I.

INTRODUCTION

The nervous system is an organ system containing a network of specialized cells

called neurons that coordinate the actions of an animal and transmit signals between different
parts of its body. In most animals the nervous system consists of two parts, central and
peripheral. The central nervous system of vertebrates (such as humans) contains the brain, spinal
cord, and retina. The peripheral nervous system consists of sensory neurons, clusters of neurons
called ganglia, and nerves connecting them to each other and to the central nervous system.
These regions are all interconnected by means of complex neural pathways. The enteric nervous
system, a subsystem of the peripheral nervous system, has the capacity, even when severed from
the rest of the nervous system through its primary connection by the vagus erve, to function
independently in controlling the gastrointestinal system. (Accessed at:
http://www.merck.com/mmhe/sec06/ch086/ch086a.html on August 12, 2010)

The autonomic nervous system regulates certain body processes, such as blood pressure
and the rate of breathing. This system works automatically (autonomously), without a person's
conscious effort. The autonomic nervous system has two main divisions: the sympathetic and the
parasympathetic. After the autonomic nervous system receives information about the body and
external environment, it responds by stimulating body processes, usually through the
sympathetic division, or inhibiting them, usually through the parasympathetic division. (Giraldo,
Elias A., 2007)

An autonomic nerve pathway involves two nerve cells. One cell is located in the brain
stem or spinal cord. It is connected by nerve fibers to the other cell, which is located in a cluster
of nerve cells (called an autonomic ganglion). Nerve fibers from these ganglia connect with
internal organs. Most of the ganglia for the sympathetic division are located just outside the
spinal cord on both sides of it. The ganglia for the parasympathetic division are located near or in
the internal organs. (Giraldo, Elias A., 2007)

Generally, the sympathetic division prepares the body for stressful or emergency
situations—fight or flight. Thus, it increases heart rate and the force of heart contractions and
widens (dilates) the airways to make breathing easier. It causes the body to release stored energy.
Muscular strength is increased. This division also causes palms to sweat, pupils to dilate, and
hair to stand on end. It slows body processes that are less important in emergencies, such as
digestion and urination.

The parasympathetic division controls body process during ordinary situations.

Generally, it conserves and restores. It slows the heart rate and decreases blood pressure. It
stimulates the gastrointestinal tract to process food and eliminate waste. Energy from the
processed food is used to restore and build tissues.

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, acetylcholine has parasympathetic (inhibiting) effects and
norepinephrine has sympathetic (stimulating) effects. However, acetylcholine has some
sympathetic effects. For example, it sometimes stimulates sweating or makes the hair stand on
end. (Giraldo, Elias A., 2007)

In the brain there are certain arteries that supply blood into different portion in the brain. The
anterior cerebral artery supplies the medial portions of the frontal and parietal lobes and corpus
callosum. The middle cerebral artery supplies large portions of the frontal, parietal, and temporal
lobe surfaces. Branches of the anterior and middle cerebral arteries (lenticulostriate arteries)
supply the basal ganglia and anterior limb of the internal capsule. The vertebral and basilar
arteries supply the brain stem, cerebellum, posterior cerebral cortex, and medial temporal lobe.
The posterior cerebral arteries bifurcate from the basilar artery to supply the medial temporal
(including the hippocampus) and occipital lobes, thalamus, and mammillary and geniculate
bodies. The anterior and posterior circulations communicate in the circle of Willis which is at the
base of the brain. (Accessed at: http://www.merck.com/mmhe/sec06/ch086/ch086a.html on
August 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. Arteries may also be blocked by a blood clot (thrombus). Blood clots may form

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on an atheroma in an artery. Clots may also form in the heart of people with a heart disorder. Part
of a clot may break off and travel through the bloodstream (becoming an embolus). It may then
block an artery that supplies blood to the brain, such as one of the cerebral arteries. (Giraldo,
Elias A., 2007)

Cerebrovascular accident (CVA) is the medical term for what are commonly termed as
CVA, brain attack, cerebral infarction or stroke. It refers to the acute neurological injury to the
brain that occurs when flow of blood to brain tissue is interrupted by a clogged or ruptured
artery. The brain requires a steady supply of oxygen in order to pump blood effectively to all of
the body. Oxygen is supplied to the brain in the blood that flows through arteries. Total cessation
of blood flow produces irreversible brain infarction within 3 minutes. Once the oxygen-rich
blood flow stops, the tissues become ischemic, toxins released by damaged neurons, cerebral
edema, and alterations in local blood flow contribute to neuron dysfunction, leading to hypoxia
or anoxia with destruction or necrosis of the glia, and vasculature causing brain tissue to die
because of lack of nutrients and oxygen. (Lippincott Williams & Wilkins, 2003, Handbook of
Diseases)

CVA or Strokes can be classified into two major categories: ischemic and hemorrhagic.
Ischemic strokes are those that are caused by interruption of the blood supply, while hemorrhagic
strokes are the ones which result from rupture of a blood vessel or an abnormal vascular
structure. 87% of strokes are caused by ischemia and the remainder by hemorrhage. Some
hemorrhages develop inside areas of ischemia ("hemorrhagic transformation"). It is unknown
how many hemorrhages actually start off as ischemic stroke. Stroke symptoms lasting < 1 h are
termed a transient ischemic attack (TIA). Strokes damage brain tissue; TIAs often do not, and
when damage occurs, it is less extensive than that due to strokes. (Accessed on:
http://www.eurekalert.org/pub_releases/2008-03/arrs-wbm032808.php at August 2, 2010)

Risk factors for a cerebrovascular accident include having hypertension, heart disease,
diabetes, high cholesterol and obesity. Other risk factors include being of African-American
ancestry, being male, drinking excessive amounts of alcohol, smoking and having a family
history of heart disease or cerebrovascular accident. Having a brain aneurysm puts a person at an

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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,

one of the small arteries deep in the brain becomes blocked by a mixture of fat and connective
tissue—a blood clot is not the cause. This disorder is called lipohyalinosis and tends to occur in
older people with diabetes or poorly controlled high blood pressure. Lipohyalinosis is different
from atherosclerosis, but both disorders can cause blockage of arteries. Only a small part of the
brain is damaged in lacunar infarction. (Lippincott Williams & Wilkins, 2003, Handbook of
Diseases)

Rarely, small pieces of fat from the marrow of 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, may resemble a stroke.

The incidence of stroke increases exponentially from 30 years of age, and etiology varies
by age. Advanced age is one of the most significant stroke risk factors. 95% of strokes occur in
people age 45 and older, and two-thirds of strokes occur in those over the age of 65. A person's
risk of dying if he or she does have a stroke also increases with age. However, stroke can occur
at any age, including in fetuses. Men’s stroke incidence rates are 1.25 times greater than
women’s. The difference in incidence rates between the sexes is somewhat higher at younger
ages but nonexistent at older ages. The male/female incidence was 1.59 for ages 65–69; 1.46 for
ages 70–74; 1.35 for ages 75–79 and 0.74 for age 80 and older. (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 suggest that
even a small blood pressure reduction (5 to 6 mmHg systolic, 2 to 3 mmHg diastolic) would
result in 40% fewer strokes. Lowering blood pressure has been conclusively shown to prevent
both ischemic and hemorrhagic strokes. It is equally important in secondary prevention. Even
patients older than 80 years and those with isolated systolic hypertension benefit from
antihypertensive therapy. Studies show that intensive antihypertensive therapy results in a greater

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risk reduction. The available evidence does not show large differences in stroke prevention
between antihypertensive drugs —therefore, other factors such as protection against other forms
of cardiovascular disease should be considered and cost. (US Census Bureau, International Data
Base, 2004)

An ischemic stroke can also result from any disorder that reduces the amount of blood or
oxygen supplied to the brain, such as severe blood loss or very low blood pressure. Occasionally,
an ischemic stroke occurs when blood flow to the brain is normal but the blood does not contain
enough oxygen. Disorders that reduce the oxygen content of blood include a severe deficiency of
red blood cells (anemia), suffocation, and carbon monoxide poisoning. Usually, brain damage in
such cases is widespread (diffuse), and coma results. (Lippincott Williams & Wilkins, 2003,
Handbook of Diseases)

An ischemic stroke can occur if inflammation of blood vessels (vasculitis) or infection

(such as herpes simplex) narrows blood vessels that supply the brain. Migraine headaches or
drugs such as cocaine and amphetamines can cause spasm of the arteries, which can narrow the
arteries supplying the brain and cause a stroke. (Lippincott Williams & Wilkins, 2003, Handbook
of Diseases)

The group found Cerebrovascular Accident as an interesting case for the case study.
Utilizing the available resources at the library as well as the internet to provide accurate
information about the said disease. The group also chose this case so that expand the familiarity
and understanding that will also be of assistance in the future.

A. Objectives

After the completion of the study, the student nurses shall be able to:

 Identify and differentiate risks for cerebrovascular accident

 Be updated with the latest trends in the treatment of cerebrovascular accident
 Perform a comprehensive assessment of Cerebrovascular accident
 Enumerate the different signs and symptoms of Cerebrovascular accident

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  List down the different diagnostic procedures that would help in the diagnosis of
Cerebrovascular accident.
 Identify and understand different types of medical treatment necessary for the treatment
of Cerebrovascular accident.
 Formulate nursing care plans utilizing the nursing process
 Formulate conclusions based on the findings and enumerated a recommendations
concerning Cerebrovascular accident.

Nurse Centered Objectives:

At the end of the study, the student nurses:

 Shall have critical thinking skills necessary for providing safe and effective nursing care.

 Shall have a comprehensive assessment and implement care base on our knowledge and
skills of the condition

 Shall have familiarized us with effective inter-personal skills to emphasized health

promotion and illness prevention.

 Shall have imparted the learning experience from direct patient care.

Patient Centered Objectives:

At the end of this study, the patient/family will be able to:

1. Identify measures that could minimize the risk of occurrence of the disease.
2. Identify possible risk factors that may have contributed to the development of
Cerebrovascular accident.
3. Increase awareness on the risk factors of Cerebrovascular accident.
4. Develop the family’s support system and distinguish their respective roles in improving
patient’s health status.
5. Involve them in promoting the health care of the patient.

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Page | 6
 II. NURSINGASSESSMENT

A. Personal History

Tatay Stroke, is the father of seven children with his first marriage and three step-
children from his first wife. He is the second eldest among seven children. He is currently
living with his second wife whom is his primary caregiver. He was a overseas worker for
25 years at Saudi Arabia as a Engineering for an air-conditioning company to be able to
support his wife and children.

After all of his children graduated, he stopped working and receiving support from
his children who are currently overseas, three of which are working as nurses. Other that
the support he is receiving from his children, he also receives money from his pension
which he and his wife are consuming for their expenses like in his hospitalization.

A college graduate, he met his first wife at a church while hearing mass. They
eloped after getting a stable job at a soft drinks company to be able to support their family.
During the time that he was married with his first wife he was working overseas and
would come home back once or twice a year to see his family. Once he stopped working
and came home to the country he and his first wife have separated and got annulled. Then
he met his second wife, who was a common friend of him and one of his friends, after
meeting and getting to know each other, he married her who he is living with now and the
one who is taking care of him. He has been a chain smoking since his college years. His
smoking started from 2 sticks a day partially increasing in years of his smoking. He later
developed Hypertension which also had been running in his family. Hypertension was
diagnosed when got a doctor’s appointment because of persistent headaches, nape pain
and dizziness. His blood pressure was monitored and final diagnosed with Hypertension.

B. Pertinent family history

Grandfather Grandmother Grandfather Grandmother

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Father Mother
 Brother Tatay stroke Brother Brother Sister Sister Brother
Ø(78y/o) (75y/o) 72(y/0) Ø69(y/o) 66(y/o) Ø(63y/o) Ø59(y/o)

Legend: Male Female Married

No Known Disease Diabetes Mellitus

Deceased Hypertension
Ø   

 Asthma  Old Age

 Bronchitis

Tatay stroke comes from a big family. He is the second eldest among the seven children.
Four of them are males while two are females. Both his grandfather in his father and mother’s
side died because of Hypertension. While one of her grandmother died due to Diabetes Mellitus
and the other one because of old age. His father suffered from asthma and unfortunately, it until
he got diagnosed with Bronchitis and died. His mother was a smoker, with a lot of vices such as
excessive alcohol intake that brought up her condition and reason for her death. There were no
other family members who suffered from CVA.

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 C. History of Past illness

The patient had no previous hospital confinement. Though his wife said that, Tatay
Stroke suffers from productive cough and colds whenever cold weather sets in, medicines for
common cough and colds are given and if it was accompanied by fever, she would give him
antipyretics. She assumed that maybe, concurrent cough episode is caused by her husband’s
deadly practice, which is smoking. During his childhood days, Tatay stroke, have experienced
having Measles, Chicken Pox, Mumps and Tonsillitis.

D. History of Present illness

Tatay Stroke suffers from headache, right body weakness and has difficulty in speaking
brought about mainly by his current diagnosis which is Cerebrovascular accident due to
hypertension. Two days prior to admission, his mother-in-law of his second wife noticed Tatay
Stroke, the right side of his face is flaccid and right upper and lower extremities seemed to be
numbed. The right side of his body has an observable weakness that left him in a complete bed
rest for two days in their house. When his mother-in-law came to visit, she forced Tatay Stroke
to come with her to local hospital nearby where he was admitted with a chief complaint of right
sided body weakness.

Type
Assessment Normal
Cranial Nerve and Client’s Response
Technique Response
Function

Type: Ask the client to Client is able to Tatay Stroke was able
I. Olfactory smell and identify identify to identify the
Sensory the smell of different smell different scents (garlic
garlic/coffee with with each and coffee) that he had

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 Function: each nostril nostril smelled.
separately and with separately and
Sense of smell the eyes closed. with eyes
closed unless
such condition
like colds is
present.

II. Optic Type: The client is The client Tatay Stroke was able
instructed to cover should spot the to spot the moving
Sensory an eye and looked moving object object in his right
directly on the in her peripheral vision.
Function: examiner’s nose (as periphery. However on the left
well as the examiner, side, the cient had a
Sense of  as it looks at the difficulty seeing
vision client’s nose). An things.
object is move into
visual fields in the
periphery. The client
is informed to tell
the examiner when
the moving object is
spotted.

III. Oculomotor Motor Reaction to light: Illuminated and The illuminated and
non-illuminated non-illuminated pupil
  Using a penlight and pupil should of Tatay Stroke
approaching from the constrict. constricted.
Pupil side, shine a light on
constriction, the pupil. Observe
movement of the response of the
eye up and illuminated pupil.
down Shine the light on the

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 pupil again, and
observe the response
of the other pupil.

Reaction to
accommodation:
Pupils constrict Tatay Stroke pupils
Ask client to look at when looking constricted when
a near object and at a near object, asked to look at a near
then at a distant dilate when object, dilated at a far
object. Alternate the looking at a object, and when an
gaze from the near to distant object, object is moved
the far object. Next, converge when towards the nose, the
move an object near object is iris converged.
towards the client’s moved towards
nose. the nose.

IV. Trochlear Motor Hold a penlight 1 ft. Client’s eyes Both eyes of Tatay
in front of the should be able Stroke are able to
  client’s eyes. Ask the to follow the move as necessary.
client to follow the penlight as it
Downward, movements of the moves.
superior and penlight with the
inferior eyes only. Move the
oblique, penlight upward,
lateral downward, sideward
and diagonally.

V. Trigeminal Motor The patient is asked Client should There is the affectation
to swallow as being be able to move of his jaw movement
  observed by the his jaw and and has difficulty in
examiner. swallow mastication.
without

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   difficulty.

VI. Abducens Motor Hold a penlight 1 ft. Both eyes Both eyes of Tatay
in front of the coordinated, Stroke move in
Lateral client’s eyes. Ask the move in unison coordination.
client to follow the with parallel
movement of movements of the alignment.
eyes penlight with the
eyes only. Move the
penlight through the
six cardinal fields of
gaze.

VII. Facial Motor and Ask client to smile, Client should Tatay Stroke wasn’t
Sensory raise the eyebrows, be able to able to raise eyebrows,
frown, and puff out smile, raise and puff out his cheek
Movement of cheeks, close eyes eyebrows, and at the left side of the
muscles of the tightly. puff out cheeks face.
faces. and close eyes
without any
difficulty.

VIII. Sensory and Have the client Client should Tatay Stroke was able
Vestibulocochlear motor occlude one ear. Out be able to hear to hear tickling in both
of the client’s sight, the tickling of ears.
place a tickling the watch in
watch 2 to 3 cm. ask both ears.
Sense of what the client can
hearing hear and repeat with
the other ear.
 

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IX. Glossopharyngeal Sensory and Ask the client to say Client should Tatay Stroke was able
motor “ah” and have the be able to elicit to elicit gag reflex and
patient yawn to gag reflex and able to swallow with
Sense of taste observe upward swallow difficulty.
on the movement of the soft without any
posterior 1/3 palate. difficulty.
of the tongue
Elicit gag response.
 
Note ability to
Gag reflex swallow.

X. Vagus Motor Ask the patient to The client Tatay Stroke was able
swallow and speak should be able to swallow with
Swallowing (note hoarseness) to swallow difficulty and has
and speaking without slurred speech..
and gag reflex difficulty and
speak audibly.

XI. Accessory Motor Ask client to shrug Client should Tatay Stroke was able
shoulders against be able to shrug to shrug only his left
Movement of resistance from your shoulders and shoulders and turn his
shoulder hands and turn head turn head from head from one side.
muscle to side against side to side.
resistance from your
hand (repeat for
other side).

XII. Hypoglossal Motor Ask client to The client Tatay Stroke has
protrude tongue at should be able restricted movement
Movement of midline and then to move tongue of the tongue.
tongue. move it side to side. without any

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difficulty.

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DIAGNOSTIC AND LABORATORY PROCEDURES

DATE
OREDERE
DIAGNOSTIC OR D
INDICATIONS OR RESULT NORMAL ANALYSIS AND
LABORATORY
PURPOSES S VALUES INTERPRETATION
PROCEDURES DATE
RESULTS
IN

COMPLETE BLOOD
COUNT (CBC) OR
HEMATOLOGY
> consists of several tests
that allow for the evaluation
of different cellular
components of the blood on
a broad range of clients. The
items commonly evaluated
include hgb, hct, RBC, RBC
indices, WBC, WBC
differential, platelets and
microscopic examination of
stained blood smears.
D.O: HEMOGLOBIN (HGB) The patient’s Hgb is in the normal
7/22/10 range which means that there is no
-to monitor Hgb value in presence of anemia and there is
D.R: the RBC adequate oxygenation. There is
sufficient oxygen carried by the
7/22/10
-Iron status and oxygen 150 g/dL 120-170 g/dL blood.
carrying capacity of the
RBCs.
-to suggest the presence
of body fluid deficit due
to elevated Hgb level.
RBC COUNT
-it measures the number 5.25 x 10 4.0-5.0 x 10 The patient’s RBC count is
of RBC to detect the moderately elevated which means

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WBC DIFFERENTIAL
COUNT
determines the percentage
of each kinds of white blood
cells in the white blood cell
count
oxygen carrying capacity
the cells.
-it used to assess further
if the patient had
episodes of bleeding
HEMATOCRIT (HCT)
- to aid diagnosis of
abnormal states of
0.45 %
hydration, polycythemia
and anemia.
-It measures the
concentration of RBC
within the blood volume
and is expressed as a
percentage.
8.2 x 10
g/L
WBC COUNT
-to detect infection or
inflammation
-this blood test evaluates
the number of condition
and differentiates causes
of alteration in the total
presence of inflammation.
The patients Hct count is
within the normal range
which means that the
0.37-0.54 % percentage of RBC in blood
is within the normal range
indicating absence of
conditions which contributes
to hemoconcentration and
hemodilution of blood.
5-10 x 10g/L
The WBC count is within the
normal range. WBCs are cells
of the immune system
involved in defending the
body against both infectious
disease and foreign materials.
The body has the adequate
ability to defend the body
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WBC count including against invading
inflammation, infection microorganism which means
and tissue necrosis. that the patient’s immune
defenses patient’s body.

LYMPHOCYTES The value is within the

normal range which means
-to determine viral that there is an absence of
infection viral infections. The body has
the ability produce antibodies
-produces antibodies and
and other chemicals
other chemicals
responsible for destroying
responsible for
microorganisms.
destroying 0.27 % 0.20-0.40 %
microorganisms;
contributes to allergic
reactions, graft rejection,
tumor control, and
regulation of the immune
system.

SEGMENTERS Segmenters are elevated indicating

existence of inflammation.
-are mature neutrophils 0.73 % 0.50-0.70 %
which act as phagocytes
and defend the body and
if levels are elevated it
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 indicates inflammation.

PLATELETS Platelets are elevated in which

causes aggregation of clotting and
-are special cell thrombus formation.
fragments that play an
important role in blood
clotting. If a patient does 450 x 150 – 400 x
not have enough 10/L 10/L
platelets, he will be at an
increased risk of
excessive bleeding and
bruising.

-the CBC measures and

size of platelets present.

NURSING RESPONSIBILITIES:

 Prior

1. Explain the procedure to the patient’s significant other.

2. Explain to the patient that this test will help in the patient’s response to treatment.
3. Tell the patient’s significant other that no fasting is required.
4. Explain to the patient that the test requires blood sample and venipuncture will be performed.
5. Inform the patient that the patient will experience discomfort from the needle puncture and pressure of the tourniquet.

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 6. Inform that she will be experiencing mild pain on site where the needle was pricked.
7. Assure that collecting the blood sample take less than 3 minutes.

 During:

1. Maintain sterile technique.

2. Collect 5-7 ml of venous blood in a vacum.

 After:

1. Apply pressure or pressure dressing to the venipuncture site.

2. Check the venipuncture site for bleeding.
3. Fill-up the laboratory form properly and send it to the laboratory technician during the collection of the sample of the
specimen.

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 DATE
DIAGNOSTIC
OREDERED INDICATION
OR ANALYSIS AND
S OR RESULTS NORMAL VALUES
LABORATORY INTERPRETATION
DATE PURPOSES
PROCEDURES
RESULTS IN

COMPUTED D.O: 7/22/10 To identify the Lacunar infarct, left No evidence of mass The result of the CT
TOMOGRAPHY extent the extent capsuloganglionic lesion or acute scan dated 7/22/10
SCAN (CT-scan, D.R: 7/22/10 of the brain region. parenchymal shows lacunar infarct at
Non-contrast) injury or Microvascular hemorrhage, the left
damage and the ischemic changes, hypodense foci are capsuloganglionic
- An x-ray areas involve both periventricular seen at the left region. The infarction
procedure that that are affected. white matter and left capsuloganglionic may be due to decrease
combines many x- parietal white matter, region, both cerebral oxygenation
ray images with age related cerebral periventritcular white because of the presence
the aid of a atrophy changes, matter and, no of emboli that impedes
computer to atheromatous internal evidence of subfalaine blood supply in the
generate cross- carotid arteries herniation, brain. The result of the
sectional views hydrocephalus or CT scan also shows the
and, if needed, cerebral edema. No affectation of the left
three-dimensional extraaxial fluid side of the brain, which
images of the collection or blood is is why Tatay Stroke
internal organs and seen. The internal manifested
structures of the carotid arteries are Contralateral
body. atheromatous. Note or Hemiparesis or right
age related cerebral sided weakness. The
atrophy changes. CT scan also shows
Orbits petromastoids, affectation of the

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 sella turnica, included Frontal and Parietal
sinuses and bony Lobe wherein the
calvarium are intact, patient manifested
slurred speech and
change in mental status
with a GCS score of 12
at July 26, 2010.

NURSING RESPONSIBILITIES:

 Prior:
1. Inform the patient that the procedure assesses the brain.
2. Obtain a list of medication the patient is taking.
3. Explain the procedure to the patient. The patient’s cooperation is necessary, because he must lie still during the procedure.
4. Obtain information consent if required by the institution.
5. Tell the patient that fasting is not usually required.
6. Review the procedure with the patient. Explain the purpose of the test and how the procedure is performed.
7. Shoe the patient a picture of the CT machine and encourage the patient to verbalize his concerns, because some patients may
have claustrophobia. Most patients who are mildly claustrophobic can be scanned after appropriate premedication with anti-
anxiety drugs.
8. Instruct the patients that wigs, hairpins, clips or partial dental plates cannot be worn during the procedure because they hamper
visualization of the brain.
9. Tell the patient that he may hear a “clicking” noise as the scanning machine moves around the head.

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 During:
1. Ensure that the patient has complied with medications restrictions and pretesting preparations. Ensure that the patient has
removed all external metallic objects prior to procedure.
2. Have emergency equipment readily available.
3. Instruct the patient to cooperate fully and to follow directions. Instruct the patient to remain still throughout the procedure
because movement produces unreliable results.
4. Administer an anti-anxiety agent, as ordered, if the patient has claustrophobia.
5. Ask the patient to inhale deeply and hold his breath while the x-ray images are taken, and then to exhale after the images are
taken.
6. Instruct the patient to take slow deep breaths if nausea occurs during the procedure. Monitor and administer an antiemetic
agent if ordered.
7. Note the following procedure for the brain CT-scan:
 The patient lies in a supine position on an examining table with the head resting on a snug-fitting rubber cap within a
water-filled box. The patient’s head is enclosed only to the hairline. The face is not covered, and the patient can see out of
the machine at all times. Sponges are placed along the side of the head to ensure that the patient’s head does not move
during the study.
8. The scanner passes an x-ray beam through the brain from one side to the other. The machine then rotates 1 degree, and the
procedure is repeated at each degree through a 180-degree arc.
 After:
1. Instruct the patient to resume medications and activity, as directed by the health care practitioner.
2. Monitor vital signs and neurologic status every 15 minutes for 30 minutes.

Document the procedure done.

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Page | 23
III. ANATOMY AND PHYSIOLOGY

CENTRAL NERVOUS SYSTEM

*FIGURE NO. 1: Lateral surface of the cerebral cortex

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, and memory. Some reflex movements can
occur via spinal cord pathways without the participation of brain structures. 

The spinal cord is connected to a section of the brain called the brainstem and runs
through the spinal canal. Cranial nerves exit the brainstem. Nerve roots exit the spinal cord to
both sides of the body. The spinal cord carries signals (messages) back and forth between the
brain and the peripheral nerves.

Cerebrospinal fluid surrounds the brain and the spinal cord and also circulates within the
cavities (called ventricles) of the central nervous system. The leptomeninges surround the brain

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and the spinal cord. The cerebrospinal fluid circulates between 2 meningeal layers called the pia
matter and the arachnoid (or pia-arachnoid membranes). The outer, thicker layer serves the role
of a protective shield and is called the dura matter. The basic unit of the central nervous system
is the neuron (nerve cell). Billions of neurons allow the different parts of the body to
communicate with each other via the brain and the spinal cord. A fatty material called myelin
coats nerve cells to insulate them and to allow nerves to communicate quickly.

*FIGURE NO. 2: Medial surface of the cerebral cortex

Anatomy of the Brain

The Cerebrum 

The cerebrum is the largest part of the brain and controls voluntary actions, speech,
thought, and memory. 

The surface of the cerebral cortex has grooves or infoldings (called sulci), the largest of
which are termed fissures. Some fissures separate lobes.

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

delimited by 2 sulci and is also called a gyrus (gyri in plural). The cerebrum is divided into 2
halves, known as the right and left hemispheres. A mass of fibers called the corpus callosum
links the hemispheres. The right hemisphere controls voluntary limb movements on the left side

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of the body, and the left hemisphere controls voluntary limb movements on the right side of the
body. Almost every person has one dominant hemisphere. Each hemisphere is divided into 4
lobes, or areas, which are interconnected. 

 The frontal lobes are located in the front of the brain and are responsible for voluntary
movement and, via their connections with other lobes, participate in the execution of
sequential tasks; speech output; organizational skills; and certain aspects of behavior,
mood, and memory.

 The parietal lobes are located behind the frontal lobes and in front of the occipital 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 one’s
body parts, the space around one’s body, and one's relationship to this space.
 The temporal lobes are located on each side of the brain. They process memory and
auditory (hearing) information and speech and language functions.
 The occipital lobes are located at the back of the brain. They receive and process visual
information.

The cortex, also called gray matter, is the most external layer of the brain and
predominantly contains neuronal bodies (the part of the neurons where the DNA-containing cell
nucleus is located). The gray matter participates actively in the storage and processing of
information. An isolated clump of nerve cell bodies in the gray matter is termed a nucleus (to be
differentiated from a cell nucleus). The cells in the gray matter extend their projections, called
axons, to other areas of the brain.

Fibers that leave the cortex to conduct impulses toward other areas are termed efferent,
and fibers that approach the cortex from other areas of the nervous system are termed afferent
(nerves or pathways). Fibers that go from the motor cortex to the brainstem (for example, pons)

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or the spinal cord receive a name that generally reflects the connections (that is, corticopontine
tract for the former and corticospinal tract for the latter). Axons are surrounded in their course
outside the gray matter by myelin, which has a glistening whitish appearance and thus gives rise
to the term white matter.  

Cortical areas receive their names according to their general function or lobe name. If in
charge of motor function, the area is called motor cortex. If in charge of sensory function, the
area is called a sensory or somesthetic cortex. The calcarine or visual cortex is located in the
occipital lobe (also termed occipital cortex) and receives visual input. The auditory cortex,
localized in the temporal lobe, processes sounds or verbal input. Knowledge of the anatomical
projection of fibers of the different tracts and the relative representation of body regions in the
cortex often enables doctors to correctly locate an injury and its relative size, sometimes with
great precision.

Central Structures of the Brain

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

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 are
made up of gray matter and include the amygdala (localized in the temporal lobe), the caudate
nucleus, and the lenticular nucleus (putamen and globus pallidus). Because the caudate and
putamen are structurally similar, neuropathologists have coined for them the collective term
striatum.

The thalamus integrates and relays sensory information to the cortex of the parietal,
temporal, and occipital lobes. The thalamus is located in the lower central part of the brain (that

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is, upper part of the brainstem) and is located medially to the basal ganglia. The brain
hemispheres lie on the thalamus. Other roles of the thalamus include motor and memory control.

The hypothalamus, located below the thalamus, regulates automatic functions such as
appetite, thirst, and body temperature. It also secretes hormones that stimulate or suppress the
release of hormones (for example, growth hormones) in the pituitary gland.

The pituitary gland is located at the base of the brain. The pituitary gland produces
hormones that control many functions of other endocrine glands. It regulates the production of
many hormones that have a role in growth, metabolism, sexual response, fluid and mineral
balance, and stress response.

The ventricles are cerebrospinal-fluid–filled cavities in the interior of the cerebral

hemispheres.  

The Base of the Brain

The base of the brain contains the cerebellum and the brainstem. These structures serve
complex functions. Below is a simplified version 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
as participating in some types of memory and exerting a complex influence on musical and
mathematical skills.

The brainstem connects the brain with the spinal cord. It includes the midbrain, the pons,
and the medulla oblongata. It is a compact structure in which multiple pathways traverse from

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the brain to the spinal cord and vice versa. For instance, nerves that arise from cranial nerve
nuclei are involved with eye movements and exit the brainstem at several levels. Damage to the
brainstem can therefore affect a number of bodily functions. For instance, if the corticospinal
tract is injured, a loss of motor function (paralysis) occurs, and it may be accompanied by other
neurologic deficits, such as eye movement abnormalities, which are reflective of injury to cranial
nerves or their pathways in the brainstem.

The midbrain is located below the hypothalamus. Some cranial nerves that are also responsible
for eye muscle control exit the midbrain.

The pons serves as a bridge between the midbrain and the medulla oblongata. The
pons also contains the nuclei and fibers of nerves that serve eye muscle control, facial muscle
strength, and other functions.

The medulla oblogata is the lowest part of the brainstem and is interconnected with the
cervical spinal cord. The medulla oblongata also helps
control involuntary actions, including vital processes,
such as heart rate, blood pressure, and respiration, and it
carries the corticospinal (that is, motor function) tract
toward the spinal cord.

The Spinal Cord

The spinal cord is an extension of the brain and is

surrounded by the vertebral bodies that form the spinal
column (see Multimedia File 3). The central structures of

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the spinal cord are made up of gray matter (nerve cell bodies), and the external or surrounding
tissues are made up of white matter.

  Within the spinal cord are 30 segments that belong to 4 sections (cervical, thoracic,
lumbar, sacral), based on their location: 

 Eight cervical segments: These control signals from or to areas of the head, neck,
shoulders, arms, and hands.  
 Twelve thoracic segments: These control signals from or to part of the arms and the
anterior and posterior chest and abdominal areas.
 Five lumbar segments: These control signals from or to the legs and feet and some pelvic
organs. 
 Five sacral segments: These control signals from or to the lower back and buttocks,
pelvic organs and genital areas, and some areas in the legs and feet. 
 A coccygeal remnant is located at the bottom of the spinal cord

PERIPHERAL NERVOUS SYSTEM

Nerve
fibers that exit
the
brainstem and
spinal cord
become part
of the

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*FIGURE NO. 4: Meninges
peripheral nervous system. Cranial nerves exit the brainstem and function as peripheral nervous
system mediators of many functions, including eye movements, facial strength and sensation,
hearing, and taste.

The optic nerve is considered a cranial nerve but it is generally affected in a disease of
the central nervous system known as multiple sclerosis, and, for this and other reasons, it is
thought to represent an extension of the central nervous system apparatus that controls vision. In
fact, doctors can diagnose inflammation of the head of the optic nerve by using an
ophthalmoscope, as if the person's eyes were a window into the central nervous system.

Nerve roots leave the spinal cord to the exit point between 2 vertebrae and are named
according to the spinal cord segment from which they arise (a cervical eight nerve root arises
from cervical spinal cord segment eight). Nerve roots are located anterior with relation to the
cord if efferent (for example, toward limbs) or posterior if afferent (for example, to spinal 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 take a long route downward in the spinal canal before
they exit in a bundle that resembles a horse's tail, hence its name, cauda equina.

The spinal cord is also covered, like the brain, by the pia matter and the arachnoid
membranes. The cerebrospinal fluid circulates around the pia and below the outer arachnoid, and
this space is also termed the subarachnoid space. The roots of the cauda equina and the rootlets
that make up the nerve roots from higher segments are bathed in cerebrospinal fluid. The dura
surrounds the pia-arachnoid of the spinal cord, as it does for the brain.

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CSF and the Ventricles

All exposed surfaces of the central nervous system are bathed in cerebrospinal fluid
(CSF), which has several important functions:

1. Firstly, it acts to cushion the delicate brain structure by acting as a buffering 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) some of the fluid must leave - either venous blood or
CSF.
2. CSF also supports the weight of the brain through the buoyant properties of the fluid; the
brain weighs 1400g in air, but as little as 50g when supported by CSF.
3. The CSF also acts as a transport medium for nutrients, chemical messengers and waste
products.

Production of CSF is mostly from a network of vessels called the choroid plexus. It is
produced at a speed of about 350 microliters a minute, or half a litre a day. These areas are
localised networks of highly convoluted vascular material of specialized cells and permeable
capillaries (the smallest type of blood vessel). Each ventricle contains an area of choroid plexus.

CSF is formed by pushing individual substances (mostly salts) across the walls of the
choroid plexus, and water follows. There are some substances that are then transported back
from the CSF to the blood, as well as some specific transporters for nutrients, vitamins and some
other substances. This means that while CSF may be formed from blood, there are substantial
differences in their compositions.

The CSF is released into a series of ventricles that lie within the brain. A ventricle is

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basically a small fluid filled 'lake' in within the brain and there are four 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 the pons and the cerebellum.

The lateral ventricles are separated from each other by a thin barrier called the septum
pellucidum, and there is no direct connection between the two. The third ventricle is connected
to the lateral ventricles through small holes called the interventricular foramen. This third
ventricle lies within the diencephalon. CSF then flows out of the third ventricle through a small
canal known as the mesencephalic aqueduct (or the aqueduct of Sylvius or cerebral aqueduct).
This connects to the fourth ventricle that lies between the pons and the cerebellum. At the base of
the fourth ventricle, the space becomes narrow and joins up with a small canal that runs through
the centre of the spinal cord. The remaining CSF enters the arachnoid space (see below). After
circulating around the spinal cord and brain, the CSF eventually re-enters the blood through little
areas known as arachnoid granulations.

The Meninges

Within the brain, there are several layers of cranial meninges that act as shock absorbers,
as well as preventing direct contact with bone. Meninges are basically coatings, with the three
layers having different thicknesses, textures and purposes. The three layers are named the dura
matter (most external and the toughest), the arachnoid (middle) and the pia mater (innermost).
The image to the right provides a general overview of their structure.

Dura Matter

The dura mater is composed of two fibrous layers; the outermost is called the endosteal
layer as it is fused to the skull. The inner layer is known as the meningeal, and in many areas
blood vessels run between them. Some of these blood vessels are very large, such as the dural
sinuses that deliver blood to the internal jugular veins.

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 There are four locations in which the dura extends into the brain itself, stabilising the
structure. They are:

1. The falx cerebri that dives between the cerebral hemispheres into the longitudinal fissure.
At the back it attaches to the dura that covers the cerebellum (the tentorium cerebelli),
and at the front it attaches to the internal occipital crest. The superior sagittal and inferior
sagittal sinuses (big veins that deposit blood back into the jugular veins in the neck)
travel within the falx.
2. The tentorium cerebelli separates and protects the cerebellum. It lies perpendicular to the
falx cerebri and contains the transverse sinus.
3. The falx cerebelli lies between the two hemispheres of the cerebellum.
4. The diaphragma sellae lines part of the skull called the sella turcica that surrounds the
base of the pituitary gland.

The Arachnoid

The arachnoid layer provides a smooth covering for the brain that does not dive deep into
the sulci (the dips in the surface of the brain). Beneath this layer is the subarachnoid space where
there is a delicate, weblike network of fibres that link the arachnoid to the pia mater. Along the
superior sagittal sinus, areas of the arachnoid can be seen (called arachnoid granulations) that
allow a passage of CSF into the venous system. The arachnoid acts as a support to the cerebral
arteries and veins.

The Pia Mater

The pia mater is very tightly linked to the surface of the brain, anchored by the processes
of astrocytes. The pia mater has a very large blood supply and acts to support the cerebral
arteries as they branch over the brain.

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Blood Supply in the Brain

*FIGURE NO. 5: Inferior view of the cerebral circulation

The blood supply to the brain comes from the internal carotid and vertebral arteries, lying
in the subarachnoid space. The internal carotid arteries branch from the common carotid arteries
(that can be felt pulsing 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,
anterior cerebral artery that supplies the frontal and parietal lobes and a middle cerebral artery
that supplies the midbrain and lateral surfaces of the cerebral hemispheres.

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 The vertebral arteries start at the base of the neck and pass upward through holes in the
side of the vertebral bones of the neck. After ascending to the brain, the two vertebral arteries
fuse to form the basilar artery. The basilar artery goes up the front surface of the pons, sending
off many branches, before dividing into the posterior cerebral arteries. The vertebral arteries and
their branches supply the brain posterior to the area supplied by the internal carotids.

To keep flexibility in the circulatory system, there are many connections between the
different blood supplies, and these connections form a loop that is known as the circle of Willis.
The circle is made whole by smaller arteries such as the posterior communicating artery and
anterior communicating artery. The purpose of this is that if one of the arteries becomes blocked,
or blood supply is cut off for whatever reason, then blood supply can be increased from one of
the other arteries to compensate.

 CARDIOVASCULAR SYSTEM

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 circuit of vessels as it passes again and again through the various
"circulations" of the body.

The Heart

The heart is enclosed by a sac known as the pericardium. There are three layers of 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 cavity of the heart is divided
into four chambers:

*FIGURE NO. 6
 Right atrium

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  Right ventricle
 Left atrium
 Left ventricle

The two atria are thin-walled chambers that receive blood from the veins. The two
ventricles are thick-walled chambers that forcefully pump blood out of the heart. Differences in
thickness of the heart chamber walls are due to variations in the amount of myocardium present,
which reflects the amount of force each chamber is required to generate.

The right atrium receives deoxygenated blood from systemic veins; the left atrium
receives oxygenated blood from the pulmonary veins.

Valves of the Heart

Pumps need a set of valves to keep the fluid flowing in one direction and the heart is no
exception. The heart has two types of valves that keep the blood flowing in the correct direction.
The valves between the atria and ventricles are called atrioventricular valves (also called cuspid
valves), while those at the bases of the large vessels leaving the ventricles are called semilunar
valves.

The right atrioventricular valve is the tricuspid valve. The left atrioventricular valve is the
bicuspid, or mitral, valve. The valve between the right ventricle and pulmonary trunk is the
pulmonary semilunar valve. The valve between the left ventricle and the aorta is the aortic
semilunar valve. When the ventricles contract, atrioventricular valves close to prevent blood
from flowing back into the atria. When the ventricles relax, semilunar valves close to prevent
blood from flowing back into the ventricles.

Pathway of Blood through the Heart

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 While it is convenient to describe the flow of blood through the right side of the heart and
then through the left side, it is important to realize that both atria contract at the same time and
both ventricles contract at the same time. The heart works as two pumps, one on the right and
one on the left, working simultaneously. Blood flows from the right atrium to the right ventricle,
and then is pumped to the lungs to receive oxygen. From the lungs, the blood flows to the left
atrium, then to the left ventricle. From there it is pumped to the systemic circulation.

Blood Supply to the Myocardium

The myocardium of the heart wall is a working muscle that needs a continuous supply of
oxygen and nutrients to function with efficiency. For this reason, cardiac muscle has an extensive
network of blood vessels to bring oxygen to the contracting cells and to remove waste products.

The right and left coronary arteries, branches of the ascending aorta, supply blood to the walls of
the myocardium. After blood passes through the capillaries in the myocardium, it enters a system
of cardiac (coronary) veins. Most of the cardiac veins drain into the coronary sinus, which opens
into the right atrium.

Blood
Vessels
*FIGURE NO. 7: Layers and functions of blood vessels

Blood
vessels are the
channels or
conduits
through which
blood is

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distributed to body tissues. The vessels make up two closed systems of tubes that begin and end
at the heart. One system, the pulmonary vessels, transports blood from the right ventricle to the
lungs and back to the left atrium. The other system, the systemic vessels, carries blood from the
left ventricle to the tissues in all parts of the body and then returns the blood to the right atrium.
Based on their structure and function, blood vessels are classified as arteries, capillaries, or veins.

Arteries

Arteries carry blood away from the heart. Pulmonary arteries transport blood that has low
oxygen content from the right ventricle to the lungs. Systemic arteries transport oxygenated
blood from the left ventricle 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 arterioles play a key role in regulating blood flow
into the tissue capillaries. About 10 percent of the total blood volume is in the systemic arterial
system at any given time.

The wall of an artery consists of three layers. The innermost layer, the tunica intima (or
just intima), contains simple squamous epithelium, basement membrane and connective tissues.
The epithelium is in direct contact with the blood flow. The middle layer, the tunica media, is
primarily smooth muscle 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 attaches the vessel to the surrounding tissue, is the tunica externa or tunica
adventitia. This layer is connective tissue with varying 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 connective tissue near the periphery of the vessel.

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Veins

*FIGURE NO. 8: Internal view of the brain

Veins carry blood toward the heart. After blood passes through the capillaries, it enters
the smallest veins, called venules. From the venules, it flows into progressively larger and larger
veins until it reaches the heart. In the pulmonary circuit, the pulmonary veins transport blood
from the lungs to the left atrium of the heart. This blood has a high oxygen content because it has
just been oxygenated in the lungs. Systemic veins transport blood from the body tissue to the
right atrium of the heart. This blood has a reduced oxygen content because the oxygen has been
used for metabolic activities in the tissue cells.

The walls of veins have the same three layers as the arteries. Although all the layers are
present, there is less smooth muscle and connective tissue. This makes the walls of veins thinner
than those of arteries, which is related to the fact that blood in the veins has less pressure than in
the arteries. Because the walls of the veins are thinner and less rigid than arteries, veins can hold
more blood. Almost 70 percent of the total blood volume is in the veins at any given time.
Medium and large veins have venous valves, similar to the semilunar valves associated with the
heart, that help keep the blood flowing toward the heart. Venous valves are especially important
in the arms and legs, where they prevent the backflow of blood in response to the pull of gravity.

Capillaries

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 *FIGURE NO. 9: Arterial and venous ends of capillaries

Capillaries, the smallest and most numerous of the blood vessels, form the connection
between the vessels that carry blood away from the heart (arteries) and the vessels that return
blood to the heart (veins). The primary function of capillaries is the exchange of materials
between the blood and tissue 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 supply of oxygen and nutrients. Other tissues, such
as connective tissue, have a less abundant supply of capillaries. The epidermis of the skin and the
lens and cornea of the eye completely lack a capillary network. About 5 percent of the total
blood volume is in the systemic capillaries at any given time. Another 10 percent is in the lungs.

Smooth muscle cells in the arterioles where they branch to form capillaries regulate blood
flow from the arterioles into the capillaries.

Role of the Capillaries

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 *FIGURE NO. 10: Hydrostatic and Osmotic pressures

In addition to forming the connection between the arteries and veins, capillaries have a
vital role in the exchange of gases, nutrients, and metabolic 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 and osmotic
pressure. The net result of the capillary microcirculation created by hydrostatic and osmotic
pressure is that substances leave the blood at one end of the capillary and return at the other end.

Discharge Planning

METHODS

M Instructed the patient to take the following medications:

Aspirin 80 mg. after once

B complex VID 5 cap OD

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 Calci block 10 mg SL PRN

E Encourage the client to:

Complete bed rest with bathroom privileges.

Passive exercise

T Advise and SO that not to perform valsalva maneuver.

H Encouraged use of relaxation techniques such as assuming of comfortable position and to

change position every two hours

Encouraged patient to comply with the treatment regimen

D Instructed patient to have low salt and low fat diet

VIII. Conclusion

Hypertension is well known disease all over the world. Most people acquire it from
sedentary lifestyle and improper diet. It can also be hereditary which could affect certain races
more than others. Usually, the African Americans are more prone to this disease condition due to
unusual sensitivity to vasopressin. Proper monitoring and treatment is necessary to help client
with their condition. Without these treatments, it can cause different kinds of problems that could
be permanent and irreversible. The treatment for these kinds of disease should be taken based on
the recommendation of the doctor to properly and totally eradicate the problem. Severe
hypertension can cause cerebrovascular accident, CVA is a sudden neurological incident related
to impaired cerebral blood supply which can cause ischemia to the brain. It could paralyze the
body affecting the perception, sensory, and the motor movement of the person.

As a nurse, the student should be knowledgeable enough regarding the disease

process; however, learning through lectures and theories is not enough to completely understand
this disease. Through interaction, knowledge acquired from theories was much appreciated by
the students since he or she can actually asses the patient’s condition. With enough information

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and enhanced skills, he or she may be able to handle patients with these conditions and easily
identifying problems and treatment alike. It is important that the patient is given enough
information about the disease condition and the underlying complications. As nurses, it is our
responsibility to make sure that the patient is disclosed with adequate information. I have also
learned the importance of taking care of oneself; each part belongs to an intersystem of
physiologically functioning body. We were able to reflect about our own activity, diet and of
course the stress that we are facing each day when we made this case study, because we have
thought that what we do to our body now may have bad effects to us in the future.

As a conclusion may these piece of work serve as a guide or information not only to
patients who has been diagnosed of cerebrovascular accident but to the public that they may be
abreast with knowledge on what the disease really is.

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Page | 45
 V.THE PATIENT AND HIS CARE

A. MEDICAL MANAGEMENT

Date ordered
Indication(s) or
Medical Date performed General Description Client’s response to treatment
Purposes
management/
Treatment Date changed

PLAIN NORMAL DO: 07-23-10 Isotonic crystalloid solution

Indicated for restoring The patient was kept hydrated as
SALINE SOLUTION containing same amounts of
the loss of body fluids. evidenced by normal skin turgor (assessed
(PNSS) 1 Liter X 20-21 sodium and chloride found in
gtts/min plasma.
through the clavicle area) and the
DR: 07-23-26,2010 administration of IV medications also
became possible as a form of treatment of
Fluid Replacement
the patient condition. No untoward effects
DC: The client was were noted such as any signs of fluid
not yet discharged volume excess or fluid overload.

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Nursing Responsibilities:

 Prior to treatment:

1. Verify the physician’s order indicating the type of solution, the amount to be administered, the rate of flow of the
infusion, and any client allergies

2. Consider how long the patient is likely to have the IV, what kinds of fluids will be infused, and what medications the
patient will be receiving or is likely to receive.

3. Prepare the client. Explain the procedure to the client.

4. Arrange equipments needed for the therapy

5. Observe aseptic technique

 During treatment:

1. Ensure that the correct solution is being infused

2. Observe the rate of flow every hour

3. Inspect the patency of the IV tubing and needle

4. Inspect the fluid site for fluid infiltration

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 5. Inspect the insertion site for phlebitis

6. Inspect the intravenous site for bleeding

7. Teach the patient ways to maintain the infusion system

8. Document all relevant information

 After treatment:

1. Review the physician’s order

2. Assess the appearance of the venipuncture site

3. Inspect the appearance of IV catheter

4. Cover the venipuncture site

5. Discard the IV solution container properly

6. Document all

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 b. Drugs

Route of admin General Action

Date ordered Date Client Response to
Dosage & Functional Indication(s) or
Name of Drug performed Treatment and Actual
frequency of Classification Purposes
Date changed Side Effect
admin Mechanism of Action

Generic name: DO: 07-22, 2010 Anti hypertensive To decrease blood The client complied with
Clonidine 75 mcg./tab SL stat Thought to stimulate alpha 2 volume and blood
the medication and did not
hydrocholoride DP: 07-22-25, 2010 receptors and inhibit the pressure.
central vasomotor centers,
manifest further increase
Brand name: decreasing sympathetic in blood pressure and side
Catapres outflow to the heart, kidneys effects/adverse reactions
and peripheral vasculature were not manifested as
and lowering blood pressure.
well.

Blood Pressure 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

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 Nursing Responsibility:

 Prior to treatment:
1. Check the doctor’s order for the drug name, dosage, frequency and route of administration
2. Observe aseptic technique
3. Organize the equipments needed for administering medication
4. Prepare the medication
5. Inform the client of the name of the drug , it’s action and purpose of giving the drug
6. Assess BP and pulse.
7. Instruct to take at the same time each day.
8. Monitor I&O
 During treatment:
1. Last dose: administer at bedtime.
 After treatment:
1. Monitor BP and pulse, advice to notify health care professional of side effects.
2. For dry mouth provide god oral hygiene and sugarless gum.

Route of admin
Date ordered General Action
Dosage & Client Response to
Date performed Functional Classification Indication(s) or
Name of Drug frequency of Treatment and Actual
Date changed Mechanism of Action Purposes
admin Side Effect

Generic name: DO: 07-22-10 20 g TID now then Loop diuretic To promote diuresis The client’s urine output

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Furosemide DP: 07-22-26, 2010 every 8 hours that can help to increased and did not
DC: client was not yet Inhibits the re absorption of decrease the blood manifest further increase
Brand name: discharged sodium and chloride in the volume and blood in blood pressure.
Lasix proximal and distal tubules pressure Blood Pressure Readings:
and the loop of henle leading Before Administration:
to a sodium rich diuresis 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

Nursing Responsibility:

 Prior to treatment:
1. Check the doctor’s order for the drug name, dosage, frequency and route of administration
2. Observe aseptic technique
3. Organize the equipments needed for administering medication
4. Prepare the medication
5. Inform the client of the name of the drug , it’s action and purpose of giving the drug.
6. Assess client’s VS especially BP.

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  During treatment:
1. IV: clean the port/site were the drug will be injected.
2. Assess client’s reaction while giving the drug.
 After treatment:
1. Monitor Urine output
2. Monitor VS especially BP
3. Monitor weight
4. Increase intake of K rich foods

General Action
Date ordered Route of admin
Name of Drug Functional Indication(s) or Client Response to
Date performed Dosage &
Classification Purposes Treatment and
frequency of
Date changed Mechanism of Action Actual Side Effect
admin

Generic name: DO: 07-22-2010 50 mg./tab 1 tab Antihypertensive The client complied
Losartan now then OD Antihypertensive, with the medication
potassium DP:07-22-25, 2010 Undergoes significant alone or in
and manifested a stable
first-pass metabolism (by combination with
blood pressure as
Brand name: DC: Client was not yet CYP2C9 and CYP3A4) in other antihypertensive
evidenced by blood
Cozaar discharged the liver, where it is drug.
pressure readings of:
converted to an active
carboxylic and metabolite
Blood Pressure

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 that is responsible for most
of the angiotensin receptor
blockade.
Selectively blocks the
binding of Angiotensin II
to receptor sites in the
vascular smooth 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

Nursing Responsibility:

 Prior to treatment:
1. Check the doctor’s order for the drug name, dosage, frequency and route of administration
2. Observe aseptic technique
3. Organize the equipments needed for administering medication
4. Prepare the medication
5. Inform the client of the name of the drug, its action and purpose of giving the drug.
 During treatment:
1. Assess blood pressure and pulse periodically during therapy.
2. Assess for signs of angioedema.
 After treatment:
1. Monitor input and output and daily weight.

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 2. Encouraged the patient to comply with additional interventions for hypertension.

Date ordered Route of admin General Action

Name of Drug Date performed Dosage & Functional Classification Indication(s) or Client Response to
Date changed frequency of Mechanism of Action Purposes Treatment and Actual
admin Side Effect

Nonsteroidal, anti-
To act as an The client did not
inflammatory drug
anticoagulant so as to manifest any signs and
DO: 07-25,2010
Generic name: 80 mg once a day, Exhibits antipyretic, anti-
prevent formation of symptoms such as
Aspirin DP: 07-25-26,2010 taken after meals. inflammatory, and analgesic thrombus and difficulty in breathing
effects. The antipyretic effect is embolus that could and alteration in
Brand name: DC: Client was not yet due to an action on the further aggravate the circulation that could
Apo- ASA/ Novasen discharged. hypothalamus, resulting in heat
client’s condition indicate formation of
loss by vasodilation of
peripheral blood vessels and
thrombus/ emboli.
promoting sweating.

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 Nursing Responsibility:

 Prior to treatment:
1. Inform the client of the name of the drug , it’s action and purpose of giving the drug.
2. Take a complete drug history and note any evidence of hypersensitivity.
 During treatment:
1. Monitor serum salicylate levels periodically.
2. Monitor for the onset of tinnitus, headache, hyperventilation, diarrhea and sweating.
3. Administer meals or with food.
 After treatment:
1. Taper dose.

Date ordered Route of admin General Action

Name of Drug Date performed Dosage & Functional Classification Indication(s) or Client Response to
Date changed frequency of Mechanism of Action Purposes Treatment and Actual
admin Side Effect

Generic name: DO: 07-22,2010 1 capsule once a day.

Vitamin supplements Vitamin B complex The client complied
Vitamin B complex
was given to the with the therapy and
DP: 07-22-26,2010
client to further did not manifest further
Brand name: DC: Client was not yet enhance nerve aggravation of the
Theravite discharged functions which may sensory and motor

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 be impaired due to deficits of the client.
the infarction causing
an alteration in the
sensory and motor
abilities of the client.

Nursing Responsibility:

 Prior to treatment:
1. Check the doctor’s order for the drug name, dosage, frequency and route of administration
2. Observe aseptic technique
3. Organize the equipments needed for administering medication
4. Prepare the medication
5. Inform the client of the name of the drug , it’s action and purpose of giving the drug.
6. Assess Vitamin levels as indicated.

During treatment:
1. Monitor levels to ensure requirements are met and levels are as
2. Take with food for best absorption and utilization.
 After treatment:
1. Comply with dietary recommendations.
2. Avoid self-medicating that exceeds the RDAs

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 Date ordered Route of admin General Action
Name of Drug Date performed Dosage & Functional Classification Indication(s) or Client Response to
Date changed frequency of Mechanism of Action Purposes Treatment and Actual
admin Side Effect

Generic name: DO: 07-22,2010 10 mg SL PRN Calcium channel blocker The medication was given The client’s blood pressure
Nifedipine to the client to decrease was stabilized and did not
DP: 07-22-26, 2010 Inhibits the influx of calcium the patient’s blood further increased as
through the cell membranes, pressure and cardiac evidenced by blood pressure
Brand name: DC: Client was not yet resulting in a depression of workload. This is done by readings of:
Calcibloc discharged automaticity and a conduction decreasing the client’s
velocity leading to a depression peripheral resistance and Before Administration: July
of contraction. contractions. 22, 2010: 180/100
After:
Decreases total peripheral July 22, 2010: 120/90
resistance thus reducing energy July 23, 2010: 140/ 70
and oxygen requirements of the July 24, 2010: 120/70
heart. July 25, 2010: 130/90
July 26, 2010: 130/90
Nursing Responsibility:

 Prior to treatment:
7. Check the doctor’s order for the drug name, dosage, frequency and route of administration
8. Observe aseptic technique
9. Organize the equipments needed for administering medication

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 10. Prepare the medication
11. Ask the name of the cient.
12. Inform the client of the name of the drug , it’s action and purpose of giving the drug.

During treatment:
3. Monitor levels to ensure requirements are met and levels are as
4. Administer SL at the buccal mucosa to avoid aspiration
 After treatment:
3. Comply with dietary recommendations.
4. Avoid self-medicating that exceeds the RDAs
5. Do not give water after administration
6. Perform routine oral care.

c. Diet

Date ordered
Type of Diet Date performed General Description Indication(s) or Client’s response and/or
Date changed Purposes reaction to diet

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Low fat and low salt DO: 07-22,2010 Law salt, low fat diet is a Aside from the anti- The client complied with the
diet with strict diet that is rich in fruits hypertensive drugs diet and the client’s blood
aspiration precaution DP: 07-22-26, 2010 and vegetables, low fat being taken by the pressure did not further increase
dairy products and low in client it is also and was stabilized as evidenced
DC: Client was not saturated and total fat. essential to provide by:
yet discharged This usually includes diet restrictions which
unprocessed and white can help in further Blood Pressure Readings:
meats, bread and cereals, stabilizing the client’s Before Administration: July 22,
skim milk and fruits and blood pressure. Fat 2010: 180/100
vegetables. usually deposits in After:
blood vessels which July 22, 2010: 120/90
may narrow its lumen July 23, 2010: 140/ 70
causing a higher July 24, 2010: 120/70
resistance needed by July 25, 2010: 130/90
the blood to get July 26, 2010: 130/90
through the vessel
while excessive salt
(sodium) can cause an
elevated blood volume
because of its ability
to retain water in the

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 body thus also
increasing the client’s
blood pressure.
Limiting intake of
foods which
excessively contain
these substances may
greatly help in
managing
hypertension.

Nursing Responsibilities:

 Prior to treatment:
1. Check the doctor’s order.
2. Explain the purpose of diet and the specific foods to be taken.
3. Educate the client regarding the foods that is allowed and food that are restricted.

 During:
1. Monitor compliance of the patient to the prescribed diet.

 After:
1. Monitor patient for tolerance to food.

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 2. Document patient’s response.
d. Activity/ Exercise
Type of Date Ordered General Indication/purposes Client’s Response and/or
exercise Date Performed description reaction to treatment
Date Change
Complete bed -The client is -to minimize client’s movement The client complied with the
rest with DO: 07-22, 2010 confined in bed and which may further increase therapeutic regimen and did not
bathroom is not allowed to oxygen demands that could manifest any signs and symptoms
privileges DP: 07-22-26,2010 get up to perform compromise the client’s such as difficulty of breathing,
his bathroom condition, to minimize client’s fatigue, formation of thrombi/emboli,
DC: client was not yet discharged necessities. risk for injury due to sensory pressure sores, and contractures that
and motor deficits caused by indicates increase in oxygen demand
the infarction. and presence of injury.

-to facilitate movement and

circulation of the different body
parts.
- the client complied and was able to
DO: 07-22,2010 perform the exercises properly. He
also tolerated the activity and did not

Passive exercise DP: 07-22-26,2010 -There are set of manifest difficulty of breathing and
exercises where in fatigue.
DC: The client was not yet the nurse provides
discharged assistance for the -no further complication was noted
client’s on the client.
performance of

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 movements.

Nursing Responsibilities:

 Prior to treatment:
4. Check the doctor’s order.
5. Explain the purpose of diet and the specific foods to be taken.
6. Educate the client regarding the foods that is allowed and food that are restricted.

 During:
2. Monitor compliance of the patient to the prescribed diet.

 After:
3. Monitor patient for tolerance to food.
4. Document patient’s response.

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Page | 63
IX. RECOMMENDATION:

Health is a major concern that should be given adequate attention; it is not something that
should be taken for granted. The public should be aware of how to prevent occurrence of illness.
Although it is inevitable for anyone to get sick more than once in his lifetime, it is a must that
people take care of their health to prevent occurrence of diseases.

To the public:

Proper diet is very crucial in achieving optimal health status. Prevention is very
important with this disease and we should watch out for the food that we eat. We should avoid
fatty foods and high sodium because these can cause harmful effects and could elevate blood
pressure. The people should know what is too much and learn how to control themselves.

Proper weight management should be observed since obesity can cause hypertension.
Ideal weight decreases the rate of having hypertension related CVA. By being obese, there could
be hyperlipidimia and it will be hard for the blood to pass through.

Smoking and other sedentary lifestyle is prohibited because smoking can constrict the
blood vessel and elevate blood pressure. Stress should be avoided and the public should find
ways to alleviate stress. Relaxation techniques should be performed always.

To health care practitioner:

CVA related to hypertension, like any other diseases are highly preventable. In the
health care practice, we are well equipped with the knowledge as well as the skills in the
prevention. A major problem is the general public’s lack of information about the strategies of
how to do so. It is our responsibility on how to educate them properly. Monitoring patient’s

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compliance to treatment regimen is very crucial for the patient. Nurses should inform the clients
regarding the reasons of every intervention and medication being given to them.

X. Learning Derived

This case study made us realize the importance of obtaining accurate patient history
because from this alone, the health care team member can be directed to the proper management
of the patient together with his family. Assessment of a patient experiencing a neurologic

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disorder is a challenge. Neurologic assessment establishes baseline data that are used to compare
ongoing assessments, diagnose actual and potential health problems, manage client care, and
evaluate the outcome. Because of the complexity of the nervous system, neurologic assessment
is both multifaceted and lengthy.

Lastly, the group also learned from the case study presented that a number of health
problems present and can be identified with patients with CVA. With the case study, the group
profoundly explored the role of nurses in preserving the quality of life of the patients with CVA
and the importance of family support in their care and recovery.

VIII. BIBLIOGRAPHY

Internet:

 http://www.wisegeek.com/what-is-anemia.htm
 http://www.faqs.org/abstracts/Health/Current-trends-CDC-Criteria-for-anemia-in-
children-and-childbearing-aged-women.html
 http://www.jstor.org/pss/3454306

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  Foundation for education and research in Neurological Emergencies
 http://tigger.uic.edu/com/ferne/pdf/subarachnoidhem0501.pdf
 http://www.hmnews.org/article2767.html
 http://www.sciencedaily.com/releases/2004/06/040622014818.htm
 http://www.sciencedaily.com/releases/2006/04/060429125428.htm
 The internet Stroke center - http://www.strokecenter.org/pat/sah.htm
 Emedicine from webMD - http://www.emedicine.com/emerg/topic559.htm
 Emedicine.com
 http://www.emedicine.com/aaem/topic239.htm
 Wake forest university Medical Center -
http://www1.wfubmc.edu/neurosurgery/Brain+Tumor+Center+of+Excellence/Subarachn
oid+Hemorrhage+of+Unknown+Etiology.htm
 http://www.emc.maricopa.edu/faculty/farabee/BIOBK/BioBookNERV.html
 mayoclinic.com - http://www.mayoclinic.com/health/nervous-system/BN99999
 http://www.surgeryencyclopedia.com/Ce-Fi/Craniotomy.html
 http://uscneurosurgery.com/infonet/surgery/procedures/aneurysm_clip.htm#surgical
%20indications

Books:

Stanley et. al. Pathology and Pathophysiology of Uterine Smooth-Muscle Tumors. The National
Institute of Environmental Health Sciences (NIEHS). 2000

Black, Joyce. Medical Surgical Nursing. (Philadelphia: Lippincott Williams & Wilkins, 2004

Braunwald et.al. Harrison’s Principles of Internal Medicine 2. 11th edition. McGraw Hill Book
Company. Copyright 1987.

Seeley et. al. Essentials of Anatomy and Physiology. 5th edition. McGraw Hil Book of Company.
Copyright 2003.

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