A

CASE PRESENTATION
on
Cerebrovascular
Accident
(Intracranial
Hemorrhage)
 Group A
Lobigas Fediliza … Objectives / Introduction
Globio Syrel … Nursing Health History
Gapud Richell … Physical Assessment
Magno Angeline … Pattern of functoning
Abuda Vinah … Laboratory
Alegre Nathaniel … Anatomy and Physiology
Almazan Diana Rose… Pathophysiology
Abriol Ma. Precious … Nursing Care Plan
Amoyo Jesseca … Nursing Care Plan
Lobigas Fediliza … Nursing Care Plan
Candido Lou Kristoffer Doxi … Pharmacology
Abunales Robinson………….Health teaching and prognosis
OBJECTIVE
S
 OBJECTIVES
• To present the patient’s profile with
her health history to be able to
determine how the patient acquired
this condition.
• To analyze the laboratory results to
be able to relate its significance to
the patient’s illness.
• To study the anatomy and physiology
of the patient’s body system that is
most affected by the disease.
• To trace the disease process and
to understand how did the
patient’s condition developed.
• To study the medicine prescribed
for the patient and identify why it
is indicated for him.
• To develop an organized and
appropriate plan of nursing care
for the patient.
• To determine patient’s prognosis
and suggest reaction that will be
benefit to the patient.
INTRODUCTI
ON
 CEREBROVASCULAR ACCIDENT
(STROKE)
Stroke is defined as the onset and
persistence of neurologic
dysfunction lasting longer than 24
hours which occurs when the
blood supply to a part of your
brain is interrupted or severely
reduced, depriving brain tissue of
oxygen and nutrients.
It can be classified into major
categories: ischemic and hemorrhagic
strokes. Ischemic stroke occurs when
blood clots or other particles block
arteries to your brain and cause severely
reduced blood flow (ischemia).
Hemorrhagic stroke occurs when a blood
vessel in your brain leaks or ruptures.
It is the leading cause of serious, long-
term adult disability in the United
States. It is also the third leading cause
of death after heart disease and cancer
killing nearly 160,000 people each year.
The incidence of stroke is higher for
males than for females, especially in the
under 65 age group.
 It is the leading cause of serious, long-
term adult disability in the United States. It
is also the third leading cause of death after
heart disease and cancer killing nearly
160,000 people each year. The incidence of
stroke is higher for males than for females,
especially in the under 65 age group.
Hypertensive intra-cerebral hemorrhage
is a type of stroke in which there is bleeding
in the brain due to high blood pressure.
When blood pressure has remained high for
a significant period of time, the walls of the
blood vessel become weak. Constant, high
blood pressure wears away the vessel walls
and can lead to blockage of the vessels and
leakage into the brain.
Brain tissue swelling and a
Hematoma within the brain put
increased pressure on the brain and
can eventually destroy it. Bleeding
may occur in the hollow spaces
(ventricles) in the center of the
brain or into the subarachnoid
space (the space within the brain
and the members that cover the
brain).
Intracerebral hemorrhage can affect
the body and is most common in
older people.
NURSING
HEALTH
HISTORY
 Biographical data

• NAME OF CLIENT: CGL

• AGE: 66yrs old
• SEX: Female
• CIVILSTATUS: Married
• ADDRESS: Brgy.Lalawigan, borongan E.
Samar
• OCCUPATION: Retired Teacher
• RELIGION: Roman catholic
• BIRTHDATE: March 18, 1943
• ADMISSION DATE: August 29, 2009
• ADMISSION TIME: 2:15PM
• CHIEF COMPLAINT: Severe headache and
dizziness
• SOURCE OF INFORMATION: Husband
• PRINCILPE DIAGNOSIS: Cerebrovascular
Accident (intracranial hemorrhage)
• ATTENDING PHYSICIAN: Dra.
Sabalbarino
 HISTORY OF PRESENT
ILLNESS:
A case of client CGL, 66 years old,
female, Filipino, residing at
Lalawigan, Borongan E. Samar, was
admitted at Eastern Samar Provincial
Hospital (ESPH) last August 29, 2009
at 2:15pm with a chief complaint of
severe headache and dizziness.
• A week prior to admission, she
experienced episodes of
headache and dizziness. Her BP
was monitored at home. She has
been known hypertensive for
15yrs with BP reading from
160/100mmHg and she’s taking
versant to lower her blood
pressure and glimepiride for her
DM.
• Prior to admission while Mrs. CGL was
doing her household chores( washing
dishes), she suddenly experienced
severe headache and dizziness. She
was immediately brought to Borongan
Doctors Hospital and accompanied
by her husband because she cannot
tolerate anymore the pain. She was
confined for 3 days before being
transferred to ESPH.
 PAST MEDICAL HISTORY
Client husband state that the
patient had experienced childhood
illness such as measles, chicken pox,
mumps, cough, and common colds.
She had no allergies to food or any
medication and had not encountered
accidents or serious injuries before
however the client had under gone
appendectomy when she was at her
20’s.
• Year 1993 she was diagnosed
with hypertension at ESPH
without recalling the exact date
as claimed by her husband.
After 5 years she was also
diagnosed with type II DM. she
was taking versant for her
hypertension and glimiperide
for her DM but not taking it
regularly only when she
experienced headache and
dizziness.
Family
History
FAMILY HISTORY
 PSYCHOSOCIAL
HISTORY
Client is a non smoker, she drinks wine
occasionally. Her food consist of fish and
vegetables, but she also loves to eat fatty
and dried foods. Her sleep wake pattern is
from 10pm-5am. She goes to church every
morning then spends most of her time
walking around their brgy, visiting friends.
When at home she does the usual
household chores.
She has good relationships w/
her husband, daugther and
relatives. She is a retired
teacher from Lalawigan
Elementary school. According to
his husband her wife has been a
very good teacher w/ good
record during her teaching
career.
PHYSICAL
HEALTH

ASSESSMEN
T
 REVIEW OF SYSTEM
GENERAL ASSESSMENT:
Seen lying on bed conscious with an IVF of
D5LR inserted at the right metacarpal vein
regulated at 30gtts/min, with NGT for feeding
and with indwelling catheter draining to
urobag
appears weak and pale, warm to touch.
with the following vital signs
Temp – 38.7oC
PR – 91 bpm
RR - 24 cpm
BP 150/90 mmhg
Body Parts
 technique used: inspection
 actual findings: symetrical in size no lumps and
lesions noted
 normal findings: Symmetrical in size absence of lumps,
lesions and nodules
 remarks: normal
Head
 technique used: inspection
 actual findings: Evenly distributed hair whitish in
color no infections or infestation noted
 normal findings: Evenly distributed hair with shiny
black in color absence of infection and infestation
 Eyes
 technique used: inspection
 actual findings: Blurring of vision noted
on the left eye, pupil is black and equal in size.
 normal findings: No edema or tenderness
over the lacrimal gland, pupil black equal in
size, conjunctiva is shiny and smooth and pink
transparent capillaries
 remarks: normal
 Ears
 technique used: inspection
 actual findings: Color is the same as
facial skin, symmetrical in size pinna recoils
slowly after it is folded.
 normal findings: Symmetrical auricle
alignedin outer canthus of eye sounds is heard
on both ears pinna is firm and recoils after it is
folded
 remarks: normal
Nose
 technique used: inspection
 actual findings: Symmetric in
shape no lesion no discharges and no
nasal flaring note
 normal findings: Symmetric and
straight no tenderness, no lesion no
discharge or flaring
 remarks: normal
Mouth
 technique used: inspection
 actual findings: Oral mucosa is
pink no discharges noted, inability to
purse lips and dry lips.
 normal findings: Lips are pink in
color ability to purse lips pink gums
and white shiny tooth enamel
 remarks: due to hemiparesis
Skin
 technique used: inspection
 actual findings: Light brown in
complexion uniform in color except for
areas expose to sun light no skin lesion
noted
 normal findings: Uniform in skin color
when pinch skin springs back to
previous sate
 remarks: normal
Nails
 technique used: inspection
 actual findings: Capillary refill of 5
sec and cyanosis noted no clubbing.
 normal findings: Capillary refill is
2-3 secs. absence of cyanosis or clubbing
 remarks: due to altered tissue
perfusion
Abdomen
 technique used: inspection
 actual findings: Skin at the abdominal
area is unblemished and uniform in
color, whole abdomen is slightly
rounded in shape
 normal findings:No evidence of
enlargement of liver and spleen, no
lumps, masses or tenderness noted.
 remarks: Normal
Upper and lower extremities
 technique used: Inspection
 actual findings: Upper and lower
extremities are of equal size of both sides of
the body no contractures noted. Weakness
on left arm and leg noted.
 normal findings: Absence of edema
contractures and masses symmetrical in
size and length
 remarks: due to hemiparesis
 NEUROLOGIC
ASSESSMENT
• Consciousness
– The client is conscious but slightly
unresponsive. Drowsy and slightly
difficult to arouse with normal stimuli,
however, patient is easily aroused by
loud noise, deep pressure and pain.
• Mentation
– Patient is oriented to time, place and
person and is aware of her current
illness. Patient can recall recent and
past memory with mild difficulty.
Emotional lability noted.
• Language and Speech
– Patient has slurred speech and
dysarthria.
• Motor Function
– Patient is able to project facial
expressions such as smile and a pout.
Unable to eat on her own due to lack of
muscle strength and inability to swallow,
has NGT for feeding.
– Eye movements are visible. Patient is
able to open eyelids.
– Hemiparesis noted at the left side of the
body.
• Sensory Function
– The patient is able to see and
follow movements. Vision on
the left eye is unclear. The
nose to fingertip assessment
reveals that the patient can’t
see where the examiner’s
fingertips are particularly
when it is positioned on the L
side..
– Patient is able to smell unable
to hear, but can hear voices
when spoken louder.

– Patient cannot easily detect soft

objects like blanket on the
affected side but feels the touch
of the hand(when pressed)
when she is awake.
• Bowel and Bladder Function
– Client has FCTUB draining
at an average of 160
cc/day.

– The client’s stool is

brownish and hard and
defecate an interval of 2-3
days.
Cardiovascular system Analysis
no complain of chest pain and has Normal
a cardiac rate of 91bpm, chest is
symmetric in size.
Respiratory System Due to body weakness and
The client respiratory rate is hemiplegia.
slightly increased with an RR of 24
cpm and no crackles noted.
Gastrointestinal System
Client defecate 2-3 days of interval Due to body weakness and
with brownish in color and slightly hemiplegia.
hard stool.

Genitourinary System Due to decreased fluid intake.

Client has difficulty in urination
with foley catheter attached to
urobag . With urine output of
20ml/hr, yellow in color.
Cranial Name Type Function Findings
nerve
1 Olfactory Sensory Smell Normal

2 Optic Sensory Visual and vision Blurred vision of the

left eye

3 Oculomotor Motor Pupil constriction Pupil in the left eye

is nonreactive

4 Trocheal Motor Eye movement, Eyeballs on the left

Controls superior eye is unable to
oblique muscle move constantly
because of
hemiparesis and
hemiplegia

5 Trigeminal Sensory Controls muscle of Impaired

mastication; swallowing or
optalmic sensation of the dysphagia,
branch face and cornea trigeminal neuralgia
6 Abducens Motor Eye movement Partial gaze palsy

7 Facial Motor and sensory Controls muscles There was paralysis

for facial expression on the left side of
the face due to
hemiparesis and
hemiplegia, other
side of the face can
able to project
facial expression.

8 Auditory Sensory Hearing Unable to hear soft

voices on the left
ear because of
hemiparesis and
hemiplegia
9 Glossopharygea Motor and Controls muscle Inability to
l sensory of the throat swallow(dyspha
gia)
10 Vagus nerve Motor and Controls muscle Inability to
sensory of the throat, swallow(dyspha
parasympatheti gia)
c nervous Loss of gag
system reflex
stimulation of Dysarthria
thoracic and
abdominal
organs

11 Spinal Motor Controls Inability move

Accessory strenocleidom the head and
astoid and the shoulders
trapezius on the left
muscles side of the
body
12 Hypoglossal Motor Movement of Deviation of
the tongue the tongue to
 GLASGOW COMA SCALE
Faculty Measured Score Response

Eye Opening 4 Spontaneous

3 To verbal command
2 To pain
1 No response
Motor Response 6 To verbal command
5 To localize pain
4 Flexes and withdraws
3 Flexes abnormally
2 Extends abnormally
1 No response
Verbal Response 5 Oriented, converses
4 Disoriented, converses
3 Uses inappropriate words
2 Makes incomprehensible sounds
1 No response
Moderate stroke: 13
 MUSCLE STRENGTH
RIGHT
LEFT

3/5 2/5

3/5 2/5
 N.I.H. STROKE SCALE
• Level of Consciousness
– Not alert, requires loud noise or
painful stimuli to arouse
– Answers 1 of 2 questions correctly
– Performs 1 of 2 tasks correctly – there
is noted lack of cooperation

• Best Gaze
– Partial gaze palsy, gaze is abnormal
on one (L) eye but gaze paresis is not
present.
• Visual
– (L) homonymous Hemianopia. (R) gaze
preference.
• Facial Palsy
– Normal symmetrical movement
• Motor Arm and Leg
– Arm and legs drift down to bed with
effort against gravity (when elevated at
45 and 30 degrees correspondingly)
• Limb Ataxia
– Present on left upper and lower
extremities.
• Sensory
– Mild sensory loss
• Best Language
– Mild to moderate aphasia.
• Dysarthria
– Mild to moderate, patient slurs some
words and can be understood with
some difficulty.
• Distal motor function
– No voluntary extension after 5 secs.
 PATTERN
Pattern Before illness During OF
hospitalization
Analysis

Diet FUNCTIONING 
o Client eat 3x a o 250-300 ml o Clients
day, she loves to of eating
eat fried and fatty osteorized pattern
foods . feeding or declined bec
o She usually eat approximate of her
two cups of rice ly 900 ml/ illness.
with dried fish, day
meat, chicken w/
vegetables as her
viand. She also eat
sweet and salty
food.
Habit o Goes to church o Clients o Clients
every morning daily habit daily habit
at around 5:00 has totally has
am. spend most stopped stopped
of her time due to her
walking around present
their BRGY illness
visiting friends
and reading
books and bible.
Exercise o Client o Clients o Clients
consider daily daily
her house Exercise Exercise
routine as has has
her daily totally stopped
exercise stop due to
and her
walking present
around illness
Sleeping o She usually sleeps 6-7 o she usually o client sleeping
pattern hours a day Sleeps sleep 4-5 pattern has
around 10 pm and hours daily, decline from
wake up at around 4 o sleeping 6-7 hours to 4-
-5 am on typical day. position is 5 hours of
she takes day time semi fowlers, sleep a day.
naps for 2-3 hours o use only one o this may
o Her favorite sleeping pillow that indicate
position is side lying support her disturbance
position head during sleep
o She uses two pillow or deprivation
one pillow to support of sleep
her head and one for
the legs
Elimination Defecate once Defecate with Client’s
pattern a day early in an interval of elimination
the morning. 2-3 days. Stool was declined
Urination was was brownish due to her
normal. and slightly illness.
hard.
Was oliguric,
with fully
catheter attach
to the urobag.
Urine color is
turbid and
160ml w/n a
shift.
Drinki She drinks 7- 3 glass of Clients
ng 8 glasses of water per drinking
water daily or day or pattern has
approximatel approxim decline due to
y 1,920ml of ately her illness
water per day 90ml/day experience
She Totally
occasionally stopped
Drinks wine drinking
wine
Personal She takes a Unable to Capability in
hygiene bath every take a bath doing her
day at since personal
around 4:30 admitted, hygiene has
am with her way of decline due
warm water bathing is by to her
Brush her means of illness.
teeth after sponge bath.
eating her
breakfast,
lunch and
dinner.
LABORATOR
Y
AND
DIAGNOTICS
COMPUTED TOMOGRAPHY
SCAN
A medical imaging method
employing tomography. Digital
geometry processing is used to
generate a three-dimensional image
of the inside of an object from a large
series of two-dimensional X-ray
images taken around a single axis of
rotation.
• Indications for CT Scanning:
– Bleeding, brain injury and skin fractures
– Brain tumors
– A blood clot or bleeding
– Enlarged brain cavities, etc.

• Technique
– Plain CT Scan of the brain using fused
5.0 and 10.0 mm axial slices were
done.
• Findings:
– There is hyper-density noted on the right
side of the pons and midbrain
– Grey white matter differentiation is
observed
– The midline structures are in place
– The cisterns, sulci and ventricles are
normal in size and configuration
– The mastoids are well aerated
– No fracture on the cranial vault noted.

• Impression:
ACUTE CEREBRAL
HEMATOMA,
PONS AND MIDBRAIN
• Chest AP view
• The basal lung markings are still
accentuated with no significant interval
change in present radiograph as
compared with previous study dated 8-
26-09
• The rest of the findings are unchage
 12-LEAD
ELECTROCARDIOGRAM
• The standard ECG is a representation of
the heart’s electrical activity recorded
from electrodes on the body surface.

• Rate : 75 beats per minute

• Rhythm : Sinus

• Remarks : Regular Sinus Rhythm

 DATE TIME RESULT REMARKS CLINICAL
CAPILLARY BLOOD GLUCOSE SIGNIFICA
NT
09-06- 6:10MONITORING
177 mg/dl Increased DM
09 AM 255 mg/dl Increased
12:00 161 mg/dl Increased
NN
6:00
PM
09-07- 7:00 200 mg/dl Increased DM
09 AM
09-08- 6:00 189 mg/dl Increased DM
09 AM 195 mg/dl Increased
6:00
PM
09-09- 6:00 172 mg/dl Increased DM
09 AM
 SIGNIFICANCE RESULT NORMAL REMARKS CLINICAL
VALUES SIGNIFI
CLINICAL CHEMISTRY CANT
K+ Potassium is09/01/09 3.6-5.5 Normal
3.9
checked in ordermmol/L mmol/L
to assess a known
09/12
or suspected 3.7mmol/L
disorder
associated with
renal disease,
glucose
metabolism,
trauma or burns 09/01/09
Na+ 162.9 Hyperna
Sodium plays ammol/L 134-148 Incresed tremia
major role in09/12 mmol/L
homeostasis in a151mmol/L Increased
variety of ways
including
 SIGNIFICANCE RESULT NORMAL REMARKS CLINICAL

HEMATOLOGY VALUES SIGNIFICANCE

Hgb To monitor Hgb value in 09/01/0 M: 140-180 Normal

the RBC; To suggest the 9 g/L
presence of body fluid 135 g/L F: 120-160
deficit due to elevated Hgb 09/12/0 g/L
levels. 9
116g/L 5-10 X decreased
10g/L
WBC 09/01/0 Slightly Could
To detect infection or 9 Increased. indicate
inflammation. This 11.0 g/L presence of
evaluates the number of 09/12/0 infection.
condition and differentiates9
the causes of alteration in 12.80g/L
the total WBC count increased
including inflammation, 09/01/0 Aspiration
infection and tissue 9 pneumonia
Hct necrosis. 0.40g/L M: 0.40-0.52 Normal
09/120 F: 0.37-0.47
To aid the diagnosis of 09
abnormal states of 0.33
hydration, polycythemia 09/01/0
anemia 1 decreased
Lympho- 0.23g/L 0.18-0.48
cytes 09/12/0 Normal
To detect presence of 9
infection within the body. 0.10g/L
Drug Study
Pirac Nootr • increase • used in • First • anxiety, • patients • do not
etam opic blood cases of trimester insomnia, suffering take
flow and severe of from liver medicat
oxygen to brain pregnanc irritability, diseases, a ion if
the disease y; severe monitoring your
brain, • cerebro- parenchy headache, of liver pregna
aid cranial mal liver enzymes nt or
stroke trauma or kidney agitation, and lactatin
recovery in acute disease; function is g
stage agitated nervousness,necessary
• Piraceta depressio and • distribution
m tablets n, tremor of breast
are used particula milk into
in rly in the the breast-
cerebro- elderly feeding
vascular should be
disease discontinue
d for the
period of
treatment
 • & Neurotonics
Citicoline Nootropics Citicoline • Cerebrovasc • Must not • elevated • Must not • Instruct
seems to ular accident be body be client to
increase a in acute and administ temperat administ take a
brain recovery ered to ure, ered capsule
chemical phase and patients restlessn along per day in
called signs of with ess, and with the
phosphatidyl cerebral hyperton difficulty medicati morning.
choline. This insufficiency ia of the sleeping ons
brain such as parasym if the containin
chemical is dizziness, patetic. supplem g
important for memory ent is meclofen
brain loss, poor taken in oxate
function. concentratio the (also
Citicoline n, evening known
might also disorientatio as
decrease n, etc. and clopheno
brain tissue recent xate).
damage when cranial
the brain is traumatism
injured. and their
sequelae.
Simvastatin • Antilip • Inhibits HMG- • Reduce risk • Contraindic • Headache, • To pt with • Instruct
emics CoA reductase, of death ated to sleep hypersensiti client yo
an early step in from CV pregnant disturbance vity to take drug
cholesterol disease and and , diarrhea, drugs and with eving
biosynthesis CV event in lactating flatulents with active meal .
pt at high women heartburns, liver
risk for • Pt with abdominal disease.
coronary hyper pain, • Pt should
event sensitivity dyspepsia, follow a
to drugs liver standard
and with failure. low
lactive liver cholesterol
disease. diet during
therapy
• Obtain liver
function
test.
• Use drug on
if non drug
and diet
prove
ineffective.
Fluimucil mucolytics • It reduces • URTIs • Hypersensit • nausea, • should be – Instr
the viscosity • LRTIs ivity to any headache, given in uct
of LRTIs of the tinnitus, caution in client
• bronchial • COPD ingredients. urticaria, asthma to
secretions. COPD • Pregnancy stomatitis, patients take
bronchial & Lactation rhinorrhoea • should also drug
secretions Pregnancy , Chills, be in the
• Fluimucil & Lactation fever, used with eveni
prevents the • bronchospa caution in ng
formation sm may be patients – Shoul
of observed.br with history d be
disulphide onchospasm of peptic taken
bonds & may be ulceration, after
thereby observed. both meal.
• regulates because
the viscosity dused with
of the muc caution in
regulates patients
the viscosity with history
of mucus of peptic
ulceration
Ceftazidime • 3rd • Inhibit cell • CNS • Pt with • Headache • Before • Instruct
generation wall infection. hypersensiti • Dizziness administrat client to
cephalospor synthesis, bity to • Seizure ion. Ask report
in promoting drugs or • Nausea nad client ill discomfort
osmotic other vomiting allergic to at IV
instobility cephalospor • Diarrhea penicillin or insertion
ins cephalospor site
ins • Advise Pt.
• Obtain To notify
speciment prescriber
for culture about loose
and stool or
sensitivity diarrhea
test before
giving 1st
dose
• For IM
inject on
deep large
muscle
Levofloxacin Antibiotic • It functions • . indicated • patients • Constipatio • taken • taken once
daily for 7-14
by for the with a n; diarrhea; once a days.
inhibiting treatment of known dizziness; day • Avoid taking
adults (>/=18 • The antacids,
DNA gyrase, years of age)
hypersensiti gas;
a type II vity to headache; solution vitamin or
with mild, mineral
topoisomerase, moderate, Levofloxaci lightheaded should be
supplements
and and severe n or other ness; taken 1
, sucralfate
topoisomer infections quinolone nausea; hour (Carafate), or
caused by before or didanosine
ase iv [44], drugs. stomach
susceptible 2 hours (Videx)
which is an strains of the • Caution pain.
after powder or
enzyme designated should be
eating chewable
necessary to microorgani exercised in tablets
• You should
separate sms prescribing within 2
not use this
replicated to patients medication if hours before
DNA, with you are or after you
allergic to take
thereby liver disease
levofloxacin levofloxacin.
inhibiting • To • Do not share
or similar
cell pregnant antibiotics this
division. mother • Do not use medication
• Levofloxaci this with another
medication if person
n is also
you are (especially a
considered child), even
pregnant or
to be lactating if they have
contraindic the same
ated in symptoms
you have.
patients
• Take
with levofloxacin
epilepsy or with a full
other glass of
seizure water (8
disorders ounces).
Drink several
extra glasses
of fluid each
day while
you are
Sucralfate Antiulcer drugs • Protect the • Maintenace • Allegy to • Dizziness, • Give drug • Take drug
ulcer therapy for sucralfate, sleeplessnes on empty on empty
against duodenal chronic s,rash, stomach 1h stomach 1
pepsin and ulcer at renal constipation before meal hr before
bile salt, reduced failure or , diarrhea, or 2 hrs meal or 2 hr
promote dosage dialysis. indigestion, after meal, after meal
ulcer gastric and at and at bed
healing discomfort, bedtime time.
• Inhibits dry mout, • Monitor
pepsin pacpain pain, use
activity in antacid to
gastric relive pain
juices • Administer
antacid
between
doses, not
after 30 min
before or
after
sucralfate
doses.
 ANATOMY
AND
PHYSIOLOG
Y
 Central Nervous System:
Composed of brain and spinal
cord
Composed of three major
functional divisions:
• higher level brain ( cerebral
cortex )
• lower level brain ( basal ganglia,
thalamus, hypothalamus )
• spinal cord
 The Brain
largest and most complex
part of the nervous system
receives 20% of the total
resting cardiac output or
750 ml of blood per minute.
4 main regions : brainstem,
diencephalons,
cerebellum, cerebrum.
A. Brainstem
composed of medulla
oblongata, pons,
midbrain.
Medulla Oblongata:
the most inferior portion of
the brainstem
 functions:
regulator of heart rate and
blood vessel diameter
breathing, swallowing, vomiting
center
coughing, sneezing center
balance and coordination
sensory relay and autonomic
function
Pons
relays information between
cerebrum and cerebellum
functions:
respiratory center: apneustic
and pneumotaxic center
regulator of breathing and
swallowing
Midbrain
short section of brainstem
between the
diencephalons and pons.
main function is
coordination of eye
movements
Diencephalon
located bet the cerebrum and
the brainstem.
composed of the thalamus,
hypothalamus, and epithalamus
 Hypothalamus
Small portion of diencephalons
located below the thalamus
Functions are as follows:
1. cardiovascular regulation
2. body temp regulatio
3. water and electrolyte imbalance
4. regulation of hunger
5. control of gastrointestinal
activity
6. sexual response
7. limbic and emotion
8. control of endocrine
function
9. sleeping and wakefullness
 Thalamus
largest part of the diencephalons
functions:
performs some sensory interpretation
responding to general sensory stimuli
and provides crude awareness
plays a role in the initial autonomic
response of the body to intense pain.
partly responsible for the physiologic
shock that follows serious trauma
 Epithalamus:
consist of vascular choroids
plexus where cerebrospinal
fluid is produced
involved in emotional
response to odor
consist of pineal body and
endocrine gland that
influences the onset of
puberty.
Cerebellum
known as “little brain”
2nd largest structure of the
brain.
functions:
1. maintain balance and
muscle tone
2. coordination of fine motor
movements
 Cerebrum
>largestand most
obvious part of the
brain.
>accounts 80% of the
total mass of the
brain.
divided by the longitudinal fissure into
right and left hemisphere
each of the hemisphere is connected by
the corpus callosum that contain central
cavity called lateral ventricle that is
filled with cerebrospinal fluid
Functions:
responsible for higher mental functions:
memory and reason
Frontal Lobe
anterior portion of the
cerebral hemisphere
functions:
control of voluntary motor
movement
motivation, mood
aggression, olfactory
reception
Temporal lobe
 below the parietal lobe and
posterior of the frontal lobe
function:
 olfactory and auditory
sensation, and memory
Parietal Lobe
 posterior portion of frontal
lobe.
Function:
 principal center for reception
and conscious perception of
general sensory information:
touch, temperature, taste,
balance, pain.
Occipital Lobe
posterior portion of the cerebrum
Functions:
for vision
integrates eye movement by
focusing and directing the eye
visual association- correlating visual
images with previous visual
experiences.
Functional Areas of the Cerebral Cortex:
A. Primary Sensory Area
 sensory pathway that project to
specific regions of the cerebral
cortex where sensations are
perceived

B. Secondary Sensory Area/ Primary

Somesthetic Cortex
 located in the parietal lobe
C. Primary Motor Cortex
posterior portion of the frontal lobe
control voluntary movement of skeletal
muscles.
D. Premotor Area
anterior portion of frontal lobe/ pre
frontal area
staging area where motor function are
organized before they are actually
initiated at the primary motor cortex
foresight to plan and initiate movement
Speech Area
 left cortex
consist of 2 cortical areas:
1.Wernicke’s Area
 sensory speech area
 parietal lobe
2. Broca’s Area
 motor speech area
 frontal lobe
 damage to these areas may result to
aphasia, absent or defective speech or
problem in language comprehension.
PATHOPHYSIO
LOGY
Predisposing Factor:
Hypertension
DM
Head injury

HPN
 NURSING
CARE PLAN
• Assessment
• Subjective:
• “no verbal cues”
• Objective:
• altered LOC dysphagia
• lack of cooperation with FCUB
• hemiparesis with NGT for feeding
• Hemiplegia Vital signs:
• Apraxia T-38.7o C
• Dysarthria P-91 bpm
• Dry skin R-24 cpm
• Febrile BP-150/90 mmHg
• impairment of touch
• left visual field cut
Nursing diagnosis:
• Ineffective Cerebral Tissue perfusion related to
interruption of blood flow secondary to Intracranial
Hemorrhage as evidenced by altered LOC,
hemiparesis, and hemiplegia.
Rationale:
• Extravasated blood from any ruptured vessel is
irritating to brain tissue possibly leading to
vasospasm and edema in the surrounding areas. The
extravasation of blood from a circular type of mass
that distrupts blood supply to the brain and
compresses surrounding brain tissue, resulting to
infarction and tissue necrosis .
• Source: FOCUS ON PATHOPHYSIOLOGY p. 958-959 by: Barbara Bullock Reet Henze 
• Decreased cerebral perfusion is usually
caused by occlusion of a cerebral artery or
intra-cerebral hemorrhage. 
• Source: MEDICAL SURGICAL NURSING p.2110 by: Joyce Black Jane Hawks

Expected outcome:
• Within 8 hours of nursing intervention
(collaborative: oxygen therapy,
• Independent: monitor v/s, neurologic status
frequently to compare with baseline) the
patient will be able to demonstrate v/s within
client’s normal range of BP 120/90mmHg, RR
20 cpm, temp. of 37.5˚c and absence of signs
of increase ICP.
 Nursing intervention
•
Collaborative:
•
Oxygen administration.
•
Reduce hypoxemia to avoid increase cerebral pressure.
–
Independent:
•
Monitor vital signs
•
For baseline data purposes
–
Position head on 30-40˚ and in neutral mode
•
Reduces arterial pressure and promote venous drainage and may improve cerebral perfusion.
–
Conduct a neurologic assessment every one to two hours initially and every four hours after PT
•
become stable.
To screen for changes in LOC and neurologic studies
–
• Maintain bed rest.
– Activity can increase ICP
• Provide quiet environment
– Absolute rest and quiet may be needed to
prevent bleeding.
• Monitor laboratory studies
– Provide information about the drug
effectiveness/ therapeutic level.
• Evaluation
• After 8 hours of nursing intervention
(collaborative: oxygen therapy,
• Independent: monitor v/s, neurologic
status frequently to compare with
baseline) the patient was able to
demonstrate v/s within client’s normal
range of BP 120/90mmHg, RR 20 cpm,
temp. of 37.5˚c and absence of signs of
increase ICP.
Assessment:
• Subjective:
No verbal cues
• Objective:
• Dysphagia Dry skin
• w/ NGT for feeding Febrile
• Hemiplegia with NGT for feeding
• Hemeparesis with FCUB
• Dysarthia Vital signs:
• Apraxia T-38.7o C P-91 bpm
• altered LOC R-24 cpm BP-150/90 mmHg
• lack of cooperation
Nursing diagnosis
• Impaired swallowing related to
neuromuscular impairment secondary to
disease process as evidenced by
dysphagia, w/ NGT for feeding,
hemiparesis, hemiplegia & body
weakness.
 Expected outcome:
• Within 3-5 days of nursing intervention
(evaluating the ability to swallow using
small sips of water, providing food/ fluid
that are easily swallowed) the pt will be
able pass food and fluid from mouth to
stomach safely as manifested by ability
to swallow semi solid foods and no NGT
for feeding
• Nursing intervention
• Assist client ability to swallow and gag reflex, LOC,
awareness of surrounding and cognitive function.
– Impairments of this area increase for aspiration and
depress gag reflex and increases the risk of
aspiration
• Elevate head of the bed 30o during meal times and 30
min. after completion of a meal.
– To decrease the risk of aspiration.
• Stay with the patient when she tries to eat
– Basic safety measure to the patient who has
difficulty in swallowing
• Provide of food/fluid that is most easily swallowed such
as gelatin, soup, yogurt and scramble eggs
– To avoid choking
• Keep suction apparatus at the bed side,
observe and report instances of cyanosis,
dyspnea or choking
– Symptoms indicate the presence of material in
the lungs
• Provide mouth care three times daily
– Promote comfort and enhance apatite
• Provide rest period prior to feeding time,
– The rested client may have less difficulty with
swallowing.
• Consult with the dietitian to modify Pt. diet
– To establish nutritional .requirement.
• Evaluation
• After 3-5 days of nursing intervention
(evaluating the ability to swallow using
small sips of water, providing food/ fluid
that are easily swallowed) the pt was
able pass food and fluid from mouth to
stomach safely as manifested by ability
to swallow semi solid foods and no NGT
for feeding
 Assessment :
Subjective: “Nanluya iton hiya kahuman
mastroke” as verbalized by the husband.
Objectives:
• limited ROM apraxia
• body weakness dysarthria
• hemiplegialeft eye visual cut
• hemiparesis with foley catheter to urobag
• altered LOC with NGT feeding
• with slurred speech V/S
• dysphagia T-38.7o C P-91 bpm
• lack of cooperation R-24 cpm BP-150/90 mmHg
Nursing diagnosis
• Impaired physical mobility related to
neuromuscular impairment secondary to
cerebrovascular accident as evidenced by
hemiparesis, hemiplegia body weakness.
• Rationale
• CVA disease refers to any functional or structural
abnormality of the brain cause by pathologic
condition of the cerebral vessel this may be a
cause of hemorrhage and impairs the cerebral
circulation by the partial or complete occlusion,
therefore causing distraction to different body
systems such as neuromuscular involvement
weakness or paralysis.
• Source: www.emedicine.com
Expected outcome
• Within 1-2 months of nursing intervention
the client will show possible increase in
muscle strength and function of affected or
compensatory body part as evidenced by
improve muscle strength.
Nursing intervention:
• Assess client’s functional ability or extent of
impairment initially and on a regular basis.
– Identifies strength/deficiencies and may provide
information regarding recovery.
• Support affected body parts by pillows.
– Maintains position of function and reduce risk of
pressure ulcers
• Begin active/passive ROM to all extremities, once on
twice a day if patient can tolerate.
– Minimize muscle atrophy promotes circulation and
prevent contractures.
• Encourage client to assist in alternate movement in
using unaffected extremities.
– Promote optimal level of functioning and regain
muscle strength on weak areas.
• Assist to develop sitting balance (examples: raise
head of bed, assist to sit on edge of bed, having
patient use the strong arm to support body weight
and strong leg to move affected leg) and standing
balance (example: put flat walking shoes on patient,
support patient’s lower back with hands while
positioning own knees outside patient’s knees, assist
in using parallel bar/walkers)
– Aids in retraining neuronal pathways, enhancing
proprioception and motor response.
• Dependent:
• Consult with physical therapist regarding
active, resistive exercise and patient
ambulation.
– Individualized program ca be developed to
meet particular needs or deal with deficits in
balance coordination strength.
• Administer muscle relaxants
antispasmodics, as indicated.
– May be required to relieve spasticity in
affected extremities.
Evaluation
• After 1-2 months of nursing interventions
the client was partially able to increase
muscle strength and function as
evidenced by decrease body weakness,
increased ROM.
• Assessment
• Subjective:
• “no verbal cues”
• Objective:
• Slurred speech febrile
• Dysarthria apraxia
• Aphasia left visual field cut
• altered LOC Dry skin
• lack of cooperation Vital sign
• hemiparesis T-38.7o
• Hemiplegia P-91 bpm
impairment of touch R-24 cpm
• w/ NGT feeding BP-150/90
• inability to swallow

•
• Nursing diagnosis
• Impaired verbal communication related to
decrees circulation to the brain secondary to
intracranial hemorrhage as evidence by
dysarthia, aphasia, slurred speech.
• Rationale:
– Loss of verbal communication is usually
caused by ischemia of the dominant cerebral
hemisphere, leading to loss of the function
of muscles that produce speech. 
•  Source: MEDICAL SURGICAL NURSINGp.1863
• by: joyce M. Black
•  
• Expected outcome
• With in 1 ½ months of nursing
intervention the client will participate in
therapeutic communication as active
listening, maintaining eye contact,
establish method of communication in
which needs can be expressed.
– Monitor records changest in Pt speech
pattern or level of orientation.
– Observe Pt closely to her need’s and desire.
– Reorient Pt in reality such as calling by her
name.
Nursing intervention:
• Observe pt closely for her cues, to his needs and
desires, such as gesture, looking at item and
pantomime
– To enhance understanding
• Monitor record changes in pt speech pattern or level
of orientation.
– Changes may indicate improvement or deterioration of
condition.
•  Speak slowly and distinctly in a normal tone when
addressing client and stand where client can see and
hear you.
– This action promote comprehension
• Reorient pt to reality : call pt by name, tell
pt your name, give pt back ground
information, (place date and time) use large
calendar and orientation boards
– This measure develop orientation skills through
repetition and recognition of familiar object.
• Use your simple phrases, allow ample time
for response,
– This improves pt self concept and reduces
forestation.
• Remove distraction from the environment
during attempts atcommunication
– Reduce distraction improve comprehension
• Refer to a SLP (speech-language pathologist)
– Appropriate aid of communication.
• Administer medicine as prescribe by the
physician.
– To facilitate treatment and recovery.
Evaluation
• After 1 ½ months of nursing intervention the
client was able to participate in therapeutic
communication as active listening ,
maintaining eye contact, establish method of
communication in which needs can be
expressed
Assessment
• Subjective:
• “no verbal cues”
• Objective: hemiparesis
• altered LOC hemiplegia
• dry skin with FCUB draining
• paralysis of the left side febrile
of the body apraxia
• Slurred speech Vital sign
• Dysarthria T-38.7o P-91 bpm
• Aphasia
• lack of cooperation R-24 cpm BP-150/90
• Nursing diagnosis
• Impaired skin integrity related to physical
immobilization as evidence by
hemiparesis, hemiplegia,, limited ROM,
dry skin.

Rationale
– The stroke pt may at risk for skin integrity
being potentially vulnerable to break down
because of immobilization.  
• www.itvest.com
• Expected outcome
• With in the shift of nursing intervention
the pt will not show evidence of skin
breakdown and will show normal skin
turgor
– Position client comfort and change her
position every 2 hrs
– Massage and lunricate skin with bland lotion
oil
– Perform prescribe treatment for the skin and
monitor prognosis
Nursing intervention:
• Inspect skin every shift and document skin
condition
– To provide evidence of effectiveness of the skin
care regiment.
• Performe prescribe treatment regiment for
the skin condition involve. Monitor progress.
– To maintain or modify current therapy.
• Position client for comfort and minimal
pressure on bony prominences . change her
position every two hours.
– This measures reduce pressures, promote
circulation and minimize skin breakdown.
• Provide support measure as indicated: assist
for general hygiene and comfort, maintain
proper environment condition, maintain
infection control in standards, use a foam
mattress or bed cradle and other devices
administer pain medication and monitor its
effectiveness.
– To promote comfort and sense of wellbeing, to
minimize skin breakdown and to relief pain to
maintain health.
• Massage and lubricate skin with bland lotion
or oil.
– Enhances circulation and protect skin surfaces
reducing risk of ulceration.
Evaluation
• After a series of nursing intervention the
pt’s skin remains intact as evidence by
absence of lesions and bedsores.
 HEALTH TEACHING
• 1 Therapies such as positioning and range of motion
exercise can help prevent complication related to stroke,
such us infection and bedsore
• 2 Recommending that all patient with high blood ressure
monitor their bood pressure at home on regular basis
• 3 Caregivers may need to show the person pictures,
repeatedly demonstrate how to performe task or use
another communication strategies, depending on the type
and extend of the laungeuge problem.
• 4. Encourage high fiber,low salt, low fat diet.
• 5. Encourage to stop smoking and control alcohol
use.
• 6. Teach the patient and family to adapt home
environment for safety.
• 7. Instruct the patient in need for rest periods
throughout the day.
• 8. Encourage to participate in cognitive retraining
program, reality orientation, visual imagery, and
cueing procedure
• 9. Teach patient to use nonaffected side for activities
of daily living but not to neglect affected side
• 10. Reassure th family that it is common for
poststroke patient to experience emotional
labilityand depresion.
 PROGNOSIS
RECOMMENDA
TION AND
SUMMARY
 PROGNOSIS
• The case of our patient Mrs. CGL, 66 years of
age, residing at Brgy. Lalawigan Borongan E.
Samar is presented with the diagnosis of
Cerebrovascular Accident (Intracranial
hemorrhage). Prognosis is good since the
treatment regimen was implemented and the
patients family complied with the treatment
regimen further more, the patient was
already discharge and went home improved
medical condition.
 SUMMARY

• A case of CGL, female, 66 years of

age and is married is presented with
the diagnosis of Intracranial (or intra-
cerebral) Hemorrhage, is presented.
A known hypertensive and diabetic
for years, such conditions, including
her age and familial tendencies,
increased the risk of having the
disease.
• After a thorough assessment of physical and
neurological health, and a review and analysis
of her laboratory examinations and diagnostic
procedures, the pathophysiology was traced
and appropriate nursing care plans were
produced.
• The prognosis of the client is good since the
treatment regimen was implemented and the
patient and patient’s family complied with the
treatment regimen. Further more, the patient
was already discharged and went home with
improved medical condition.
Recommendations were also suggested to
help the patient maximize her recovery.
THANK YOU!!!