PERIPHERAL NERVOUSSYSTEM

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Nerve fibers thatexit the brainstem andspinal cord becomepartofthe

peripheral nervous system.Cranial nerves exit the brainstem and function as

peripheral nervous system mediators of many functions, including eye

movements,facial strength andsensation,hearing, andtaste.

Theoptic nerve is considered a cranial nerve but it isgenerally affected ina diseaseofthe central nervoussystemknown asmultiplesclerosis, and,forthis

andotherreasons, it isthoughttorepresent an extension ofthe central nervous

system apparatus that controls vision. In fact, doctors can diagnose

inflammation oftheheadoftheoptic nerve byusing an ophthalmoscope, as if

theperson'seyeswere a window intothe central nervoussystem.

Nerve roots leave the spinal cord to theexitpoint between 2 vertebrae

and are named accordingtothespinal cordsegmentfromwhichthey arise (a

cervical eight nerveroot arisesfrom cervical spinal cordsegmenteight).Nerve

roots are located anterior with relation to the cord if efferent (for example,

toward limbs)orposterior if afferent (forexample,tospinal cord).

Fibers that carry motor input to limbs and fibers that bring sensory

information from the limbs to the spinal cord grow together to form a mixed

(motor and sensory)peripheral nerve. Some lumbar and all sacral nerve roots

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Thespinal cord is also covered, like the brain, by thepia matterandthe

arachnoidmembranes. The cerebrospinal fluid circulates around thepia and

below theouter arachnoid, and this space is also termed the subarachnoid

space.Therootsofthe cauda equina andtherootletsthatmakeupthe nerve

rootsfromhighersegments are bathed in cerebrospinal fluid.Thedura surrounds

thepia-arachnoidofthespinal cord, as itdoesforthe brain.

CSF and the Ventricles

All exposed surfaces of the central nervous system are bathed in

cerebrospinal fluid (CSF),whichhasseveral importantfunctions:

1. Firstly, it acts to cushion the delicate brain structure by acting as abuffering system.This fluid is required because the skull is so rigid that for

the brain to enlarge at all (as happens with every heart beat, for

example)someofthefluidmust leave - eithervenous bloodorCSF.

2. CSF alsosupportstheweightofthe brain throughthe buoyantpropertiesof the fluid; the brain weighs 1400g in air, but as little as 50g when

supported byCSF.

3. The CSF also acts as a transport medium for nutrients, chemicalmessengers andwasteproducts.

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material of specialized cells and permeable capillaries (the smallest type of

bloodvessel). Eachventricle contains an area of choroidplexus.

CSF is formed bypushing individual substances (mostly salts) across the

wallsofthe choroidplexus, andwater follows.There aresomesubstances that

are then transported back from theCSF tothe blood, aswell assomespecific

transporters for nutrients,vitamins and someother substances. Thismeans that

whileCSF may be formed from blood, there are substantial differences in their

compositions.

TheCSF is released into a seriesofventricles that liewithin the brain. Aventricle is basically a small fluidfilled 'lake' in within the brain andthere arefour

ventricles in an adult brain. There are two lateral ventricles (one in each

hemisphere), a third ventricle in the diencephalon, and a fourth ventricle in

between thepons andthe cerebellum.

The lateral ventricles are separated from each other by a thin barrier

called theseptumpellucidum, and there is nodirect connection between the

two.Thethirdventricle is connectedtothe lateral ventriclesthroughsmall holes

called the interventricular foramen. This third ventricle lies within the

diencephalon.CSF then flowsoutof the thirdventricle through a small canalknown asthemesencephalic aqueduct (orthe aqueductof Sylviusorcerebral

aqueduct).This connectstothefourthventriclethat lies between thepons and

the cerebellum. Atthe baseofthefourthventricle,thespace becomes narrow

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The Meninges

Within the brain,there areseveral layersof cranial meningesthat act as

shockabsorbers, aswell aspreventingdirect contactwith bone. Meninges are

basically coatings,with the three layers having different thicknesses, textures

andpurposes.Thethree layers are namedthedura matter (mostexternal and

thetoughest),the arachnoid (middle) andthepia mater(innermost).The image

totherightprovides a general overviewoftheirstructure.

DuraMatter

Thedura mater is composedoftwofibrous layers;theoutermost is called

theendosteal layer as it is fused to the skull. The inner layer is known as the

meningeal, and in many areas bloodvesselsrun between them. Someofthese

bloodvessels arevery large,such asthedural sinusesthatdeliverbloodtothe

internal jugularveins.

There are four locations in which the dura extends into the brain itself,

stabilisingthestructure.They are:

1. The falx cerebri that dives between the cerebral hemispheres into thelongitudinal fissure. At the back it attaches to thedura that covers the

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2. The tentorium cerebelli separates and protects the cerebellum. It liesperpendiculartothefalx cerebri and containsthetransversesinus.

3. Thefalx cerebelli lies between thetwohemispheresofthe cerebellum.4. Thediaphragma sellae linespartof the skull called the sella turcica that

surroundsthe baseofthepituitarygland.

The Arachnoid

The arachnoid layerprovides a smooth covering for the brain thatdoes

notdivedeep into the sulci (thedips in the surfaceof the brain). Beneath this

layer is the subarachnoid spacewhere there is a delicate,weblike networkof

fibresthat linkthe arachnoidtothepia mater. Alongthesuperiorsagittal sinus,areasofthe arachnoid can beseen (called arachnoidgranulations)that allow

a passageofCSF intothevenoussystem.The arachnoid acts as a supporttothe

cerebral arteries and veins.

The PiaMater

Thepiamater isverytightly linkedtothesurfaceofthe brain, anchored by

theprocessesof astrocytes. Thepia materhas a very large blood supply and

actstosupportthe cerebral arteries asthey branchoverthe brain.

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Blood Supply in the Brain

The blood supply to the brain comes from the internal carotid and

vertebral arteries, lying in thesubarachnoid space.The internal carotid arteriesbranchfromthe common carotid arteries (that can befeltpulsing in the neck)

and enter the head. Each internal carotid artery ascends to the level of the

optic nerve,where each divides into three branches: the ophthalmic artery,

anteriorcerebral arterythatsuppliesthefrontal andparietal lobes and a middle

cerebral artery that supplies themidbrain and lateral surfacesof the cerebral

hemispheres.

The vertebral arteries start at the base of the neck and pass upward

*FIGURENO. 5: Inferior view of the cerebral circulation

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dividing into the posterior cerebral arteries. The vertebral arteries and their

branchessupplythe brain posteriortothe area supplied bythe internal carotids.

To keep flexibility in the circulatory system, there aremany connections

between thedifferent bloodsupplies, andthese connectionsform a loopthat is

known asthe circleof Willis.The circle ismadewhole bysmallerarteriessuch as

the posterior communicating artery and anterior communicating artery. The

purposeofthis isthat ifoneofthe arteries becomes blocked,orbloodsupply is

cutoff forwhatever reason, then blood supply can be increased fromoneof

theotherarteriesto compensate.

CARDIOVASCULARSYSTEM

The cardiovascular system is

sometimes called the circulatory

system. It consists of the heart,

which is a muscular pumping

device, and a closed system of

vessels called arteries, veins, and

capillaries. As the name implies,

blood contained in the circulatory

system is pumped by the heart

around a closed circuitofvessels as

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The Heart

Theheart isenclosed by a sac known asthepericardium.There arethree layersof tissues that form the heart wall. The outer layer of the heart wall is the

epicardium, the middle layer is the myocardium, and the inner layer is the

endocardium.The internal cavityoftheheart isdivided intofourchambers:

y Right atriumy Rightventricley Left atriumy Leftventricle

Thetwo atria arethin-walled chambersthatreceive bloodfromtheveins.

Thetwoventricles arethick-walled chambersthatforcefullypump bloodoutof

the heart. Differences in thickness of the heart chamber walls are due to

variations in the amountofmyocardiumpresent,which reflects the amountof

forceeach chamber isrequiredtogenerate.

Theright atriumreceivesdeoxygenated bloodfromsystemic veins;the left

atriumreceivesoxygenated bloodfromthepulmonaryveins.

Valves of the Heart

Pumps need a setofvalvestokeepthefluidflowing in onedirection and

theheart is noexception.Thehearthastwotypesofvalvesthatkeepthe blood

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The right atrioventricular valve is the tricuspid valve. The left atrioventricular

valve isthe bicuspid,ormitral,valve.Thevalve between therightventricle and

pulmonary trunk is thepulmonary semilunarvalve. Thevalve between the left

ventricle and the aorta is the aortic semilunar valve. When the ventricles

contract, atrioventricularvalves close toprevent blood from flowing back into

the atria. When theventriclesrelax,semilunarvalves closetoprevent bloodfrom

flowing back intotheventricles.

Pathway of Blood through the Heart

While it is convenienttodescribetheflowof bloodthroughtherightside

of theheart and then through the left side, it is important to realize that both

atria contract atthesametime and bothventricles contract atthesametime.

Theheartworks as twopumps,oneon the right andoneon the left,working

simultaneously. Bloodflowsfromtheright atriumtotherightventricle, andthen is

pumpedtothe lungstoreceiveoxygen. Fromthe lungs,the bloodflowstothe

left atrium, then to the left ventricle. From there it ispumped to the systemic

circulation.

Blood Supply to the Myocardium

The myocardium of the heart wall is a working muscle that needs a

continuous supplyofoxygen and nutrients to function withefficiency. For this

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The right and left coronary arteries, branches of the ascending aorta, supply

bloodtothewallsofthemyocardium. Afterbloodpassesthroughthe capillaries

in themyocardium, itenters a systemof cardiac (coronary)veins. Mostof the

cardiac veinsdrain intothe coronarysinus,whichopens intotheright atrium.

Blood Vessels

Blood vessels are the channels or conduits through which blood is

distributedto bodytissues.Thevesselsmakeuptwo closedsystemsoftubesthat

begin and end at the heart. One system, the pulmonary vessels, transports

bloodfromtherightventricletothe lungs and backtothe left atrium.Theother

system,thesystemic vessels, carries bloodfromthe leftventricletothetissues in

*FIGURENO. 7: Layers and functions of blood vessels

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Arteries

Arteries carry blood away from the heart. Pulmonary arteries transport

bloodthathas lowoxygen contentfromtherightventricletothe lungs. Systemic

arteries transportoxygenated blood from the leftventricle to the body tissues.

Blood is pumped from the ventricles into large elastic arteries that branch

repeatedly into smaller and smaller arteries until the branching results in

microscopic arteries called arterioles.The arteriolesplay a keyrole in regulating

bloodflow intothetissue capillaries. About 10 percentofthetotal bloodvolume

is in thesystemic arterial system at anygiven time.

The wall of an artery consists of three layers. The innermost layer, the

tunica intima (or just intima), contains simple squamousepithelium, basement

membrane and connective tissues.Theepithelium is in direct contactwith the

bloodflow.Themiddle layer,thetunica media, isprimarilysmoothmuscle and is

usually the thickest layer. It not only provides support for the vessel but also

changes vessel diameter to regulate blood flow and blood pressure. The

outermost layer,which attachesthevessel tothesurroundingtissue, isthetunica

externa ortunica adventitia.This layer is connectivetissuewithvarying amounts

of elastic and collagenous fibers. The connective tissue in this layer is quite

dense where it is adjacent to the tunic media, but it changes to loose

connectivetissue neartheperipheryofthevessel.

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Veins

Veins carry blood toward the heart. After blood passes through the

capillaries, itenters thesmallestveins, calledvenules. From thevenules, it flows

into progressively larger and larger veins until it reaches the heart. In the

pulmonary circuit,thepulmonaryveinstransport bloodfromthe lungstothe left

atriumof theheart. This bloodhas a highoxygen content because ithas just

been oxygenated in the lungs. Systemic veins transport blood from the body

tissuetotheright atriumoftheheart.This bloodhas a reducedoxygen content

becausetheoxygen has been usedformetabolic activities in thetissue cells.

Thewallsofveinshavethesamethree layers asthe arteries. Although all

the layers arepresent, there is less smoothmuscle and connective tissue. This

makes thewallsofveins thinner than thoseof arteries,which is related to the

fact that blood in theveinshas lesspressure than in the arteries. Because the

wallsof theveins are thinner and less rigid than arteries,veins can holdmore

blood. Almost 70 percentofthetotal bloodvolume is in theveins at anygiven

*FIGURENO. 8: Internal view of the brain

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Capillaries

Capillaries,thesmallest andmost numerousofthe bloodvessels,formthe

connection between thevesselsthat carry blood awayfromtheheart (arteries)

and thevessels that return blood to theheart (veins). Theprimary function ofcapillaries istheexchangeofmaterials between the blood andtissue cells.

Capillary distribution varies with the metabolic activity of body tissues.

Tissues such as skeletal muscle, liver, and kidney have extensive capillary

networks because they are metabolically active and require an abundant

supplyofoxygen and nutrients.Othertissues,such as connectivetissue,have a

less abundant supplyof capillaries.Theepidermisof the skin and the lens and

cornea oftheeye completely lacka capillary network. About 5 percentofthe

total bloodvolume is in the systemic capillaries at anygiven time. Another 10

percent is in the lungs.

*FIGURENO. 9: Arterialand venous ends of capillaries

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Role of the Capillaries

In addition to forming the connection between the arteries and veins,

capillarieshave a vital role in theexchangeofgases, nutrients, andmetabolic

waste products between the blood and the tissue cells. Substances pass

through the capillaries wall by diffusion, filtration, and osmosis. Oxygen and

carbon dioxide move across the capillary wall by diffusion. Fluid movement

across a capillary wall is determined by a combination of hydrostatic andosmotic pressure. The net result of the capillary microcirculation created by

hydrostatic andosmotic pressure isthatsubstances leavethe blood atoneend

of the capillary and return at the other end

*FIGURENO. 10: Hydrostatic and Osmotic pressures

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Discharge Planning

METHODS

M Instructedthepatienttotakethefollowingmedications:

Aspirin 80 mg. afteronce

B complexVID 5 capOD

Calci block10 mg SL PRN

E Encouragethe clientto:

Complete bedrestwith bathroomprivileges.

Passiveexercise

T Advise and SOthat nottoperformvalsalva maneuver.

H Encourageduseofrelaxation techniquessuch as assumingof comfortable

position andto changeposition everytwohours

Encouragedpatientto complywiththetreatmentregimen

D Instructedpatienttohave lowsalt and lowfatdiet

VIII. Conclusion

Hypertension is well known disease all over the world. Most people

acquire it from sedentary lifestyle and improperdiet. It can also behereditary

which could affect certain races more than others. Usually, the African

ki d f di h ld b t k b d th d ti f th d t

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kindsofdiseaseshould betaken basedon therecommendation ofthedoctor

toproperly and totallyeradicatetheproblem. Severehypertension can cause

cerebrovascular accident,CVA is a sudden neurological incident related to

impaired cerebral bloodsupplywhich can cause ischemia tothe brain.It could

paralyzethe body affectingtheperception,sensory, andthemotormovement

oftheperson.

As a nurse, the student should be knowledgeable enough

regardingthediseaseprocess;however, learningthrough lectures andtheories

is not enough to completely understand this disease. Through interaction,

knowledge acquiredfromtheorieswasmuch appreciated bythestudentssince

heor she can actually asses thepatients condition. Withenough information

and enhanced skills, he or she may be able to handle patients with these

conditions andeasily identifyingproblems and treatment alike. It is important

that thepatient isgiven enough information about thedisease condition and

theunderlying complications. As nurses, it isour responsibilitytomakesure that

the patient is disclosed with adequate information.I have also learned the

importanceof taking careofoneself;eachpart belongs to an intersystemof

physiologically functioning body. We were able to reflect about our own

activity,diet andof course the stress thatwe are facingeachdaywhen we

madethis casestudy, becausewehavethoughtthatwhatwedotoourbody

nowmayhave badeffectstous in thefuture.

As a conclusion may these piece of work serve as a guide or

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Page | 52

V.THEPATIENT AND HIS CARE

A. MEDICAL MANAGEMENT

Medical

management/

Trea

tm

ent

Date ordered

Date

performed

Date ch

anged

GeneralDescriptionIndication(s) or

PurposesClients response to treatment

PLAIN NORMAL

SALINE SOLUTION

(PNSS) 1 Liter X 20-

21 gtts/min

DO: 07-23-10

DR: 07-23-26,2010

DC:The clientwas

notyetdischarged

Isotonic crystalloidsolution

containingsame amounts

of sodium and chloride

found in plasma.

Indicated for

restoringthe lossof

bodyfluids.

FluidReplacement

Thepatientwas kepthydrated as

evidenced by normal skin turgor

(assessed through the clavicle

area) andthe administration ofIV

medications also becamepossible

as a form of treatment of the

patient condition. No untoward

effects were noted such as any

signsoffluidvolumeexcessorfluid

overload.

\

Nursing Responsibilities:

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Page | 53


Priortotreatment:1. Verifythephysiciansorder indicatingthetypeofsolution,the amountto be administered,therate

offlowofthe infusion, and any client allergies

2. Considerhow longthepatient is likelytohavetheIV,whatkindsoffluidswill be infused, andwhatmedicationsthepatientwill bereceivingor is likelytoreceive.

3. Preparethe client. Explain theproceduretothe client.4. Arrangeequipments neededforthetherapy5. Observe aseptic technique

Duringtreatment:1. Ensurethatthe correctsolution is being infused2. Observetherateoffloweveryhour3. InspectthepatencyoftheIVtubing and needle4. Inspectthefluidsiteforfluid infiltration5. Inspectthe insertion siteforphlebitis6. Inspectthe intravenoussiteforbleeding7. Teachthepatientwaystomaintain the infusion system8. Document all relevant information

Aftertreatment:1. Reviewthephysiciansorder2. Assessthe appearanceofthevenipuncturesite

3 Inspect the appearance of IV catheter

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3. Inspectthe appearanceofIV catheter4. Coverthevenipuncturesite5. DiscardtheIVsolution containerproperly6. Document all

b. Drugs

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b. Drugs

Name of

Drug

Date ordered

Date performed

Date changed

Route of adminDosage &

frequency of

admin

General Action

Functional

Classification

Mechanism of

Action

Indication(s) or

Purposes

Client Response to

Treatment and Actual

Side Effect

Generic name:

Clonidine

hydrocholoride

Brand name:

Catapres

DO: 07-22, 2010

DP: 07-22-25, 2010

75 mcg./tab SL stat

Anti hypertensive

Thought to stimulate

alpha 2 receptors and

inhibit the central

vasomotor centers,

decreasing sympathetic

outflow to the heart,

kidneys and peripheralvasculature and

lowering bloodpressure.

To decrease blood

volume and bloodpressure.

The client complied

with the medication

and did notmanifest

further increase in

blood pressure and

side effects/adverse

reactions were not

manifested aswell.

Blood Pressure

Readings:

Before Administration:

July 22, 2010: 180/100

After:

July 22, 2010: 120/90

July 23, 2010: 140/ 70

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Page | 56

y , /

July 24, 2010: 120/70

July 25, 2010: 130/90

Nursing Responsibility:

Priortotreatment:1. Checkthedoctorsorderforthedrug name,dosage,frequency androuteof administration2. Observe aseptic technique3. Organizetheequipments neededforadministeringmedication4. Preparethemedication5. Informthe clientofthe nameofthedrug, its action andpurposeofgivingthedrug6. Assess BP andpulse.7. Instructtotake atthesametimeeachday.8. MonitorI&O

Duringtreatment:1. Lastdose: administerat bedtime.

Aftertreatment:1. MonitorBP andpulse, adviceto notifyhealth careprofessional ofsideeffects.

2. Fordrymouthprovidegodoral hygiene andsugarlessgum.

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Name of Drug

Date ordered

Date performed

Date changed

Route of admin

Dosage &

frequency of

admin

General Action

Functional

Classification

Mechanism of Action

Indication(s) or

Purposes

Client Response to

Treatment and

ActualSide Effect

Generic name:

Furosemide

Brand name:

Lasix

DO: 07-22-10

DP: 07-22-26, 2010

DC: clientwas not

yetdischarged

20 gTID now

then every 8

hours

Loopdiuretic

Inhibitsthere

absorption ofsodium

and chloride in the

proximal anddistal

tubules andthe loopof

henle leadingto a

sodiumrichdiuresis

Topromotediuresis

that can helpto

decreasethe

bloodvolume and

bloodpressure

The clientsurine

output increased

anddid notmanifest

further increase in

bloodpressure.

Blood PressureReadings:

Before

Administration: July

22, 2010: 180/100

After:

July 22, 2010: 120/90

July 23, 2010: 140/ 70

July 24, 2010: 120/70

July 25, 2010: 130/90

July 26, 2010: 130/90

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Priortotreatment:1. Checkthedoctorsorderforthedrug name,dosage,frequency androuteof administration2. Observe aseptic technique3. Organizetheequipments neededforadministeringmedication4. Preparethemedication5. Informthe clientofthe nameofthedrug, its action andpurposeofgivingthedrug.6. Assess clientsVS especially BP.

Duringtreatment:1. IV: clean theport/sitewerethedrugwill be injected.2. Assess clientsreaction whilegivingthedrug.

Aftertreatment:

1. MonitorUrineoutput

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2. MonitorVS especially BP3. Monitorweight4. Increase intakeof K richfoods

Name of DrugDate ordered

Date performed

Date changed

Route of

admin

Dosage &

frequency of

admin

General Action

Functional

Classification

Mechanism of

Action

Indication(s) or

Purposes

Client Response

to Treatment and

ActualSide Effect

Generic

name:

Losartan

potassium

Brand name:

Cozaar

DO: 07-22-2010

DP:07-22-25, 2010

DC:Clientwas not

yetdischarged

50 mg./tab 1

tab nowthen

OD

Antihypertensive

Undergoessignificant

first-passmetabolism

(byCYP2C9 and

CYP3A4) in the liver,

where it is converted

to an active

carboxylic and

metabolitethat is

Antihypertensive,

aloneor in

combination with

other

antihypertensive

drug.

The client complied

withthe

medication and

manifested a

stable blood

pressure as

evidenced by

bloodpressure

readingsof:

responsibleformostof Blood Pressure

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Page | 60

the angiotensin

receptorblockade.Selectively blocksthe

bindingof Angiotensin

IItoreceptorsites in

thevascularsmooth

muscles and adrenal

glands.

Readings:

Before

Administration: July

22, 2010: 180/100

After:

July 22, 2010:

120/90

July 23, 2010: 140/

70

July 24, 2010:

120/70

July 25, 2010:

130/90

July 26, 2010:

130/90


Priortotreatment:1. Checkthedoctorsorderforthedrug name,dosage,frequency androuteof administration2. Observe aseptic technique

3. Organizetheequipments neededforadministeringmedication

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4. Preparethemedication5. Informthe clientofthe nameofthedrug, its action andpurposeofgivingthedrug.

Duringtreatment:1. Assess bloodpressure andpulseperiodicallyduringtherapy.

2. Assessforsignsof angioedema.

Aftertreatment:1. Monitor input andoutput anddailyweight.

2. Encouragedthepatientto complywith additional interventionsforhypertension.

Name of Drug

Date ordered

Date performed

Date changed

Route of admin

Dosage &

frequency of

admin

General Action

Functional

Classification

Mechanism of Action

Indication(s) or

Purposes

Client Response to

Treatment and

ActualSide Effect

Generic name:

Aspirin

DO: 07-25,2010

DP: 07-25-26,2010

80 mg once a

day, taken after

meals.

Nonsteroidal, anti-

inflammatorydrug

Exhibits antipyretic, anti-

inflammatory, and

analgesic effects. The

To act as an

anticoagulant so

as to prevent

formation of

thrombus and

The client did not

manifest any signs

and symptoms

such asdifficulty in

breathing and

Brand name:

A ASA/

DC:Clientwas notyet

di h d

antipyretic effect isdueto

ti th

embolus that alteration in

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Apo- ASA/

Novasen

discharged. an action on the

hypothalamus, resulting in

heat loss by vasodilation

ofperipheral bloodvessels

andpromotingsweating.

could further

aggravate the

clients condition

circulation that

could indicate

formation of

thrombus/emboli.


Priortotreatment:1.Informthe clientofthe nameofthedrug, its action andpurposeofgivingthedrug.

2.Take a completedrughistory and note anyevidenceofhypersensitivity.

Duringtreatment:1. Monitorserumsalicylate levelsperiodically.

2. Monitorfortheonsetoftinnitus,headache,hyperventilation,diarrhea andsweating.

3. Administermealsorwithfood.

Aftertreatment:1.Taperdose.

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Name of Drug

Date ordered

Date performed

Date changed

Route of admin

Dosage &

frequency of

admin

General Action

Functional

Classification

Mechanism of Action

Indication(s) or

Purposes

Client Response to

Treatment and

ActualSide Effect

Generic name:

Vitamin B

complex

Brand name:

Theravite

DO: 07-22,2010

DP: 07-22-26,2010

DC:Clientwas notyet

discharged

1 capsuleonce a

day.Vitamin supplements Vitamin B

complex was

given tothe client

to further

enhance nerve

functions which

may be impaired

due to the

infarction causing

an alteration in

the sensory and

motor abilities of

the client.

The client complied

with the therapy

and did not

manifest further

aggravation of the

sensory and motor

deficits of the

client.


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Priortotreatment:1. Checkthedoctorsorderforthedrug name,dosage,frequency androuteof administration2. Observe aseptic technique3. Organizetheequipments neededforadministeringmedication4. Preparethemedication5. Informthe clientofthe nameofthedrug, its action andpurposeofgivingthedrug.6. AssessVitamin levels as indicated.

Duringtreatment:

1. Monitor levelstoensurerequirements aremet and levels are as2. Takewithfoodforbest absorption andutilization.

Aftertreatment:1. Complywithdietaryrecommendations.2. Avoidself-medicatingthatexceedstheRDAs

Name of Drug

Date ordered

Date performed

Date changed

Route of admin

Dosage &

frequency of

General Action

Functional

Classification

Indication(s) or

Purposes

Client Response to

Treatment and

admin Mechanism of Action ActualSide Effect

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Priortotreatment:7. Checkthedoctorsorderforthedrug name,dosage,frequency androuteof administration

Generic name:

Nifedipine

Brand name:

Calcibloc

DO: 07-22,2010

DP: 07-22-26, 2010

DC:Clientwas notyet

discharged

10 mg SL PRN Calcium channel blocker

Inhibits the influx of

calcium through the cell

membranes, resulting in a

depression of

automaticity and a

conduction velocity

leadingto a depression of

contraction.

Decreasestotal peripheral

resistance thus reducing

energy and oxygen

requirementsoftheheart.

The medication was

given to the client to

decrease the

patients blood

pressure and cardiac

workload.This isdone

by decreasing the

clients peripheral

resistance and

contractions.

The clients blood

pressure was stabilized

and did not further

increased as

evidenced by blood

pressurereadingsof:

Before Administration:

July 22, 2010: 180/100

After:

July 22, 2010: 120/90

July 23, 2010: 140/ 70

July 24, 2010: 120/70

July 25, 2010: 130/90

July 26, 2010: 130/90

8. Observe aseptic technique9 Organize the equipments needed for administering medication

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9. Organizetheequipments neededforadministeringmedication10.Preparethemedication11.Askthe nameofthe cient.12.Informthe clientofthe nameofthedrug, its action andpurposeofgivingthedrug.

Duringtreatment:

3. Monitor levelstoensurerequirements aremet and levels are as4. AdministerSL atthe buccal mucosa to avoid aspiration

Aftertreatment:3. Complywithdietaryrecommendations.4. Avoidself-medicatingthatexceedstheRDAs5. Do notgivewaterafteradministration6. Performroutineoral care.

c. Diet

Date ordered

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Type of Diet

Date ordered

Date performed

Date changed

GeneralDescription Indication(s) or

Purposes

Clients response and/or

reaction to diet

Low fat and low

salt dietwith strict

aspiration

precaution

DO: 07-22,2010

DP: 07-22-26, 2010

DC: Client was

notyetdischarged

Law salt, low fatdiet

is a dietthat isrich in

fruits and

vegetables, low fat

dairy products and

low in saturated and

total fat. This usually

includes

unprocessed and

white meats, bread

and cereals, skim

milk and fruits and

vegetables.

Aside from the

anti-hypertensive

drugs being taken

by the client it is

also essential to

provide diet

restrictions which

can help in further

stabilizing the

clients blood

pressure. Fat

usually deposits in

blood vessels

whichmay narrow

its lumen causing

a higherresistance

The client complied with

the diet and the clients

blood pressure did not

further increase and was

stabilized as evidenced

by:

Blood PressureReadings:

Before Administration: July

22, 2010: 180/100

After:

July 22, 2010: 120/90

July 23, 2010: 140/ 70

July 24, 2010: 120/70

July 25, 2010: 130/90

July 26, 2010: 130/90

needed by the

blood to get

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Page | 68

blood to get

through the vessel

while excessive

salt (sodium) can

cause an

elevated blood

volume because

of its ability to

retain water in the

body thus also

increasing the

clients blood

pressure. Limiting

intake of foods

which excessively

contain these

substances may

greatly help in

managing

hypertension.

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Page | 69


Priortotreatment:1. Checkthedoctorsorder.2. Explain thepurposeofdiet andthespecific foodsto betaken.3. Educatethe clientregardingthefoodsthat is allowed andfoodthat arerestricted.

During:1. Monitorcomplianceofthepatienttotheprescribeddiet.

After:1. Monitorpatientfortolerancetofood.2. Documentpatientsresponse.

d. Activity/ Exercise

Type of

exercise

Date Ordered

Date Performed

Date Change

General

description

Indication/purposes Clients Response and/or

reaction to treatment

Complete

bed rest with DO: 07-22, 2010

-The client is

confined in bed

-to minimize clients

movement which may

The client complied with the

therapeutic regimen and did

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bathroom

privileges

Passive

exercise

DP: 07-22-26,2010

DC: client was not yet

discharged

DO: 07-22,2010

DP: 07-22-26,2010

DC: The client was not yet

discharged

and is not

allowed to get

up to perform

his bathroom

necessities.

-There aresetof

exerciseswhere

in the nurse

provides

assistance for

the clients

performance of

movements.

further increase oxygen

demands that could

compromise the clients

condition, to minimize

clientsriskforinjurydueto

sensory andmotordeficits

caused bythe infarction.

-to facilitate movement

and circulation of the

different bodyparts.

not manifest any signs and

symptoms such asdifficultyof

breathing, fatigue, formation

of thrombi/emboli, pressure

sores, and contractures that

indicates increase in oxygen

demand and presence of

injury.

- the client complied andwasable to perform the exercises

properly. He alsotoleratedthe

activity and did not manifest

difficulty of breathing and

fatigue.

-no further complication was

notedon the client.


P i t t t t

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Priortotreatment:4. Checkthedoctorsorder.5. Explain thepurposeofdiet andthespecific foodsto betaken.6. Educatethe clientregardingthefoodsthat is allowed andfoodthat arerestricted.

During:2. Monitorcomplianceofthepatienttotheprescribeddiet.

After:3. Monitorpatientfortolerancetofood.4. Documentpatientsresponse.

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IX. RECOMMENDATION:

Health is a majorconcern thatshould begiven adequate attention; it is

notsomethingthatshould betaken forgranted.Thepublic should be awareof

howtopreventoccurrenceof illness. Although it is inevitableforanyonetoget

sickmore than once in his lifetime, it is a must thatpeople take careof their

healthtopreventoccurrenceofdiseases.

Tothepublic:

Properdiet isvery crucial in achievingoptimal healthstatus. Prevention

isvery importantwiththisdisease andweshouldwatchoutforthefoodthatwe

eat. We should avoid fatty foods andhigh sodium because these can cause

harmful effects and could elevate blood pressure. The people should know

what istoomuch and learn howto control themselves.

Proper weight management should be observed since obesity can

cause hypertension. Ideal weight decreases the rate of having hypertension

relatedCVA. By beingobese,there could behyperlipidimia and itwill behard

forthe bloodtopassthrough.

Smoking and other sedentary lifestyle is prohibited because smoking

Tohealth carepractitioner:

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CVA related to hypertension, like any other diseases are highlypreventable. In the health care practice, we are well equipped with the

knowledge aswell astheskills in theprevention. A majorproblem isthegeneral

publics lack of information about the strategies of how to do so. It is our

responsibility on how to educate them properly. Monitoring patients

compliance to treatment regimen isvery crucial for thepatient.Nurses should

inform the clients regarding the reasonsofevery intervention andmedication

beinggiven tothem.

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X. Learning Derived

This case studymade us realize the importanceofobtaining accurate

patienthistory becausefromthis alone,thehealth careteammembercan be

directed to the propermanagement of the patient togetherwith his family.

Assessment of a patient experiencing a neurologic disorder is a challenge.

Neurologic assessment establishes baseline data that are used to compare

ongoing assessments,diagnose actual andpotential healthproblems,manage

client care, and evaluate the outcome. Because of the complexity of the

nervoussystem, neurologic assessment is bothmultifaceted and lengthy.

Lastly, the group also learned from the case study presented that a

number of health problems present and can be identifiedwith patientswith

CVA. With the case study, thegroupprofoundlyexplored the roleof nurses in

preserving the qualityof lifeof thepatientswithCVA and the importanceof

familysupport in theircare andrecovery.

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VIII. BIBLIOGRAPHY

Internet:

y http://www.wisegeek.com/what-is-anemia.htmy http://www.faqs.org/abstracts/Health/Current-trends-CDC-Criteria-for-

anemia-in-children-and-childbearing-aged-women.html

y http://www.jstor.org/pss/3454306y Foundation foreducation andresearch in Neurological Emergenciesy http://tigger.uic.edu/com/ferne/pdf/subarachnoidhem0501.pdfy http://www.hmnews.org/article2767.htmly http://www.sciencedaily.com/releases/2004/06/040622014818.htmy http://www.sciencedaily.com/releases/2006/04/060429125428.htmy The internet Stroke center- http://www.strokecenter.org/pat/sah.htmy EmedicinefromwebMD -

http://www.emedicine.com/emerg/topic559.htm

y Emedicine.comy http://www.emedicine.com/aaem/topic239.htmy Wakeforestuniversity Medical Center-

http://www1.wfubmc.edu/neurosurgery/Brain+Tumor+Center+of+Excellen

ce/Subarachnoid+Hemorrhage+of+Unknown+Etiology htm

y http://www.surgeryencyclopedia.com/Ce-Fi/Craniotomy.htmly http://uscneurosurgery.com/infonet/surgery/procedures/aneurysm_clip.ht

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m#surgical%20indications

Books:

Stanleyet. al. Pathology and PathophysiologyofUterine Smooth-MuscleTumors.

TheNational Instituteof Environmental Health Sciences (NIEHS). 2000

Black, Joyce. Medical Surgical Nursing. (Philadelphia: Lippincott Williams &

Wilkins, 2004

Braunwaldet.al. Harrisons PrinciplesofInternal Medicine 2. 11thedition. McGraw

Hill BookCompany.Copyright 1987.

Seeleyet. al. Essentialsof Anatomy and Physiology. 5thedition. McGraw Hil Book

ofCompany.Copyright 2003.

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