A Case Study on Cerebrovascular Accident

In partial fulfillment of The course requirement of Medical-Surgical Nursing

Presented to the aculty of Cebu !octors" #niversity College of Nursing

Submitted by$ Adal% Aileen A& 'SN (A Class of )**+

,une )**-

2 Table of Contents I& Introduction II& /b0ectives III& Nursing Assessment 2& Personal 3istory 2&2 Patient"s Profile 2&) amily and Individual Information% Social and 3ealth 3istory 2&. 4evel of 5ro6th and !evelopment 2&.&2 Normal !evelopment at Particular Stage 2&.&) The ill Person at Particular Stage of the Patient )& !iagnostic 7esults .& Present Profile of unctional 3ealth Patterns (& Pathophysiology and 7ationale (&2 Anatomy and Physiology (&) Schematic !iagram (&. !isease Process (&( Comparative Chart I8& Nursing Intervention 2& Care 5uide for a Stro9e Patient )& Actual Patient Care )&2 'runs6ic9 4ens Model )&) Nursing Care Plan )&. S/API: )&( 3ealth Teaching Plan 8& :valuation and 7ecommendation 8I& :valuation and Implication of This Case Study 8II& 'ibliography . 1 + + 2* 2* 2( 22). )( ).2 .2 .2 .( .1 () (. (; (; (+

3 I. Introduction Cerebrovascular Accident refers to any functional or structural abnormality of the brain caused by a pathological condition of the cerebral vessels or of the entire cerebrovascular system& This pathology either causes hemorrhage from a tear in the vessel 6all or impairs the cerebral circulation by a partial or complete occlusion of the vessel lumen 6ith transient or permanent effects& If blood flo6 is disrupted at any point bet6een the heart and the brain% portions of the brain relying on blood from the obstructed blood vessel become deprived of o<ygen& Thus% ma9ing it starve to death& A stro9e results in permanent damage to the brain tissue& Persons suffering from stro9e may e<perience disruption of motor% sensory% cranial nerve% cognitive and other functions& Stro9e is the third most common cause of death in developed countries& It is uncommon before the age of (* and is more common in males& Stro9e affects around 2&)= of Australian patients at sometime in their lives% 6hich corresponds to )2-%1** Australians affected& >ith the gro6ing incidence of obesity in Australia ?6hich contirbutes to stro9e through hypertension and atherosclerosis- fatty plaques in blood vessels@ the incidence of stro9es is e<pected to s9y-roc9et by )*1*& 3o6ever% the incidence in younger age groups - eg& (*-;* is dropping 6ith better control of hypertension& Stro9e is more common in certain races li9e the Afro-Caribbean& Men are at greater ris9 of stro9e than 6omen up until the age of 11 years% after 6hich both se<es have similar ris9s& Stro9e is a ma0or cause of morbidity and mortality in the elderly& >hile stro9e is considered a disease more commonly affecting men% 6omen are actually t6ice as li9ely to die from stro9e than men& In addition% females have additional ris9 factors for stro9e such as oral contraceptives% that are not present in men& Stro9e is uncommon in children accounting for only a small percentage of stro9e cases each year& Stro9e in children is often secondary to congenital heart disease ?embolic stro9e@% genetic disorders% abnormalities of intracranial vessels or blood disorders such as Thrombophilia& 3alf of stro9es in children are haemorrhagic and these may be associated 6ith long term disabilities&

4 Around )1= of people die in the first one month follo6ing an ischaemic stro9e% and up to -1= after a haemorrhagic stro9e& urthermore% the patients that survive are at a high ris9 of further stro9es - recurrent stro9es occur are seen in 2*= of survivors in the first year& In addition% patients that have suffered a stro9e are also at a very high ris9 for a myocardial infarction ?heart attac9@ due to concominant coronary artery disease& Patients that have surivived the initial period after a stro9e are usually left 6ith significant morbidity& Around 2A. are independently mobile ?move on their o6n@% and 2A. have a severe disability requiring on-going institutional care% and the rest are in bet6een&There is usually some improvement in function after a stro9e% although the patient may be left 6ith a severe deficit& The improvement made in the first month can be used to indicate the li9ely improvement the patient 6ill ma9e in future&

The reason 6hy 6e chose Cerebrovascular Accident as her case study is because that% studies sho6 that stro9e is common no6adays and being one of the primary caregivers% nurses should be fully equipped 6ith the 9no6ledge about the disease process% attitude to6ards the clients and s9ills needed to perform in giving caring care to the clients& Nurses should also be competent enough in giving holistic caring care to the stro9e clients&

After finishing this case study% the student is e<pected to have in depth 9no6ledge and understanding of the nature% signs and symptoms and prognosis of cardiovascular accident& The student also e<pected to gain the needed s9ills to care for a patient suffering 6ith this 9ind of condition&

5 II. Objectives General Objectives: At the end of this case study% the student is e<pected to acquire adequate 9no6ledge% attitude and s9ills in providing holistic caring care for patients 6ho has cerebrovascular accident 6ith the cooperation of the family and the significant others and 6ith the collaboration 6ith other health care team&

Specific Objectives:

Student-nurse centered: After . days of giving holistic caring care% the student nurse 6ill be able to$ 2& relate the patient"s history and stage of gro6th and development& )& define Cerebrovascular Accident or stro9e& .& state the different types of stro9e& (& revie6 the anatomy and physiology of the Central Nervous System& 1& e<plain the pathophysiology of C8A& ;& enumerate signs and symptoms manifested 6ith patients having C8A& -& formulate a comprehensive nursing care plan to bridge gap of communication bet6een patient and caregivers& +& integrate the formulated health teaching plan to the patient and the significant others& B& evaluate the effectiveness of nursing care rendered to the patient&

6 Patient-centered: After . days of rendering holistic caring care% the patient 6ill be able to$ 2& e<hibit reduced an<iety level& )& provide self care activities 6ithin level of o6n ability& .& establish method of communication in 6hich needs can be e<pressed& (& demonstrate intact neurologic status and normal vital signs and respiratory patterns& 1& demonstrate 6ays to increase strength and function of affected body part as evidenced by performing 7/M e<ercises 6ithout or 6ith limited assistance& ;& evaluate nursing care rendered by the student nurse&

7 III. Nursing Assessment 1. ersonal !istor" atient#s rofile Name$ Mrs& Constancia 'orres :rasmo Age$ +B years old Se<$ emale Civil Status$ >ido6 7eligion$ 7oman Catholic !ate of Admission$ March 21% )**7oom No&$ 1*; Complaints$ 7ight sided 3emiparesis and slurred speech ImpressionA !iagnosis$ Cerebrovascular !isease Infarct Physician$ !r& Manuel T& 4im 1.$ %amil" and Individual Information& Social and !ealt' !istor" Mrs& Constancia '& :rasmo% +B years of age% is an American CitiCen% a 6ido6 and a retired teacher from outside the country& She is a very religious Catholic 6ho loves to go to church all the time& She is a non-alcoholic beverage drin9er and she also doesn"t smo9e cigarettes& She has no 9no6n food or drug allergies& She is a 9no6n hypertensive 6ith a blood pressure normally ranging from 2(*-2;*AB*-2** mm3g& She has maintenance medication 6hich is Perindopril& 3ypertension is common in her family& All her children already graduated& Some has already left the country and someone 6as shot and died& According to her daughter in la6% the patient had a stro9e attac9 6hen she 6ent bac9 here to the Philippines& The patient is very fond of her grandson 6hose father already died 6hen he 6as still young& She tal9s to him 6henever she has a problem and spends time 6ith him or at his house after she 6ent to church& She al6ays visits the church everyday and staying there for long periods after 6hich her daughter in la6 6ould pic9 her up& All of her children has left the

8 country e<cept for her daughter 6ho is still here in the Philippines and 6or9ing as a nurse at 8icente Sotto Memorial Medical Center& 1.( )evel of Gro*t' and +evelopment 1.(.1 Normal development at particular stage '"sical C'anges The body changes continuously 6ith age% but the effects on a particular adult depends on health% lifestyle% stressors and environmental stressors& The s9in loses resilience and moisture in adulthood& acial features become more pronounced for loss of subcutaneous tissues& The elderly visual acuity declines leading to presbyopia& Presbycussis is a common age-related change in auditory acuity& There is a decreased cardiac output and slo6 peristalsis and alterations in secretions in 5IT& Muscle fibers are reduced in siCe& There is also a decreased sense of balance or uncoordinated muscle movement& Cognitive c'anges The mental profile of elderly is diverse& luid intelligence that controls

emotions% retention of non-intellectual information% creativity% spatial perceptions% and aesthetic appreciation is thought to decline 6ith age& CrystalliCed intelligence% involving the use of past learning and e<periences for problem solving is maintained throughout adulthood&

8igilance performance% the ability to retain information longer than (1 minutes% declines in old age& They are more easily distracted by irrelevant information and stimuli& They also have a reduced ability to perform tas9 that are complicated or

9 demands simultaneous performance& 7etrieval of information stored in long-term memory is lo6er& ,motional As 6e gro6n older% our amount of stress often increases 6hile our ability to deal 6ith it decreases& :lderly face a 6ide range of stressors$ physical limitations or incapacity% dependence on others% physical pain% losses and fear of death& s"c'osocial :lderly e<periences Integrity vs& !espair phase in his psychosocial development& This phase% especially from the perspective of youth% seems li9e the most difficult of all& irst comes a detachment from society% from a sense of usefulness% for most people in our culture& Some retire from 0obs theyDve held for yearsE others find their duties as parents coming to a closeE most find that their input is no longer requested or required& Then there is a sense of biological uselessness% as the body no longer does everything it used to& >omen go through a sometimes dramatic menopauseE men often find they can no longer Frise to the occasion&F Then there are the illnesses of old age% such as arthritis% diabetes% heart problems% concerns about breast and ovarian and prostrate cancers& There come fears about things that one 6as never afraid of before -- the flu% for e<ample% or 0ust falling do6n& Along 6ith the illnesses come concerns of death& riends die& 7elatives die& /neDs spouse dies& It is% of course% certain that you% too% 6ill have your turn& aced 6ith all this% it might seem li9e everyone 6ould feel despair& In response to this despair% some older people become preoccupied 6ith the past& After all% thatDs 6here things 6ere better& Some become preoccupied 6ith their failures% the bad decisions they made% and regret that ?unli9e some in the previous stage@ they really donDt have the time or energy to reverse them& >e find some older people become depressed% spiteful% paranoid% hypochondriacal% or developing the patterns of senility 6ith or 6ithout

10 physical bases& :go integrity means coming to terms 6ith your life% and thereby coming to terms 6ith the end of life& If you are able to loo9 bac9 and accept the course of events% the choices made% your life as you lived it% as being necessary% then you neednDt fear death& Although most of you are not at this point in life% perhaps you can still sympathiCe by considering your life up to no6& >eDve all made mista9es% some of them pretty nasty onesE yet% if you hadnDt made these mista9es% you 6ouldnDt be 6ho you are& If you had been very fortunate% or if you had played it safe and made very fe6 mista9es% your life 6ould not have been as rich as is& 1.(.$ T'e ill person at particular stage of t'e patient The patient has been diagnosed 6ith stro9e& Primary management is through medication% rehabilitation and appropriate nursing care& She has a slurred speech and difficulty in hearing 6ords spo9en to her& The patient 6as noted to be very cooperative to the care rendered by the staff& >hat the patient is e<periencing is common to individuals at the same age and development stage as hers& 'odily functions decline as a result of the body"s inability to 9eep 6ith the systemic requirements% as theoriCed in the 6ear and tear theory& The body"s inability to cope up is coupled 6ith disease and infections 6hich contribute to the generaliCed deterioration of the body& $. +iagnostic Test +IAGNOSTIC T,ST C1C 23454678 3emoglobin 3ematocrit >hite 'lood Cells 7ed 'lood Cells MC8 NO-.A) /A)0,S M$ 2(-2-&1 $ 2)&.-21&. (2&1-1*&(= (&(-22&*G2*HBAml (&1-1&BG2*H2)A4 +*-B*A4 ATI,NT#S -,S0)T 2.&()&( (&(B (&-; +B&* Normal Normal Normal Normal Normal SIGNI%ICANC,

11 MC3 MC3C )-&1-..&) pg ..&(-.1&1= )+&+ .)&. Normal decrease in a

A have

MC3C in

indicates that the erythrocyte decrease hemoglobin Platelets .-)+-*Ph 21*%***-(1*%*** -&.1--&(1 21;%*** ;&* concentration&

?hypochromic@ Normal The ph is the hydrogen ion ?3I@ e<pressed negative actual as concentration a negative ph is ion

logarithm& 'ecause it is a logarithm% hydrogen inversely proportional to the concentration& Therefore% as ph increases% the hydrogen ion concentration increases& In respiratory or metabolic Specific 5ravity Potassium 2&**2-2&*(* .&;-1&* mmolA4 2&*)1 acidosis% ph is decreased& Normal Many diuretics in lo6er decrease the blood& blood potassium !iuretics

pressure by helping your body eliminate sodium and 6ater& This reduces blood volume and helps decrease pressure 6alls& on your your artery body >hen

e<cretes e<cessive amounts of 6ater% it also loses e<tra

12 potassium& This can lead to lo6 potassium levels in your blood ?hypo9alemia@& :osinophil *=-1=

A lo6er-than-normal eosinophil count may be due to alcohol into<ication and overproduction of certain steroids in the body ?such as cortisol@&

Monocyte

*=-+=

3igh monocyte count can indicate infection% often bacterial infection&

CT Scan -esult: 2.arc' 19&$6678 3eadA'rain Completion ollo6 up non-enhanced CT scan of the brain dated March 2;% )**- as compared to the previous study done on March 21% )**- sho6s interval development of areas of lo6 attenuation at the left deep temporal lobe% the posterior limb of the left internal capsule% the left periventricular region and left parieto-occipital lobes ?small@& There is no evidence of acute intracranial hemorrhage& The ventricles and basal systems are preserved& The midline structures are not displaced& The rest of the findings are unremar9able& Impression$

13 Small subacute infarcts at the left deep temporal lobe% posterior limb of the left internal capsule% left periventricular region and left parieto-occipital lobe& No evidence of acute intracranial hemorrhage& ,CG -eport: 2.arc' 15& $6678 Interpretation$ Atrial fibrillation 6ith rapid ventricular response and an inferior 6all myocardial ischemia& >hen compared to the tracing ta9en on March 21%)**-% left ventricular hypertrophy and non-specific ST-T 6ave changes are still notedE first degree A8 bloc9 is not appreciated& Carotid +uple: Scan 2.arc' 19& $6678 Interpretation$ Minimal left carotid artery disease 6ithout hemodynamic significance& Normal right carotid and bilateral vertebral artery colors duple< scan& ;4ra"

14 (. resent rofile of %unctional !ealt' atterns (.1 !ealt' erception< !ealt' .anagement attern Mrs& Constancia :rasmo complains of right-sided hemiparesis& She loo9s at her condition as poor since the right side of her body has difficult and limited movement and also needs assistance to do activities of daily living& 3er condition is poor compared to her previous condition prior to admission& She is a 9no6n hypertensive and has a maintenance medication of Perindopril& (.$ Nutritional4.etabolic attern Prior to admission% the patient loves to eat chic9en and those food 6ith soup& 'ut no6% the patient is required to eat soft diet foods li9e Jluga6K& She has no problems 6ith eating& (.( ,limination attern The patient has no problems 6ith urinary and bo6el elimination& She though has difficulty in going to the comfort room to urinate or defecate due to 6ea9ness& She uses adult diapers instead& (.3 Activit" ,:ercise attern She has difficulty in moving due to 6ea9ness in her body& Thus% activities requiring physical mobility are lessened& :<ercise is only limited to passive 7/M e<ercises li9e armAleg fle<ion and e<tension& She still has difficulty in ambulating right no6&

15 (.= Sleep4-est attern The significant others stated that she has difficulty in sleeping at night& The patient loo9ed so tired& She had no difficulties in sleeping during his previous state or condition& The significant others noticed that she has frequent a6a9enings at night& (.9 Cognitive< erceptual .anagement attern Mrs& Constancia :rasmo has difficulty in e<pressing and hearing 6ords& This is the reason 6hy she ans6ers differently to questions as9ed& The significant others said that she can properly read and 6rite before the occurrence of this condition& 'ut after admission% her ability to read and 6rite at her right hand and eye is limited& (.7 Self4 erception attern The patient has difficulty e<pressing herself& She has difficulty in communicating and performing her usual activities of daily living& She has slurring of speech and a right sided hemiparesis& She has poor self-concept& 3er significant others are there to support her throughout the course of her hospitaliCation& (.> -ole -elations'ip attern The patient uses :nglish language and is an American citiCen& 3er voice is very lo6 as if she"s tal9ing to herself& >hen she is here in the Philippines% she lives 6ith her daughter but turns to her favorite grandson 6henever she has problems&

16 (.5 Se:ualit"4-eproductive attern The patient 6ore clothing appropriate for her age& >omen of her age usually diminish in se<ual desire& (.16 Coping4Stress Tolerance attern She finds strength in her family in coping stress& She decides 6ith her daughter and grandchildren& >hen she is under stress% she goes to church to pray and go to her favorite grandson"s home to see9 advice& (.11 /alues and 1elief S"stem The patient is a very religious Catholic& Prior to admission% she goes to church everyday and stayed there for long periods of time& She has strong faith in 5od& No6% she continuous to read the bible since she has only limited movement and 6ith assistance&

17 3. at'op'"siolog" and -ationale 3.1 Anatom" and '"siolog"

BRAIN It is the portion of the central nervous system contained 6ithin the s9ull& The brain is the control center for movement% sleep% hunger% thirst% and virtually every other vital activity necessary to survival& All human emotionsLincluding love% hate% fear% anger% elation% and sadnessLare controlled by the brain& It also receives and interprets the countless signals that are sent to it from other parts of the body and from the e<ternal environment& The brain ma9es us conscious% emotional% and intelligent& /ccupying the s9ull cavity ?cranium@% the adult human brain normally 6eighs from ) 2A( to . 2A( lb ?2-2&1 9g@& !ifferences in 6eight and siCe do not correlate 6ith differences in mental abilityE an elephantDs brain 6eighs more than four times that of a human& In invertebrates a group of ganglia or even a single ganglion may serve as a rudimentary brain& 'y means of electrochemical impulses the brain directly controls conscious or voluntary behavior% such as 6al9ing and thin9ing& It also monitors% through feedbac9 circuitry% most involuntary behaviorLconnections 6ith the autonomic nervous system enable the brain to ad0ust heartbeat% blood pressure% fluid balance% posture% and other functionsL and influences automatic activities of the internal organs& There are no pain receptors in

18 brain tissue& A headache is felt because of sensory impulses coming chiefly from the meninges or scalp& Anatomically the brain has three ma0or parts% the hindbrain ?including the cerebellum and the brain stem @% the midbrain% and the forebrain ?including the diencephalon and the cerebrum@& :very brain area has an associated function% although many functions may involve a number of different areas& 2&2 'rain stem The brain stem is the lo6est part of the brain& It serves as the path for messages travelling bet6een the upper brain and spinal cord% and is also the seat of basic and vital functions such as breathing% blood pressure% and heart rate% as 6ell as refle<es li9e eye movement and vomiting& The brain stem has three main parts$ the medulla% pons% and midbrain& A canal runs longitudinally through these structures carrying cerebrospinal fluid& Also distributed along its length is a net6or9 of cells% referred to as the reticular formation% that governs the state of alertness& The medulla% 6hich is part of the brainstem% controls basic functions such as breathing rate% heartbeat and the activity of the intestines& The midbrain% also part of the brainstem% controls movements and contains nerve centres involved in hearing and vision&

19

2&) Cerebellum The cerebellum coordinates body movements& 4ocated at the lo6er bac9 of the brain beneath the occipital lobes% the cerebellum is divided into t6o lateral ?side-by-side@ lobes connected by a fingerli9e bundle of 6hite fibers called the vermis& The outer layer% or corte<% of the cerebellum consists of fine folds called folia& As in the cerebrum% the outer layer of cortical gray matter surrounds a deeper layer of 6hite matter and nuclei ?groups of nerve cells@& Three fiber bundles called cerebellar peduncles connect the cerebellum to the three parts of the brain stemLthe midbrain% the pons% and the medulla oblongata& The cerebellum coordinates voluntary movements by fine-tuning commands from the motor corte< in the cerebrum& The cerebellum also maintains posture and balance by controlling muscle tone and sensing the position of the limbs& All motor activity% from hitting a baseball to fingering a violin% depends on the cerebellum&

20 2&. Cerebrum The cerebrum consists of t6o hemispheres that are incompletely separated by the great longitudinal fissure& This sulcus separates the cerebrum into the right and left hemispheres& The t6o hemispheres are 0oined at the lo6er portion of the fissure by the corpus callosum& The outside surface of the hemispheres has a 6rin9led appearance that is the result of many folded layers or convolutions called gyri% 6hich increase the surface area of the brain% accounting for the high level of activity carried out by such a small-appearing organ& The e<ternal or outer portion of the cerebrum ?the cerebral corte<@ is made up of gray matter appro<imately ) to 1 mm in depthE it contains billions of neuronsAcell bodies% giving it a gray appearance& >hite matter ma9es up the innermost layer and is composed of nerve fibers and neuroglia ?support tissue@ that form tracts or path6ays connecting various parts of the brain 6ith one another ?transverse and association path6ays@ and the corte< to lo6er portions of the brain and spinal cord ?pro0ection fibers@& The cerebral hemispheres are divided into pairs of frontal% parietal% temporal% and occipital lobes& The four lobes are as follo6s$

21 rontal M the largest lobe& The ma0or functions of this lobe are concentration% abstract thought% information storage or memory% and motor function& It also contains 'roca"s area% critical for motor control of speech& The frontal lobe is also responsible in large part for an individual"s affect% 0udgment% personality% and inhibitions& Parietal M a predominantly sensory lobe& The primary sensory corte<% 6hich analyCes sensory information and relays the interpretation of this information to the thalamus and other cortical areas% is located in the parietal lobe& It is also essential to an individual"s a6areness of the body in space% as 6ell as orientation in space and spatial relations& Temporal M contains the auditory areas& Contains a vital area called the interpretive area that provides integration of somatiCation% visual% and auditory areas and plays the most dominant role of any area of the corte< in cerebration& /ccipital M the posterior lobe of the cerebral hemisphere is responsible for visual interpretation& Corpus Callosum Is a thic9 collection of nerve fibers that connects the t6o hemispheres of the brain and is responsible for the transmission of information from one side of the brain to the other&

22 1asal Ganglia Are masses of nuclei located deep in the cerebral hemispheres that are responsible for control of fine motor movements% including those of the hands and lo6er e<tremities& T'alamus 4ies on either side of the third ventricle and acts primarily as a relay station for all sensation e<cept smell& All memory% sensation% and pain impulses also pass through this section of the brain& !"pot'alamus 4ocated anterior and inferior to the thalamus& The hypothalamus lies immediately beneath and lateral to the lo6er portion of the 6all of the third ventricle& It includes the optic chiasm ?the point at 6hich the t6o optic tracts cross@ and the mamillary bodies ?involved in olfactory refle<es and emotional response to odors@& The infundibulum of the hypothalamus connects it to the posterior pituitary gland& The hypothalamus plays an important role in the endocrine system because it regulates the pituitary secretion of hormones that influence metabolism% reproduction% stress response% and urine production& It 6or9s 6ith the pituitary to maintain fluid balance and maintains temperature regulation by promoting vasoconstriction or vasodilation& The site of the hunger center and is involved in appetite control& It contains the centers that regulate the sleep-6a9e cycle% blood pressure% aggressive and se<ual behavior% and emotional responses& The hypothalamus also controls and regulates the autonomic nervous system& ituitar" Gland

23 4ocated in the sella turcica at the base of the brain and is connected to the hypothalamus& The pituitary is a common site of brain tumors in adultsE frequently they are detected by physical signs and symptoms that can be traced to the pituitary% such as hormonal imbalance or visual disturbances secondary to pressure on the optic chiasm& 2&( !iencephalon The thalamus % 6hich forms the ma0or part of the diencephalon% receives incoming sensory impulses and routes them to the appropriate higher centers& The hypothalamus % occupying the rest of the diencephalon% regulates heartbeat% body temperature% and fluid balance&

3.$ Sc'ematic +iagram Precipitating - 3ypertension - Cardiovascular !isease - !iabetes Mellitus - Intracranial Aneurysm Predisposing - 3igh Cholesterol 4evels - /besity - :levated 3ematocrit - Smo9ing - !rug Abuse - :<cessive Alcohol

Cerebrovascular Accident

24 Signs and Symptoms - 3emiparesis - Aphasia - Ata<ia - 3emiplegia - !ysphagia Management - 4oss of peripheral vision - 3omonymous hemianopsia - Paresthesia - !ysarthia - !iplopia

Nursing Turning of patient every ) hours 'ed rest to prevent agitation and stress Management of vasospasm Patient is fitted 6ith plastic Compression stoc9ings to Prevent deep vein thrombosis heparin

Medical - Surgical or medical treatment to prevent rebleeding - Analgesics? codeine% acetaminophen@ may be prescribed for head and nec9 pain - Alteplase - Anticoagulations 6ith - Aspirin

Optimum evel o! "unctioning 3.( +isease rocess A stro9e is damage to the brain due to an interruption in the blood flo6& The interruption may be caused by a blood cot% constriction of a blood vessel% or rupture of a vessel accompanied by bleeding& A pouch li9e e<pansion of the 6all of a blood vessel% called an aneurysm% may 6ea9en and burst% for e<ample% because of high blood pressure& Sufficient quantities of glucose and o<ygen% transported through the bloodstream% are needed to 9eep nerve cells alive& >hen the blood supply to a small part of the brain is interrupted% the cells in that area die and function of the area is

25 lost& A massive stro9e can cause a one-side paralysis ?hemiplegia@ and sensory loss on the side of the body opposite the hemisphere damaged by the stro9e& The Pathophysiology of hemorrhagic stro9e depends on the cause and type of cerebrovascular disorder& Symptoms are produced 6hen an aneurysm or A8M enlarges and presses on nearby cranial nerves or brain tissue or% more dramatically% 6hen an aneurysm or A8M ruptures% causing subarachnoid hemorrhage ?hemorrhage into the cranial subarachnoid space@& Normal brain metabolism is disrupted by the brain being e<posed to bloodE by an increase in ICP resulting from the sudden entry of blood into the subarachnoid space% 6hich compresses and in0ures brain tissueE or by secondary ischemia of the brain resulting from the reduced perfusion pressure and vasospasm that frequently accompany subarachnoid hemorrhage& An intracerebral hemorrhage% or bleeding into the brain substance% is most common in patients 6ith hypertension and cerebral atherosclerosis because degenerative changes from these diseases cause rupture of the vessel& They also may be due to certain types of arterial pathology% brain tumor% and the use of medications ?oral anticoagulants% amphetamines and illicit drugs such as crac9 and cocaine@& The bleeding is usually arterial and occurs most commonly in the cerebral lobes% basal ganglia% thalamus% brain stem ?mostly the pons@% and cerebellum& /ccasionally% the bleeding ruptures the 6all of the lateral ventricle and causes intraventricular hemorrhage% 6hich is frequently fatal& An intracranial ?cerebral@ aneurysm is a dilation of the 6alls of a cerebral artery that develops as a result of 6ea9ness in the arterial 6all& The cause of aneurysm is un9no6n% although research is ongoing& An aneurysm may be due to atherosclerosis% resulting in a defect in the vessel 6all 6ith subsequent 6ea9ness of the 6allE a congenital defect of the vessel 6all 6ith subsequent 6ea9ness of the

26 6allE a congenital defect of the vessel 6allE hypertensive vascular diseaseE head traumaE or advancing age& Any artery 6ithin the brain can be the site of cerebral aneurysms% but they usually occur at the bifurcations of the large arteries at the circle of >illis& The cerebral arteries most commonly affected by an aneurysm are the internal carotid artery ?ICA@% anterior cerebral artery ?ACA@% anterior communicating artery ?ACoA@% posterior communicating artery ?PCoA@% posterior cerebral artery ?PCA@% and middle cerebral artery ?MCA@ Multiple cerebral aneurysms are not uncommon& An A8M is due to an abnormality in embryonal development that leads to a tangle of arteries and veins in the brain 6ithout a capillary bed& The absence of a capillary bed leads to dilation of the arteries and veins and eventual rupture& They are commonly a cause of hemorrhage in young people& A subarachnoid hemorrhage ?hemorrhage into the subarachnoid space@ may occur as a result of an A8M% intracranial aneurysm% trauma% or hypertension& The most common cause is lea9ing aneurysm in the area of the circle of >illis or a congenital A8M of the brain&

27

The patient 6ith a hemorrhagic stro9e can present 6ith a 6ide variety of neurologic deficits% similar to the patient 6ith ischemic stro9e& A comprehensive assessment 6ill reveal the e<tent of the neurologic deficits& Many of the same motor% sensory% cranial nerve% cognitive% and other functions that are disrupted follo6ing ischemic stro9e are altered follo6ing a hemorrhagic stro9e& In addition to the neurologic deficits that are similar to ischemic stro9e% the patient 6ith an intracranial aneurysm or A8M can have some unique clinical manifestations& 7upture of an aneurysm or A8M usually produces a sudden% unusually severe headache and often loss of consciousness for a variable period& There may be pain and rigidity of the bac9 of the nec9 ?nuchal rigidity@ and spine due to meningeal irritation& 8isual disturbances ?visual loss% diplopia% ptosis@ occur 6hen the aneurysm is ad0acent to the oculomotor nerve& Tinnitus% diCCiness% and hemiparesis may also occur& At times% an aneurysm or A8M lea9s blood% lea9ing to the formation of a clot that seals the site of rupture& In this instance% the patient may sho6 little neurologic deficit& In other cases% severe bleeding occurs% resulting in cerebral damage follo6ed rapidly by coma and death& Prognosis depends on the neurologic condition of the patient% age% associated diseases% and the e<tent and location of an intracranial aneurysm& Subarachnoid hemorrhage from an aneurysm is a catastrophic event 6ith significant morbidity and mortality&

28 3.3 Comparative C'art Classical S"mptom Clinical S"mptom -ationale

29

/isual %ield +eficits 2& 3omonymous hemianopsia ?loss of half of the visual field@ Manifested patient can only see in her left eye visual-perceptual dysfunctions disturbances of the primary sensory path6ays bet6een the eye and visual corte<& The affected side of vision corresponds to the paralyCed side of the body& )& 4oss of peripheral vision .& !iplopia .otor +eficits 2& 3emiparesis Manifested patient sided She has moving has right 6ea9ness& difficulty her right a stro9e is a lesion of the upper motor neurons and results in loss of voluntary control over motor movements& 'ecause the upper motor neurons decussate% a disturbance of Not manifested

Not manifested

e<tremities& She can fle< her right arm but she can"t gain full control of it&

30 I/. Nursing Intervention 1. Care Guide for a Stro?e atient Assessment asses medical history and ris9 note frequency and duration of symptoms ta9e vital signs closely monitor blood pressure listen for abnormal sounds in the carotid and peripheral arteries note changes in the level of consciousness determine current cardiac status assess hemoglobin level% platelets and clotting time

Signs and Symptoms Arm or leg 6ea9ness and paralysis Speech difficulties 'alance problems 6hen 6al9ing Numbness or lac9 of sensation 3and clumsiness Sudden vision loss Confusion Nausea 7oom spinning SeiCure Coma

#iagnosis M7I ?Magnetic 7esonance Imaging@ CAT scan ?ComputeriCed A<ial Tomography@

31 !SA ?!igital Subtraction Angiography@ A transcranial or carotid doppler ultrasound test 7adionucleotide angiography ::5 ?:lectroencephalogram@

Medical $reatment Alteplase ?a tissue plasminogen activator% or t-PA@ is an intravenous thrombolytic enCyme used to treat acute ischemic stro9e Anticoagulations 6ith heparin Aspirin

Surgical $reatment Carotid ebartectomyN removal of blood clots from carotid arteries feeding the brain Carotid angioplastyN uses a catheter- guided balloon andA or stent to open up a bloc9ed carotid artery Ris% "actors 3eredity AgeN 1= of population over age ;1 have had at least one stro9e 5enderN Men are at a higher ris9 for stro9e 3ypertension& -*= of all stro9e victims have hypertension 3eart and carotid artery disease !iabetes Cigarette smo9ing Alcohol and substance abuse Anticoagulant medications 5eographic location and climate

32 Stro%e Prevention 'lood Pressure monitoring Smo9ing cessation 4imiting alcohol consumption :<ercise 3ealthy diet

Causes: Certain irregularities such as atrial fibrillation to the brain% cause the blood clot to The blood clot moves from the carotid arteries to the brain 'lood vessels to the brain become narro6 due to cholesterol bloc9age Severely 4o6 'lood Sugar !ecreased o<ygen in the blood due to lung problems Myocardial Infarction ?heart attac9@% in 6hich the heart does not pump enough A heart arrythmia does not allo6 the heart to pump enough blood to the brain 8ery 3igh 'lood Pressure move from the valve of the heart

blood to the brain

34
Name of patient$ Mrs& Constancia :rasmo Chief complaints$ 7ight sided hemiparesis Age$ +B yrs& old Se<$ !ate$ *.-21-*- Attending Physician$ !r& Manuel 4im Impression$ Cerebrovascular Accident

1-0NS@ICA ),NS .O+,)

I& P3OSI/4/5IC !: ICIT A& 3emiparesisA right sided 6ea9ness /b0ective Cues$ -limited range of motion - reluctance to attempt movement -decrease muscle tone -inability to perform fine or motor s9ills -inability to move purposefully 6ith in physical environment - dependent on significant others Sub0ective Cues Jmaglisod man siya ug liho9 sa iyang tuo e<tremities nga 9amot ug tiilK%as verbaliCed by significant others '& !ifficulty articulating 6ords /b0ective cues$ Measures to$ A& Ma<imiCe physical mobility$ - Change positions at least every ) hours - Position in prone once or t6ice a day - Place pillo6 under a<illa to abduct arm - :levate hand and leg - Place 9nee in an e<tended position - :ncourage and facilitate early ambulation - :ncourage appropriate use of assistive devices - Provide positive reinforcement during activities - Allo6 patient to perform tas9 at her o6n rate - Perform passive or active 7/M e<ercises to all

'& Manage difficulty in producing speech - 4isten for errors of conversation - Spea9 in normal tones

Patient 6ill A case of a -Patient has difficulty in tal9ing - !iscuss familiar topics have -1 years old -/pens mouth but 6ords aren"t produce - 7espect patients prein0ury capability ;*-+*= -Patient has slurring of speech - Maintain eye contact /4/ 6oman 6ith -Patient has difficulty in articulating 6ords - 5ive ample time to respond psychologic Sub0evtive Cues$ deficits and J maglisod man siya ug storya A& Altered physical C& Promote Self care diagnosed C& Inability to perform A!4 mobility$ 7ight sided 6ea9ness - Maintain a supportive firm attitude 6ith 'ipolar /b0ective Cues$ related to interaption of blood - Provide positive feedbac9s !isorder 2 - Inability to 6ash body parts supply to the brain - :ncourage significant others to - !ifficulty completing toileting tas9 '& Altered verbal communication$ allo6 the patient to do as much !ifficulty articulating 6ords related - Place important things 6ith in - Patient 6ear"s diaper to decrease cerebral tissue perfusion patients reach - 4oss of involuntary movement C& Self care deficit$ Inability to perform M encourage good grooming Sub0ective Cues$ A!4 related to loss of muscle control JTrapohan ug sudlayan namo siya 9ada buntagK Actual state of Cues Nursing !iagnosis Nursing Actions !esired patient"s conditio /b0ectives$ 5oal$ After .*-(1 min& of student nurse-patient After . days of holistic care% interaction% the patient 6ill be able to$ the client 6ill be able to 2& demonstrate 6ays to increase strength and regain optimum level of

35
function of affected body part& functioning& )& use and accept alternative form of communication .& identify resources that can provide assistance as needed

36 $.$ Nursing Care lan Needs < roblems < Cues I& Physiologic !eficit 2& 3emiparesisA right sided 6ea9ness /b0ective Cues$ - reluctance to attempt movement on her right side - limited range of motion - decreased muscle endurance% strength% control or mass - inability to perform fine or motor s9ills as instructed - inability to move purposefully Altered Physical Mobility$ right sided 6ea9ness related to interruption of blood supply to the brain& A stro9e is a lesion of the upper motor neurons and results in loss of voluntary control over motor movements& 'ecause the upper motor neurons decussate% a disturbance of voluntary motor control of one side of the body may reflect damage to the upper motor neurons on the opposite side of the brain& 5eneral /b0ectives$ After 1 days of student nurseclient interaction% the client 6ill be able to attain optimum level of functioning& Specific /b0ectives$ After + hours of student nurseclient interaction% the client 6ill be able to$ 2& demonstrate 6ays to increase strength and function of affected body part Nursing +iagno4sis Scientific 1asis < Significance Objectives of Care Nursing Actions -ationale

Measures to$ A& ma<imiCe physical mobility& 2& change positions at least every ) hours&

2& reduces ris9 of tissue ischemiaA in0ury A !avis" NCP% ;th ed& )& helps maintain functional hip e<tension& A !avis" NCP% ;th ed& .& prevents adduction of shoulder and fle<ion of elbo6s& A !avis" NCP%;th ed& (& promotes venous return and helps prevent edema formation& A !avis"

)& position in prone once or t6ice a day if patient can tolerate&

.& place pillo6 under a<illa to abduct arm&

(&elevate arm and hand&

37 6ithin physical environment% including bed mobility% transfers and ambulation& Sub0ective Cue$ Jmaglisud man siya og lihu9 sa iya tuo na 9amut og tiilK% as verbaliCed by significant others& as evidenced by movement of affected body part 6ithout or 6ith limited assistance& NCP%;th ed& 1& place 9nee in an e<tended position& 1& maintains functional position& A !avis" NCP%;th ed& ;& the longer the patient remains immobile% the greater the level of debilitation that 6ill occur& - NCP by Myers& -& mobility aids can increase level of mobility& - NCP by Myers& +& patients maybe reluctant to move or initiate ne6 activity due to fear of falling& - NCP by Myers& B& hospital 6or9ers and family

Source$ Te<tboo9 of Medical-Surgical Nursing by 'runner and Suddarth% 2*th ed&% vol& ) p& 2++B

;& encourage and facilitate early ambulation and other A!4"s 6hen possible& Assist 6ith each initial change such as dangling% sitting in bed or chair and ambulation& -& encourage the appropriate use of assistive devices in the home setting& +& provide positive reinforcement during activity&

B& allo6 patient to perform tas9s at her

38 o6n rate& !o not rush patient& :ncourage independent activity as able and safe& caregivers are often in a hurry and do more for patient than needed% thereby% slo6ing the patient"s recovery and reducing her self-esteem& - NCP by Myers& 2*& e<ercise promotes increased venous return% prevents stiffness and maintain muscle strength and endurance& - NCP by Myers&

2*& perform passive or active assistive 7/M e<ercises to all e<tremities&

)& !ifficulty articulating 6ordsA speech /b0ective Cues$ - patient has difficulty in tal9ing - opens mouth but 6ords aren"t

Altered 8erbal Communication $ difficulty articulating 6ords related to decreased cerebral tissue perfusion secondary to stro9e&

Aphasia% 6hich impairs the patients ability to understand 6hat is being said and to e<press herself% may become apparent in various 6ays&

)& use and accept alternative form of communication as evidenced by effective use of alternative language to communication&

'& manage difficulty in producing speech& 2& place call light 6ithin reach& )& listen for errors in conversation and provide feedbac9&

2& reduces an<iety& - !oenges% -th ed& )& helps patient realiCe 6hy caregivers are not responding

39 produced - difficulty articulating 6ords - patient has slurring of speech Sub0ective Cue$ Jmaglisud man siya sturya og bungol siya& 4ahi ang iya itubag sa gipangutana sa iyaK% as verbaliCed by the significant others& The cortical area responsible for integrating the path6ays required for the comprehension and formulation of language is called 'roca"s area& It is close to the left motor area and often affects the speech area& This is 6hy so many patients paralyCed in the right side can"t spea9& Source$ Medical-Surgical Nursing% 2*th ed& by SmeltCer& p& 2++B ;& respect patient"s pre-in0ury capability& appropriately& A !avis" NCP% ;th ed& .& anticipate and provide for patient"s needs& .& helpful in decreasing frustration 6hen dependent on others& A !avis" NCP% ;th ed& (& to prevent irritating or frustrating patients& A !avis" NCP% ;th ed& 1& promotes meaningful conversation and provides opportunity to practice s9ills& A !avis" NCP%;th ed& ;& enables patient to feel esteemed% because intellectual abilities often remain intact& A !avisP

(& spea9 in normal tones and avoid tal9ing too fast&

1& discuss familiar topics&

40 NCP% ;th ed& -& provides encouragement -& maintain eye contact and support& and stand close in - !oenges% patient"s line of vision& NCP% -th ed& +& it is difficult to respond under pressure& - !oenges% NCP% -th ed& B& this enables the patient to maintain contact 6ith reality or reduce stimuli to lessen an<iety that may 6orsen the problem& - !oenges% NCP% Bth ed& 2*& to clarify discrepancies bet6een verbal and nonverbal cues& - !oenges% NCP% Bth ed&

+& give ample time to respond&

B& provide environmental stimuli as needed or reduce stimuli&

2*& use confrontation s9ills% 6hen appropriate% 6ithin an established nurseclient relationship& .& Inability to Self Care Self Care !eficit .& identify C& promote self care$

41 perform Activities of !aily 4iving !eficit$ inability to perform activities of daily living /b0ective Cues$ related to loss - inability to of muscle 6ash body parts control& by herself - difficulty completing toileting tas9 - needs assistance from the significant others to change her o6n clothes - patient 6ears diapers - loss of voluntary movement on right side of the body Sub0ective Cue$ J trapuhan og sudlayan namo siya 9ada buntagK% as verbaliCed by the significant others& may range from not being able to reach 6ith a 6ea9 arm to full dependence on others& This is applicable if an achievable outcome is obtained& Clients 6ith complete paralysis and cognitive deficits may not be able to perform self care& resources that can provide assistance as needed& 2& maintain a supportive% firm attitude& 2& patient need empathy& A !avis" NCP% ;th ed& )& enhances sense of self 6orth& Promotes independence& A !avis NCP% ;th ed& .& reestablishes a sense of independence and foster self 6orth& A !avis NCP% ;th ed& (& to provide easy access to useful things& A !avis NCP% ;th ed& 1& to enhance patient"s self 6orth& A !avis NCP% ;th ed& ;& to prevent an<iety&

)& provide positive feedbac9s for efforts and accomplishments&

.& encourage the significant others to allo6 the patient to do as much as possible&

Source$ Te<tboo9 of Medical-Surgical Nursing by 'lac9& p& )2)+

(& place important things 6ithin the patient"s reach&

1& encourage good grooming of patient&

;& Allo6 patient sufficient time to

42 accomplish tas9& -& avoid doing things that the patient can do for herself& A !avis NCP% ;th ed&

-& patient may become fearful and dependent& - !oenges NCP% -th ed& +& encourage client and build on successes& - !oenges NCP% Bth ed& B& enhances coordination and continuity of care& - !oenges NCP% Bth ed& 2*& to enhance capabilities& - !oenges NCP% Bth ed&

+& assist 6ith necessary adaptations to accomplish A!4"s& 'egin 6ith familiar easily accomplished tas9& B& provide for communication among those 6ho are involved in caring forA assisting the client& 2*& assist 6ith rehabilitation program&

43 $.( SOA I, SOA I, B 1 April 1$& $667 S4 J!i mana niya malihu9 ang iyang tuo nga la6asK% as verbaliCed by the significant others& O4 observed patient lying in bed in semi-fo6lers position supported by . pillo6s% dro6sy% has slurred speech% 9eeps on tal9ing 6hile asleep% restless% incoherent and 6ith right sided 6ea9ness& Noted the follo6ing vital signs$ 'PQ 2.*A+* mm3g TQ .;&. RC P7Q -; bpm 77Q 2A4 Altered physical mobility$ 7ight sided 6ea9ness related to interruption of blood supply to the brain& 4 to promote independent mobility 6ith limited assistance from significant others& I4 determined degree of immobility% noted emotionalAbehavioral responses to problems of immobility% assistedA have client repositioned self on a regular schedule as dictated by individual situation% instructed the use of side rails% supported affected body partsA0oints using pillo6s& ,4 patient rested and 6ent bac9 to sleep 6ith pillo6s on her affected side&

SOA I, B $ April 1( &$667 S4 JNaa man siya"y bedsores& >ala gihapon naayo% ning uga ra cyaK% as verbaliCed by the significant others& O4 received patient dangling her legs at the edge of the bed% resting% conscious% has slurred speech% doing passive e<ercises assisted by the significant others% her bac9 supported 6ith pillo6s% her foot is 6rin9led% 6ith s9in lesions% blac9 in color% has bed sores in both feet& Noted the follo6ing vital signs$ 'PQ 2.*AB* mm3g TQ .;&2 RC P7Q -* bpm 77Q )( A4 Altered S9in Integrity$ pressure ulcers related to immobility& 4 promote blood circulation& I4 encouraged implementation and posting of a turning schedule% restricted time in one position for t6o hours or less or customiCing the schedule to patient"s routine and caregivers needsE increased tissue perfusion by massaging around affected area% limitedA avoided the use of plastic materials% used appropriate padding devices 6hen indicated% encouraged early ambulation or mobiliCation% applied calmoseptine ointment to the bed sores& ,4 JSalamat day haSK as verbaliCed by the significant others% patient continued sitting at the edge of the bed% dangling her legs&

44 $.3 !ealt' Teac'ing lan Objectives 5eneral /b0ectives$ After three days of student nurse-client interaction the significant others 6ill be able to acquire adequate 9no6ledge% attitude% and s9ills in the care of a patient 6ith cerebovascular accident Specific /b0ectives$ After + hours of student nursesignificant others interaction% the significant others 6ill be able to$ 2& !efine stro9e in their o6n level of understanding& - Stro9e is a term used to describe neurologic changes caused by an interruption in the blood supply to a part of the brain& - Informal !iscussion - the significant others 6ere able to understand in their o6n level of understanding& Content .et'odolog" ,valuation

)& 5ive some ris9 factors of stro9e&

7is9 actors$ - hypertension - cardiovascular disease - atrial fibrillation - diabetes mellitus - hyperlipidemia - cigarette smo9ing - heavy alcohol consumption - cocaine use - obesity

- Informal !iscussion

- the significant others 6ere able to enumerate the ris9 factors of stro9e

45 .& :numerate the general clinical manifestations of stro9e& Clinical Manifestation$ - headache - vomiting - seiCures - transient hemiparesis - loss of speech - hemisensory loss - changes in mental status - changes in :C5 results Causes$ - certain irregularities such as atrial fibrillation to the brain% cause the blood clot to move from the valve of the heart - the blood clot moves from the carotid arteries to the brain - blood vessels to the brain become narro6 due to cholesterol bloc9age - severely lo6 blood sugar - decreased o<ygen in the blood due to lung problems& - myocardial infarction ?heart attac9@% in 6hich the heart does not pump enough blood to the brain - a heart arrythmia does not allo6 the heart to pump enough blood to the brain - very high blood pressure 1& Sho6 positive attitude in providing care to the patient& - The patient needs the support of the family throughout the hospitaliCation course& This may give them strength and enhance their self 6orth& - 7eflection - They 6ere cooperative throughout the patients" hospitaliCation& - Informal 4ecture and !iscussion - the significant others 6ere able to enumerate clinical manifestations of stro9e&

(& :numerate some causes of stro9e&

- Informal 4ecture and !iscussion

- the significant others 6ere able to enumerate some causes of stro9e&

46 ;& :numerate some treatment for stro9e& Treatment$ Medical$ - alteplase - anticoagulations 6ith heparin - aspirin Surgical$ - carotid ebartectomy - carotid angioplasty -& :numerate some 6ays to prevent stro9e& Stro9e Prevention$ - blood pressure monitoring - smo9ing cessation - limiting alcohol consumption - e<ercise - healthy diet - Informal !iscussion - the significant others 6ere able to enumerate some 6ays to prevent stro9e& - Informal !iscussion - the significant others 6ere able to enumerate some treatments for stro9e&

47 /. ,/A)0ATION AN+ -,CO..,N+ATION The patient is slo6ly recovering from her condition& The patient can perform limited passive 7/M e<ercise in her right arm 6ith assistance from her significant others& The patient"s blood pressure reduced from 2(*A2** to 2.*AB* due to inta9e of maintenance medications such as Perindopril& The significant others 9no6 the importance of strictly follo6ing the turning schedule& They truly had a great role in caring for the patient& They provided her the support that she needed& Through this case study% the student nurse realiCed the effectiveness of her care& After several days of nursing management% the student nurse observed a change in the client"s condition compared to the first day of interaction& The student nurse thin9s that there is a great possibility for the patient to recover and fully attain the optimum level of functioning prior to her present condition& Therefore% the student nurse recommends that the patient follo6s strict compliance to the maintenance medications prescribed by the physician& The student nurse also recommends the patient and the significant others of follo6ing continuous consultation and rehabilitation 6ith the physical therapist% cardiologist and neurologist& The student nurse also recommends the significant others to encourage the patient to live a healthy lifestyle free from stress& /I. ,/A)0ATION AN+ I. )ICATION O% T!IS CAS, ST0+C TO: N0-SING -ACTIC,: This case study 6ill improve the nursing practice of giving holistic care to patients 6ith stro9e or cerebrovascular accidents putting emphasis on their psychological and physiologic needs& The student nurse 6ill be able to improve her s9ills in

48 assessment and be able to formulate appropriate nursing interventions for identified problems and needs& N0-SING ,+0CATION: The disorder is a common disease and highly emerging as a 6orld6ide epidemic& Stro9e is the number one 9iller in the >estern hemisphere ne<t to heart disease and cancer& Nursing education is primarily focused on rehabilitative care& Trainings and modules on the role of nurses in the rehabilitative setting should highly be emphasiCed& Nurse"s role on the care for the emotional impact on the client is also important& Patients 6ho suffer from stro9e often suffer emotional liability% in 6hich sudden s6itch from emotional highs and lo6s is observed& The nurses initial 9no6ledge on ho6 to react to patient"s emotional struggle is needed at this stage& N0-SING -,S,A-C! 3aving this research about Cerebrovascular Accident% the student nurse 6as able to have a positive vie6 to6ards the nature of the disease& The research gives the student nurse information that is necessary in the collection of ideas that greatly contributed to the success of this research& 'y having this research% the s9ills of the student nurse in collecting ideas 6as enhanced& Not only that this research give us more information but it also aided the student nurse to come up 6ith ideas that could contribute to the 6ellness of the patients 6ith stro9e&

49 /II. 1ibliograp'" 2& 'lac9% ,oyce and :sther Mantassarin-,acobs& 4uc9mann and Sorensen"s Medical-Surgical Nursing$ A Psychophysiologic Approach& (th :d& Philadelphia& >&'& Saunders Company& 2BB. )& Craven% 7uth and Constance 3irnle& undamentals of Nursing$ 3uman 3ealth

and unction& Philadelphia& ,&'& 4ippincott Company& 2BB) .& !oenges% Moorehouse and 5eissler"s Nursing Care Plans & ;th :d Publishers Incorporated& )**( (& ToCier% 'arbara% et al& undamentals of Nursing$ Concepts% Process and Practice& 1th :d& #&S&A& Addison->esley Publishing Company Incorporated& 2BB+SmeltCer% 1& Marieb% :laine% :ssentials of 3uman Anatomy and Physiology& (th :d& California& The 'en0aminACummings Publishing Company Incorporated& 2BB( ;& P!7 Nurse"s 3andboo9& 2BBB :d& Philippines& !elmar Publishers and Medical :conomic Company Incorporated& 2BBB -& SuCanne and 'renda 'are& 'runner and Suddarth"s Te<tboo9 of Medical-Surgical Nursing& 2*th :d& Philadelphia& 4ippincott >il9ins and >illiams Incorporated& )*** &A& !avis

50