COLLEGE OF NURSING Silliman University Dumaguete City

CRITERIA FOR NURSING CARE PRESENTATION

CRITERIA ACTUAL POINTS OBTAINED Content

POINTS

1. Psychosocial Profile 1.1Personal Data ...5 1.2Family Data (include family tree) .. 3 2. Significant Results of Nursing Assessment 2.1P.A. Findings and its Base..5 2.2Laboratory Results/ Diagnostic Exam Results.3 2.3Summary of Nursing Diagnosis 8 3. Plan of Care and its Implementation 3.1 Objectives of Care.5 3.2 Independent Nursing Actions Implemented..10 3.3 Dependent Nursing Actions Implemented. .7

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3.4 Health Teachings5

3.5 Referrals within and outside the hospital...3

4. Evaluation of Care 4.1Evaluation of Objectives....4 4.2Totality of Care (including G/D and components of wholeness) ...5 4.3Involvement of patient/family.....2 (integration of anatomy and physiology, drugs, diet and principle, theories and laws is related sciences should be evident)

I. Organization.5 II. Mastery 1. Less dependence upon notes..............5 2. Ability to answer questions..20 III. Bibliography (at least 6 recent journals) ..5 _________ 100 Rating: _________________

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Date of Presentation: Rated by: Students Signature: _______________________ Carlisle Femme F. Cual _______________________ Dawn Garbielle T. Veria

College of Nursing Silliman University Dumaguete City July 8, 2013 Asst. Prof. Endyss Quilaquil Clinical Instructor Silliman University College of Nursing Dumaguete City Dear Maam: Good Day! We, Carlisle Femme F. Cual, and Dawn Gabrielle T. Veri a, junior students of Silliman University College of Nursing, currently rotated in Medicine Ward (Upper Annex) in Negros Oriental Provincial Hospital, would like to ask for your consent to do a case study on Stroke and Hypertension on our patient Mr. X. It is our privilege to have this case, and so, as a means of imparting the knowledge and skills we have gained from this experience, we would like to ask for Medicine rotation which will also serve as a tool to widen our knowledge, develop our skills and build positive attitude in the care of patients with the same condition.

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Respectfully yours, _______________________ Carlisle Femme F. Cual Approved by: __________________________ Asst. Prof. Endyss Quilaquil
Clinical Instructor Medicine Rotation

______________________ Dawn Garbielle T. Veria

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COLLEGE OF NURSING Silliman University Dumaguete City

SILLIMAN UNIVERSITY VISION AND MISSION

Vision:
A leading Christian institution committed to total human development for the well-being of society and the environment.

Mission:
1. Infuse into the academic learning the Christian faith anchored on the gospel of Jesus Christ; provide an environment where Christian fellowship and relationship can be nurtured and promoted. 2. Provide opportunities for growth and excellence in every dimension of the University life in order to strengthen character, competence and faith. 3. Instill in all members of the University community an enlightened social consciousness and a deep sense of justice and compassion. 4. Promote unity among peoples and contribute to national development.

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Acknowledgement
This study has been a product of hardwork, sleepless nights, tiresome hours, unforgettable moments and most of all, learnings that the researchers will forever cherish and treasure. The intense pressure that they felt in doing their best to finish the study on the expected deadline, the fear of not meeting the expected outcomes and not being able to produce this study with success. Despite the pressures and some constraints, the researchers were still able to successfully finish their most precious work. The researchers would like to express wholeheartedly their genuine and heartfelt thanks to the people who encouraged and believed in their ability to finish the study, and the people who served as an inspiration to make this paper a reality. Thus, their sincere and profound gratitude to: Asst. Prof. Endyss S. Quilaquil, the researchers clinical instructor for Medicine Rotation, who has always been very patient in sharing her knowledge and skills to her students, for her precious time given to all her students in guiding and molding them to be a very good nurse someday. A million words wont be enough to express the researchers heartfelt thanks to her for the much needed directives and suggestions to perfectly mold this paper; Mr. Efren Tabotabo the researchers subject for this study, for trusting the researchers by giving his full cooperation and for sharing his life without doubting its confidentiality; Silliman University Main Library Librarians, Staff and Student Assistants, for their patience and kindness in providing the necessary books and reading materials and allowing the researchers to utilize their facilities; Learning Resource Center Staffs, for the assistance they gave especially in the completion of this paperwork as well as letting the researchers use their facilities (books, journals and etc.); The Staff, Nurses and Resident Doctors of Negros Oriental Provincial Hospital, for the hospitality and kindness in allowing the researchers go through the records of Mr. Efren Tabotabo;

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The researchers parents, for financing this study, for providing their unconditional love and support, and their unending prayers for this study; Classmates and friends, for sharing their thoughts, prayers, encouragement, support, time, and all the unforgettable moments of fun and laughter in inspiring the researchers to finish the study; And above all, to God, the Almighty Father, without whose guidance all of science would be but random guesses in a chaotic universe and who made all things possible, the source of all strength; His guidance and blessings enabled the researchers to finish this paper on time. Who as a Father provided us many things (wisdom, time, money, books, etc.), for the success of the researchers case analysis.

INTRODUCTION
The human brain has been called the most complex object in the known universe, and in many ways it's the final frontier of science. A hundred billion neurons, close to a quadrillion connections between them, and we don't even fully understand a single cell. The mysterious processes that the brain are still yet to be explained further, enough to be understood by the common man. A cerebral vascular accident is another name for a stroke. It is damage to the brain caused by a disruption of the blood supply to a part of the brain. This disruption of blood supply can be caused by a blood clot, or by a ruptured artery. It is also the

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sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain. Blood vessels that carry blood to the brain from the heart are called arteries. The brain needs a constant supply of blood, which carries the oxygen and nutrients it needs to function. Each artery supplies blood to specific areas of the brain. A stroke occurs when one of these arteries to the brain either is blocked or bursts. As a result, part of the brain does not get the blood it needs, so it starts to die. The symptoms of a cerebral vascular accident depend on which part of the brain is affected. Common symptoms may include paralysis of a part of the body, loss of all or part of the vision, or loss of the ability to speak or to understand speech. Hemorrhagic stroke is caused by a blood vessel in the brain that bursts and spills blood into the brain. High blood pressure and brain aneurysms can both cause blood vessels to be weak and may cause this type of stroke as a result. An intracerebral hemorrhage is caused when a burst blood vessel bleeds into the brain. HPN is the most common cause of this type of stroke. The bleeding causes brain cells to die, and then the part of the brain where this occurs no longer works correctly. An aneurysm is a weak spot on the wall of an artery that may balloon out, forming a thin-walled bubble.as it gets bigger, the aneurysm gets weaker and can burst, leaking blood into or outside of the brain.

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In a subarachnoid hemorrhage, a blood vessel bursts near the surface of the brain and the blood pours into the area around the outside of the brain. This bleeding may increase pressure in the brain, injuring brain cells. This type of stroke has many possible causes but is usually the result of a bursts aneurysm. Hypertension, also referred to as high blood pressure, is a condition in which the arteries have persistently elevated blood pressure. Every time the human heart beats, it pumps blood to the whole body through the arteries.

Blood pressure is the force of blood pushing up against the blood vessel walls. The higher the pressure the harder the heart has to pump. Hypertension can lead to damaged organs, as well as several illnesses, such as renal failure (kidney failure), aneurysm, heart failure, stroke, orheart attack. hypertension means "High blood pressure; transitory or sustained elevation of systemic arterial blood pressure to a level likely to induce cardiovascular damage or other adverse consequences." The normal level for blood pressure is below 120/80, where 120 represents the systolic measurement (peak pressure in the arteries) and 80 represents the diastolic measurement (minimum pressure in the arteries). Blood pressure between 120/80 and 139/89 is called prehypertension (to denote increased risk of hypertension), and a blood pressure of 140/90 or above is considered hypertension. Hypertension may be classified as essential or secondary. Essential hypertension is the term for high blood pressure with unknown cause. It accounts for about 95% of cases. Secondary hypertension is the term for high blood pressure with a known direct cause, such as kidney disease, tumors, or birth control pills.

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CENTRAL OBJECTIVES FOR THE CASE PRESENTATION

CENTRAL OBJECTIVE After the one-hour discussion, the learners shall acquire knowledge, develop beginning skills, and manifest positive attitudes in the care of a patient with hemorrhagic stroke.

SPECIFIC OBJECTIVES At the end of the two-hour discussion, the learners shall: 1. Get a clear picture of the psychosocial and demographic profile, and medical history of the patient; 2. Review the anatomy and physiology of the Nervous System and the Cardiovascular System; 3. Understand the pathophysiology of Hemorrhagic stroke and Hypertension; 4. Identify possible complications of Hemorrhagic stroke and Hypertension; 5. Enumerate possible nursing diagnosis appropriate to the condition; 6. Enumerate possible nursing interventions to prevent the complications regarding the current situation; and 7. Rationalize the different interventions regarding the present condition.

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NUSING HISTORY Part I. Demographic Data Name: Tabotabo, Efren Real Civil status: Married Sex: Male Educational Attainment: High School Address: Bunao, Dumaguete City Religion: Roman Catholic Occupation: Carpenter Room and Bed no.: Alley 7 Doctor(s) in charge: Dr. Gersan Nationality: Filipino Chief Complaint(s): Dizziness noted few hours PTA, right side body weakness noted 2 hours PTA Date and time of Admission: June 27, 2013; 10:40AM Diagnosis(es): CVD- Hemorrhagic (Stroke), HPN, Stage 2 General Impression: Client is awake, oriented, active, alert, sad and responsive to verbal stimuli (when questions asked) and environment with long nails, slightly red watery eyes and relative dryness of skin. Client is on supine position. There were no signs of distress and pain due to hemorrhagic stroke as verbalized. Upon assessment, client looked tired and there were no presence of obvious edema and open lesions noted. There were no involuntary movements noted. Speech is congruent and moderately paced but at some point, speech was not understandable and audible. Verbal expressions match with the nonverbal behavior, mood is appropriate to the situation.

History of present illness: Client was not aware that he was hypertensive but verbalized that they have a heredofamilial disease which is Hypertension. He continued doing his job as a carpenter under the heat of the sun. His usual diet was meat, fish and rice. Verbalized kalit rjud kaayu tanan kay wala ko kabalo na pwede ni mahitabo nako

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Past Medical History Childhood Illnesses: Chicken Pox Cough and colds Tooth decay Fever

Immunizations as verbalized: Could no longer remember immunizations taken.

Medical

Client verbalized that he was never hospitalized.

Accidents/Injury

Had a motorcycle accident when he was still 25 years old and had minor injury such as abrasion.

Allergies

Client claimed no known allergies on foods and medications.

Current Medications Clonidine 75mg 1 tab OD

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Lactulose syrup 15cc OD Trimetazidine 35mg 1 tab BID ISMN 30mg 1 tab Captopril 25mg 1 tab PO q6H PRN for BP160/90mmHg Omeprazole 40mg IVTT OD Piracetam 3gms IVTT q6H Citicholine 1gm IVTT q6H

Habits and Lifestyle Client verbalized the following as his daily habits: Goes around the city for leisure time Stays at home when he doesnt have work

General Impression of client (appearance upon first contact): Client is awake, oriented, active, alert, sad and responsive to verbal stimuli (when questions asked) and environment with long nails, slightly red watery eyes and relative dryness of skin. Client is on supine position. There were no signs of distress and pain due to hemorrhagic stroke as verbalized. Upon assessment, client looked tired and there were no presence of obvious edema and open lesions noted. There were no involuntary movements noted. Speech is congruent and moderately paced but at some point, speech was not understandable and audible. Verbal expressions match with the nonverbal behavior, mood is appropriate to the situation.

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GENOGRAM

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GROWTH &
DEVELOPMENT

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In middle adulthood the individual makes lasting contributions through involvement with others. Generally, the middle adult years begin around the early to mid-30s and last through the late 60s. This is the settling down and the pay-off years. During this period, personal achievements have often already been experienced. Many middle adults find particular joy in assisting their children and other young people to become productive and responsible adults. They may also begin to help aging parents. Using leisure time in satisfying and creative ways is a challenge that, if met satisfactorily, enables middle adult to prepare for retirement. Growth and Development of a Normal Growth and Development of Mr. X Middle Adult Physical Changes` Major physiological changes occur between 45 Evenly distributed gray hair, wrinkling of the skin, and and 65 years of age. The most visible changes thickening of the waist are visible. Has no hearing are graying of the hair, wrinkling of the skin, and difficulties and uses reading eyeglasses when necessary. thickening of the waist. Balding commonly begins during the middle years, but it may also occur in young male adults. Decreases in hearing and visual acuity are often noted during this period. Climacteric The climacteric occurs in men in their late 40s or early 50s. It is caused by decrease levels of androgen. Throughout this period and thereafter, a man is still capable of producing fertile sperm and fathering a child. However, penile erection is less firm, ejaculation is less frequent and the refractory period is longer Cognitive Changes Change in the cognitive function of middle adults are rare except with illness or trauma. The middle adult can learn new skills and information. Some middle adults enter educational or vocational programs to prepare themselves for entering the job market or changing jobs. Client is not capable of providing sexual satisfaction to his spouse due to right hemiplegia.

Client was able to do his job prior to his admission. He felt discouraged and disappointed because he could no longer perform those duties because of his condition.

Children are single and are still living together with their

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Psychosocial Changes The psychosocial changes in the middle adult may involve expected events, such as children moving away from home, or unexpected events such as a marital separation or the death of a close friend. it is during this period that many middle-aged adults begin to take on a healthier lifestyle. According to Eriksons development theory, the primary developmental tasks of the middle years are to achieve generativity. Generativity is the willingness to care for and guide others The departure of the last child from the home may be a stressor. Many parents welcome freedom from child-rearing responsibilities, whereas others fell lonely or without direction because of this change. Many middle adults find themselves in the sandwich generation caught between the responsibilities of caring for aging and ailing parents. Health promotion in psychological concerns for the middle adult includes stress, level of wellness, and the formation of positive health habits. Two most common psychosocial health concerns of the middle adult are anxiety and depression. According to Daniel Levinsons theory of development choices must be made, a new life structure formed. person must commit to new tasks.

parents. Verbalized unsaon nalang nako pagbuhi sa akong mga anak nga dili nako kahimo ug tarong sa akong trabaho. Family members take turns in watching and caring over their father. Clients wife is very attentive to his needs in the hospital. His family serves as a good support system.

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Physical Assessment

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General Survey Client is awake, oriented, active, alert, sad and responsive to verbal stimuli (when questions asked) and environment with long nails, slightly red watery eyes and relative dryness of skin. Client is on supine position. There were no signs of distress and pain due to hemorrhagic stroke as verbalized. Upon assessment, client looked tired and there were no presence of obvious edema and open lesions noted. There were no involuntary movements noted. Speech is congruent and moderately paced but at some point, speech was not understandable and audible. Verbal expressions match with the nonverbal behavior, mood is appropriate to the situation. Vital Signs/Measurements: T=35.8C PR= 63bpm RR=20cpm BP= 150/90 mmHg Head Hair is evenly distributed to the scalp. It is gray in color, soft, smooth, and fine-grained. Client verbalized that he has no presence of lice and dandruffs. There are no presence of lumps and lesions noted upon palpation. Eyes Claimed to have good eyesight and able to read with the use of eyeglasses. The color of the sclera is china white. The palpebral conjunctivas are moist, transparent and have numerous blood vessels without any lesions or swelling noted. Extraocular movements are parallel with each other without any presence of abnormal eye movements. Has slight redness of eyes. Ears Client is responsive in answering the questions which denotes client does not have any auditory problems. Claimed does not heard any ringing sound (tinnitus) as verbalized.

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Nose External structure is smooth, brown in color and proportionate to other facial features. There are no presence of deformities and tenderness upon palpation. Claimed does not experience any nasal stuffiness during the assessment period. There is no tenderness of both frontal and maxillary sinuses. Mouth Verbalized walay umoy akong tuo na ngabil day, dry lips and have presence of cracks upon inspection. Bucal mucosa is pinkish, moist, soft and no presence of bleeding or lesions. Client verbalized that he has not experienced tooth extractions and has no defects on his teeth. Teeth are regular in size and proportionate to jaw and oral cavity. Tongue is centrally located without presence of deviations and tremors noted. Pharynx Uvula has difficulty in rising centrally as client says Ah. Client verbalized he does not experience any tonsil inflammations. Neck Neck appears symmetrical, without scars and enlargement of parotid glands. The lymph nodes are not easily palpable. Thyroid gland is located at the midline, just above the suprasternal notch. The thyroid gland is not visible upon inspection. It is smooth, small and free of nodules and it ascends as the client swallows. Chest (Anterior):

Clear lung parenchyma. There is a 1.2 nodule in the mediastinum on the right paratracheal area which could be due to lymphadenopathy, cardiomegaly, left ventricular in contour.
(Heart) Heart Rate:63 bpm

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S1 is best heart at the 5th ICS, midclavicular line S2 is best heard at the 2nd ICS on the right border of the sternum. There were no murmurs heard upon auscultation.

Abdomen: The skin color over the abdomen is brown. There are no scars noted on the abdomen. Umbilicus is at the middle, flat and with no signs of inflammation, discoloration or masses. Back: Claimed experienced back pains if during assessment. Client verbalized sakit ako likod. Extremities: Client verbalized mag lisod nakog lihok sa akong tuo There were no obvious signs of edema noted upon inspection.

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Anatomy & Physiology

The cardiovascular system
The cardiovascular system is one of the major body systems. It transports oxygen, carbon dioxide, waste products, nutrients and hormones to and from various parts of the body.

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The cardiovascular system is made up of the heart, the blood vessels (arteries and veins and capillaries) and blood. The heart has major vessels that supply it with deoxygenated blood (travels back to the heart from the body), and major vessels that carry oxygenated blood away from the heart to all the parts of the body. The major vessels that carry blood to and from the heart are:

inferior vena cava conveys deoxygenated blood (blood low in oxygen) from the lower extremities of the body to the heart superior vena cava coveys deoxygenated blood from the upper extremities of the body to the heart aorta conveys oxygenated blood (blood high in oxygen) away from the heart

Heart
The heart is a hollow organ about the size of a fist and is composed of special muscle tissue (cardiac muscle). It lies under the breast bone in the center of the cardiothoracic cavity. In the average lifetime the heart beats 250 million times and pumps 340 million liters of blood. The heart is a sophisticated pump that is controlled by an electrical current that is initiated in the brain. The heart is divided into a left and right side by a muscular wall called the septum and has four chambers.

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Heart chambers and valves The chambers of the heart includes the:

right atrium which receives deoxygenated blood (low in oxygen) from all over the body right ventricle receives blood from the right atrium and sends it to the lungs via the pulmonary artery to become oxygenated and get rid of carbon dioxide left atrium receives oxygenated blood from the lungs and sends it to the left ventricle left ventricle receives blood from the left atrium and sends it out to the body via the aorta.

The heart wall consists of three layers - the endocardium is the inner lining, the myocardium is the muscle layer and the pericardium is the outer covering.

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The chambers of the heart are separated by valves:

tricuspid valve is located between the right atrium and right ventricle bicuspid (mitral) valve is located between the left atrium and left ventricle pulmonary valve is between the right ventricle and the pulmonary artery aortic valve is between the left ventricle and the aorta

Blood vessels
The cardiovascular system consists of arteries and veins and capillaries. Arteries carry oxygenated blood to the cells of the body, veins carry deoxygenated blood away from the cells.

Arteries
Arteries are tubes that carry oxygenated blood (high in oxygen) away from the heart. Arteries have thick, muscular, elastic walls. They branch off forming arterioles with thinner walls that then become capillaries. Arteries carry blood rich in oxygen and nutrients. Blood that comes from a wound to an artery is bright red and spurts. The aorta is the largest artery and as it leaves the heart it branches into smaller arteries, eventually they become capillaries.

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Veins
Veins are tubes that carry deoxygenated blood (low in oxygen) from the cells back to the heart where it is pumped to the lungs so that the blood can pick up more oxygen. The veins have one-way valves that help move the blood toward the heart. Veins have thinner muscular walls. They carry blood back to the heart that is low in oxygen and high in carbon dioxide, a waste product.

Capillaries
Capillaries are very small vessels that surround the cells of the body and facilitate the movement of oxygen and nutrients into the cells and carbon dioxide and waste products away from the cells.

Blood
Blood is made up of a liquid (plasma) and cells. Blood is connective tissue, a red body fluid made up of liquid (plasma) and cells. The body contains 5 to 6 litres of blood. Fifty-five percent of the blood is plasma.

Plasma
Plasma is a straw colored watery fluid in which the blood cells are suspended. It contains antibodies (gamma globulin) and antitoxins, plasma proteins, mineral salts, nutrients, waste products such as urea and creatinine, gases such as oxygen and carbon dioxide, hormones and enzymes. The blood cells float in the plasma. They are produced in the bone marrow and lymphatic tissues of the body. The bone marrow, liver and spleen destroy worn-out blood cells.

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Blood cells
There are 3 types of blood cells.

1. Erythrocytes or red blood cells (RBC) - carry most of the oxygen and small amounts of carbon dioxide. Haemoglobin carries the oxygen molecule and gives blood its color. There are approximately 5 million RBC per cubic millimeter of blood and the average life span is 100 - 120 days.

Red blood cells 2. Leucocytes or white blood cells (WBC) - help fight infection as they can attack microorganisms. There are 7,000 - 8,000 WBC per cubic millimeter.

White blood cells 2. Thrombocytes (platelets) - are parts of cells which plug small leaks in the walls of blood vessels and initiate blood clotting. There are 200,000 to 400,000 per cubic millimeter.

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The Nervous System

Brain
The human brain serves many important functions ranging from imagination, memory, speech, and limb movements to secretion hormones and control of various organs within the body. These functions are controlled by many distinct parts that serve specific and important tasks. These components and their functions are listed below. The brain is made up of two types of cells: neurons (yellow cells in the image below) and glial cells (pink and purple cells in the image below). Neurons are responsible for all of the functions that are attributed to the brain while the glial cells are non-neuronal cells that provide support neurons. In an adult brain, the predominant cell type is glial cells, which outnumber neurons by about 50 to 1. Neurons communicate with one another through connections called synapses.

for

Meninges are the bony covering around the brain is called the cranium, which combines with the facial bones to create the skull. The brain and spinal cord are covered by a tissue known as the meninges, which is made up of three layers: dura mater, arachnoid layer, and pia mater. The dura mater is a whitish and nonelastic membrane which, on its outer surface, is attached to the inside of the cranium. This layer completely covers the brain and the spinal cord and has two major folds in the brain, that are called the falx and the tentorium. The falx separates the right and left halves of the brain while the tentorium separates the upper and lower parts of the brain. The arachnoid layer is a thin membrane that covers the entire brain and is positioned between the dura mater and the pia mater, and for the most part does not follow the folds of the brain. The pia mater, which is attached to the surface of the entire brain, follows the folds of the brain and has many blood vessels that reach deep into the brain. The space between the arachnoid layer and the pia mater is called the subarachnoid space and it contains the cerebrospinal fluid.

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Cerebrospinal Fluid (CSF) is a clear fluid that surrounds the brain and spinal cord, and helps to cushion these structures from injury. This fluid is constantly made by structures deep within the brain called the choroid plexus which is housed inside spaces within the brain called ventricles, after which it circulates through channels around the spinal cord and brain where is it finally reabsorbed. If the delicate balance between production and absorption of CSF is disrupted, then backup of this fluid within the system of ventricles can cause hydrocephalus. Brain ventricles are a system of four cavities, which are connected by a series of tubes and holes and direct the flow of CSF within the brain. These cavities are the lateral ventricles (right and left), which communicate with the third ventricle in the center of the brain through an opening called the intraventricular foramen. This ventricle is connected to the fourth ventricle through a long tube called the Cerebral Aqueduct. CSF then exits the ventricular system through several holes in the wall of the fourth ventricle (median and lateral apertures) after which it flow around the brain and spinal cord.

The brainstem is the lower extension of the brain which connects the brain to the spinal cord, and acts mainly as a relay station between the body and the brain. It also controls various other functions, such as wakefulness, sleep patterns, and attention; and is the source for ten of the twelve cranial nerves. It is made up of three structures: the midbrain, pons and medulla oblongata. The midbrain is involved in eye motion while the pons coordinates eye and facial movements, facial sensation, hearing, and balance. The medulla oblongata controls vegetative functions such as breathing, blood pressure, and heart rate as well as swallowing.

The thalamus is a structure that is located above the brainstem and it serves as a relay station for nearly all messages that travel from the cerebral cortex to the rest of the body/brain and vice versa. As such, problems within the thalamus can cause significant symptoms with regard to a variety of functions, including movement, sensation, and coordination. The thalamus also functions as an important component of the pathways within the brain that control pain sensation, attention, and wakefulness.

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The cerebellum is located at the lower back of the brain beneath the occipital lobes and is separated from them by the tentorium. This part of the brain is responsible for maintaining balance and coordinating movements. Abnormalities in either side of the cerebellum produce symptoms on the same side of the body. The cerebrum forms the major portion of the brain, and is divided into the right and left cerebral hemispheres. These hemispheres are separated by a groove called the great longitudinal fissure and are joined at the bottom of this fissure by a struture called the corpus callosum which allows communication between the two sides of the brain. The surface of the cerebrum contains billions of neurons and glia that together form the cerebral cortex (brain surface), also known as "gray matter." The surface of the cerebral cortex appears wrinkled with small grooves that are called sulci and bulges between the grooves that are called gyri. Beneath the cerebral cortex are connecting fibers that interconnect the neurons and form a white-colored area called the "white matter."

Several large grooves (fissures) separate each side of the brain into four distinct regions called lobes: frontal, temporal, parietal, and occipital. Each hemisphere has one of each of these lobes, which generally control function on the opposite side of the body. The different portions of each lobe and the four different lobes communicate and function together through very complex relationships, but each one also has its own unique characteristics. The frontal lobes are responsible for voluntary movement, speech, intellectual and behavioral functions, memory, intelligence, concentration, temper and personality. The parietal lobe processes signals received from other areas of the brain (such as vision, hearing, motor, sensory and memory) and uses it to give meaning to objects. The occipital lobe is responsible for processing visual information. The temporal

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lobe is involved in visual memory and allows for recognition of objects and peoples' faces, as well as verbal memory which allows for remembering and understanding language. The hypothalamus is a structure that communicates with the pituitary gland in order to manage hormone secretions as well as controlling functions such as eating, drinking, sexual behavior, sleep, body temperature, and emotions. The pituitary gland is a small structure that is attached to the base of the brain in an area called the sella turcica. This gland controls the secretion of several hormones which regulate growth and development, function of various organs (kidneys, breasts, and uterus), and the function of other glands (thyroid gland, gonads, and the adrenal glands). The basal ganglia are clusters of nerve cells around the thalamus which are heavily connected to the cells of the cerebral cortex. The basal ganglia are associated with a variety of functions, including voluntary movement, procedural learning, eye movements, and cognitive/emotional functions. The various components of the basal ganglia include caudate nucleus, putamen, globus pallidus, substantia nigra, and subthalamic nucleus. Diseases affecting these parts can cause a number of neurological conditions, including Parkinson's disease and Huntington's disease. There are 12 pairs of nerves that originate from the brain itself, as compared to spinal nerves that initiate in the spinal cord. These nerves are responsible for specific activities and are named and numbered as follows: Cranial nerve Cranial nerve Cranial nerve Cranial nerve Cranial nerve Cranial nerve Cranial nerve sensation Cranial nerve I (Olfactory nerve): Smell II (Optic nerve): Vision III (Oculomotor nerve): Eye movements and opening of the eyelid IV (Trochlear nerve): Eye movements V (Trigeminal nerve): Facial sensation and jaw movement VI (Abducens nerve): Eye movements VII (Facial nerve): Eyelid closing, facial expression and taste VIII (Vestibulocochlear nerve): Hearing and sense of balance

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Cranial Cranial Cranial Cranial

nerve nerve nerve nerve

IX (Glossopharyngeal nerve): Taste sensation and swallowing X (Vagus nerve): Heart rate, swallowing, and taste sensation XI (Spinal accessory nerve): Control of neck and shoulder muscles XII (Hypoglossal nerve): Tongue movement

Pineal Gland: The pineal gland is an outgrowth from the back portion of the third ventricle, and has some role in sexual maturation, although the exact function of the pineal gland in humans is unclear.

Spinal Cord
The spinal cord is a long, thin, tubular bundle of neurons and support cells that extends from the bottom of the brain down to the space between the first and second lumbar vertebrae, and is housed and protected by the bony vertebral column. The spinal cord functions primarily in the transmission of signals between the brain and the rest of the body, allowing movement and sensation, but it also contains neural circuits that can control numerous reflexes independent of the brain. General Structure: The length of the spinal cord is much shorter than the length of the bony spinal column, extending about 45 cm (18 inches). It is ovoid in shape and is enlarged in the cervical (neck) and lumbar (lower back) regions. Similar to the brain, the spinal cord is protected by three layers of tissue, called spinal meninges. The dura mater is the outermost layer, and it forms a tough protective coating. Between the dura mater and the surrounding bone of the vertebrae is a space called the epidural space, which is filled with fatty tissue and a network of blood vessels. The arachnoid mater is the middle protective layer. The space between the arachnoid and the underlyng pia mater is called the subarachnoid space which contains cerebrospinal fluid (CSF). The medical procedure known as a lumbar puncture (or spinal tap) involves use of a needle to withdraw cerebrospinal fluid from the subarachnoid space, usually from the lumbar (lower back) region of the spine. The pia mater is the innermost protective layer. It is very delicate and it is tightly associated with the surface of the spinal cord.

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In the upper part of the vertebral column, spinal nerves exit directly from the spinal cord, whereas in the lower part of the vertebral column nerves pass further down the column before exiting. The terminal portion of the spinal cord is called the conus medullaris. A collection of nerves, called the cauda equina, continues to travel in the spinal column below the level of the conus medullaris. The cauda equina forms as a result of the fact that the spinal cord stops growing in length at about age four, even though the vertebral column continues to lengthen until adulthood. Three arteries provide blood supply to the spinal cord by running along its length. These are the two Posterior Spinal Arteries and the one Anterior Spinal Artery. These travel in the subarachnoid space and send branches into the spinal cord that communicate with branches from arteries on the other side. The spinal cord is divided into 33 different segments. At every segment, a pair of spinal nerves (right and left) exit the spinal cord and carry motor (movement) and sensory information. There are 8 pairs of cervical (neck) nerves named C1 through C8, 12 pairs of thoracic (upper back) nerves termed T1 through T12, 5 pairs of lumbar (lower back) nerves named L1 through L5, 5 pairs of sacral (pelvis) nerves numbered S1 through S5, and 3-4 pairs of coccygeal (tailbone) nerves.

Vertebral Column
The vertebral column is made up of 33 vertebrae that fit together to form a flexible, yet extraordinarily tough, column that serves to support the back through a full range of motion. There are seven cervical vertebrae (C1-C7), 12 thoracic vertebrae (T1-T12), five lumbar vertebrae (L1-L5), five fused sacral vertebrae (S1- S5),and four coccygeal vertebrae in this column, each separated by intervertebral disks. The first two cervical vertebrae have very distinct anatomy as compared to the remaining vertebrae. The first cervical vertebra, known as the atlas, supports the head; and pivots on the second cervical vertebra, the axis. The seventh cervical vertebra joins the first thoracic vertebra. The thoracic vertebrae provide an attachment site for the ribs, and make up part of the back of the chest (thorax). The thoracic vertebrae join the lumbar vertebrae, which are particularly study and large, as they support the entire upper body weight. At the top of the pelvis, the lumbar vertebrae join the sacral vertebrae. By adulthood these five bones have usually fused to form a triangular bone called the sacrum. At the tip of the sacrum, the final part of the vertebral column projects slightly outward. This is the coccyx, better known as the tailbone. It is made up of three to five coccygeal vertebrae. A typical vertebra consists of two essential parts: the vertebral body in front and the vertebral arch in the back. The vertebral arch consists of a pair of pedicles, a pair of lamina, a spinous process, and four articular processes (joints) that connect the vertebra to one another, as depicted below.

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The vertebral bodies, stacked on top of each other, form a strong pillar for the support of the head and trunk. Between each two vertebral bodies exists a hole, called the intervertebral foramina, which allows for the transmission of the spinal nerves on either side.

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Pathophysiolog y
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HYPERTENSION For the arterial pressure to rise, there must be an increase in either CO or SVR. Increased CO is sometimes found in the prehypertensive and borderline hypertensive person. Later in the course of hypertension, SVR rises and the CO returns to normal. The hemodynamic hallmark of hypertension is persistently increased SVR. This persistent elevation of SVR may come about in various ways. Heredity. Genetic abnormalities associated with several rare form of hypertension have been identified. However, the contribution of genetic factors to BP levels in the general population is very small. Environmental factors also have a role in contributing to the development of high blood pressure. In practice, children and siblings of persons with hypertension should be more carefully screened and strongly advised to adopt healthy lifestyles to prevent hypertension. Water And Sodium Retention. Excessive sodium intake is considered responsible for initiation of hypertension in some people. Populations with a low sodium intake show little or no hypertension and no progressive increase in BP with age as is found in industrialized societies. In addition, when people from these societies adopt in industrialized lifestyles, the prevalence of hypertension increases. When sodium is restricted in many hypertensive people, their BP falls. A high sodium intake may activate a number of pressor mechanisms and cause water retention. Altered Renin-Angiotensin Mechanism. High plasma renin activity (PRA) results in the increased conversion of angiotensionogen to angiotensin I. angiotensin II causes direct arteriolar constriction, promotes vascular hypertrophy, and induces aldosterone secretion. Thus, altered renin-angiotensin mechanisms may contribute to the development and maintenance of hypertension. Any rise in BP indicates the release of renin from the renal juxtaglomerular cells. Stress And Increased Sympathetic Nervous System Activity. It has long been recognized that arterial pressure is influenced by factors such as anger, fear, and pain. Physiologic responses to stress, which are normally protective, may persist to a pathologic degree, resulting in prolonged increase in SNS activity. Increased SNS stimulation produces increased vasoconstriction, increased HR, and increased renin release. Increased renin activates the angiotensin mechanism and increases aldosterone secretion, both leading to elevated BP. People exposed to high levels of repeated psychologic stress develop hypertension to a greater extent than those who do not experience as much stress.

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Insulin Resistance And Hyperinsulinemia . Abnormalities of glucose, insulin, and lipoprotein metabolism are common in hypertension. Insulin resistance is a risk factor for the development of hypertension and cardiovascular disease. High insulin concentration in the blood stimulates the SNS activity and impairs nitric oxide-mediated vasodilation. Additional pressor effects of insulin include vascular hypertrophy and increased renal sodium reabsorption. Endothelial Cell Dysfunction. Vascular endothelial cells are known to be the source of multiple vasoactive substances. Some hypertensive people have a reduced vasodilator response to nitric oxide. Endothelin produces pronounced and prolonged vasoconstriction. The role of endothelial dysfunction in the pathogenesis and treatment of hypertension is an area of ongoing investigation. STROKE (BRAIN ATTACK) A stroke is caused by a change in the normal blood supply to the brain. The national stroke association now uses brain attack to better describe a stroke. Both terms are used in clinical practice. Any stroke is a medical emergency that strikes suddenly, and it should be treated immediately to prevent neurologic deficit and permanent disability. Stroke is the second most common cause of death and major disability worldwide. The brain cannot store oxygen or glucose and therefore must receive a constant flow of blood to provide these substances for normal function. In addition, blood flow is important in the removal of metabolic waste. If blood supply to any part of the brain is interrupted for more than a few minutes, cerebral tissue dies (infarction). The result is varying degrees if disability, depending on the location and amount of brain tissue affected. Brain metabolism and blood flow after a stroke are affected around the infarction as well as in the contralateral (opposite side) hemisphere. Effects of a stroke on the contralateral (nonaffected) side may be due to brain swelling and further changes in the blood flow throughout the brain. Anatomy Of Cerebral Circulation. Blood is supplied to the brain by two major pairs of arteries: the internal carotid arteries (anterior circulation) and the vertebral arteries (posterior circulation). The carotid arteries branch to supply most of the frontal, parietal, and temporal lobes; the basal ganglia; and part of the diencephalon (thalamus and hypothalamus). The major branches of the carotid arteries are the middle cerebral and the anterior cerebral arteries. The vertebral arteries join to form the basilar artery, which branches to supply the middle and lower part of the temporal lobes, occipital lobe, cerebellum, brain stem, and part of the diencephalon. The main branch of the basilar artery is the posterior cerebral artery. The anterior and posterior cerebral circulation is connected at the circle of Willis by the anterior and posterior communicating arteries. Anomalies in this area are common, and all connecting vessels may not be present.

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Regulation Of Cerebral Blood Flow. The brain requires a continuous supply of blood to provide the oxygen and glucose that neurons need to function. Blood flow must be maintained at 750-1000 mL/min (55mL/100g of brain tissue), or 20% of the cardiac output. For optimal brain functioning. If blood flow to the brain is totally interrupted (e.g., cardiac arrest), neurologic metabolism is altered in 30 seconds, metabolism stops in 2 minutes, and cellular death occurs in 5 minutes.

The brain is normally well protected from changes in mean systemic arterial BP over a range from 50-150 mmHg by a mechanism known as cerebral autoregulation. This involves changes in the diameter of cerebral blood vessels in response to changes in pressure so that the blood flow to the brain stays constant. Cerebral autoregulation may be impaired following cerebral ischemia and cerebral blood flow then changes directly in response to changes in BP. Carbon dioxide is a potent cerebral vasodilator, and changes in arterial carbon dioxide levels have a dramatic effect on the cerebral blood flow (increased CO 2 levels increase cerebral blood flow and vice versa). Very low arterial O2 levels (partial pressure of arterial O2 < 50 mmHg) or an increase in hydrogen ion concentration also increase cerebral blood flow. Factors that affect blood flow to the brain include systemic BP, cardiac output, and blood viscosity. During normal activity, oxygen requirements vary considerably, but changes in cardiac output, vasomotor tone, and distribution of blood flow normally maintain adequate blood flow to the head. Cardiac output has to be reduced by 1/3 before cerebral blood flow is reduced. Changes in blood viscosity affect cerebral blood flow, with decrease viscosity increasing flow. Collateral circulation may develop to compensate for a decrease in cerebral blood flow. Because of the connections between arteries at the circle of Willis, an area of the brain can potentially receive blood supply from another blood vessel if its original blood supply is cut off (e.g, because of thrombosis). Individual differences in collateral circulation partly determine the degree of brain damage and functional loss when stroke occurs. Intracranial pressure also influences cerebral blood flow. Increased ICP causes brain compression and reduced cerebral blood flow. Hemorrhagic Stroke. Hemorrhagic stroke account for approximately 15% of all strokes and result from bleeding into the brain tissue itself (intracerebral or intraparenchymal hemorrhage) or into the subarachnoid space or ventricles (subarachnoid hemorrhage or intraventricular hemorrhage).

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Intracerebral Hemorrhage. Intracerebral hemorrhage is bleeding within the brain caused by a rupture of a vessel and accounts for about 10% of all strokes. Hypertension is the most important cause of intracerebral hemorrhage. Hemorrhage commonly occurs during periods of activity. There is most often a sudden onset of symptoms, with progression over minutes to hours because of ongoing bleeding. Symptoms include neurologic deficits, headache, nausea, vomiting, decreased level of consciousness and hypertension. Progression of symptoms related to a severe hemorrhage includes hemiplegia, fixed and dilated pupils, abnormal body posturing, and coma. Thalamic hemorrhage results in hemiplegia with more sensory than motor loss. Hemorrhage in the pons can be characterized by hemiplegia leading to complete paralysis, coma, abnormal body posturing, fixed pupils, hyperthermia, and death.

Exercise, nutrition, vitamins Frequent headaches, pounding of the heart shortness Heart and works of breath mild harder to with pump exercise, weakness blood through the and dizziness, body, heart Occasional pain in muscle gets the left shoulder thickened & and chest, blood stretched, heart becomes too enlarged to pump enough blood. 43 | C u a l , Carlis l e F e If mme not treated, heart may fail.

May be controlled by

HYPERTENSION raises

Might damage May cause

Symptoms

Less salt, fat and alcohol intake, losing weight, regular exercise, smoking means cessation, managing stress, no red meat, drinking lime juice, more fruits and vegetable Prevented F intake, .& Daw n G a b C, rielle vitamin by: mineral, medicine

May cause: Sudden Stroke unconsciousn ess, redness of face, hoarse breathing, Symptoms: strong pulse and slow, T. Veri a altered speech,

Smokin Kidney, heart Due g and brain to blood vessel Kidney vasoconstrictiodisorders/infection Arteries s, blood vessel n hardening disease or constriction, (arterioscleros Prevented cushingsis) Blockage in an by vitamin syndrome or artery in the C tumors of the brain/ Is due a toblood pituitary or Less fat, oil and alcohol clot/ bleeding caused by adrenal glands, Reduced High consumption, blood fruit and inside the thyroid gland by cholesterol paralys vegetable intake, daily brain disorders,

Laboratory Results

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Date & Time collected: 06/27/2013; 2:10 PM WBC NEU LYM MON EOS BAS ALY LIC 14.0 % 69.6 22.4 5.7 1.6 0.7 2.3 1.6 10/mm # 9.74 3.13 0.80 0.22 0.10 0.33 0.22 Range 4.0 40.0 20.0 0.0 0.0 0.0 0.0 0.0 11.0 75.0 45.0 10.0 6.0 1.0 3.0 3.0 2.00 1.50 0.00 0.00 0.00 0.00 0.00 7.50 4.0 0.80 0.40 0.10 0.25 0.30

RBC HGB HCT MCV MCH MCHC RDW PLT MPV PCT PDW

4.49 15.2 45.5 101 33.8 33.4 10.3 314 7.2 0.225 11.0

10/mm g/dL % m pg g/dL % 10/mm m % %

Range 4.0 - 6.50 13.0 - 18.0 40.0 - 50.0 76 - 96 27.0 32.0 32.0 35.0 11.0 16.0 150 450 8.0 12.0 0.100 0.500 8.0 18.0

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Chest PA:
Clear lung parenchyma. There is a 1.2 nodule in the mediastinum on the right paratracheal area which could be due to lymphadenopathy, cardiomegaly, left ventricular in contour.

Urine Analysis:
Color= light yellow Transparency= clear Specific gravity= 1.030 pH=6.0 Negative for glucose and protein

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Medical Management
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CARDIOVASCULAR
Laboratory tests: Complete blood count Erythrocyte Sedimentation- measurement if the rate at which RBCs settle out of anticoagulant blood in an hour. Blood Urea Nitrogen- an indicator for renal function Urinalysis- to assess the effects of cardiovascular diseases on renal function and the existence of concurrent renal or systemic diseases Blood Uric Acid- it reflects the adequacy of renal tissue perfusion thereby glomerular infiltration of metabolities Serum Electrolytes- electrolytes affects cardiac contractility such as Na+, K+, Ca+

Diagnostic Tests: Electrocardiography-graphical recording of the electrical activities of the heart

Holter Monitoring- this attempts to assess the activities which precipitate dysrhythmias and the time of day when the client experiences dysrhythmias Sonic Studies Echocardiography- to assess the cardiac structure and mobility Transesophageal Echocardiography-allows ultrasonic imaging of the cardiac structures and great vessels via esophagus

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Stress Testing- to identify ischemic heart disease, evaluate patients with chest pain, evaluate the effectiveness of therapy Radiologic Tests Chest Roentgenogram- determines overall size and configuration bof the heart and size of the cardiac chambers Cardiac Fluoroscopy- facilitates observation of the heart from varying views while the heart is in motion Cardiac Catheterization- Can visualize the coronary artery

Magnetic Resonance Imaging- detects and defines differences between healthy and diseases tissues

NEUROLOGIC
Neurodiagnostic Tests:

Skull films- X-ray visualization of the skull. It confirms skull fracture

Spine Films- X-ray visualization of the spine

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Electroencephalopathy-graphical recording spontaneous electrical impulses of the brain from the scalp electrodes

Electromyography and nerve conduction Velocity-EMG records electrical activities in muscles at rest, during voluntary contraction and in response to electrical stimulation; NCV records speed of conduction in motor and sensory fibers of the peripheral nerves -detects neuromuscular disorders

Brain scan-detects brain tumors, cerebrovascular diseases

Magnetic Resonance Imaging- detects and defines differences between healthy and diseases tissues

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Pharma Cards

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Generic Name: irbesartan Trade Name: Avapro Drug Class: Angiotensin II receptor antagonist Therapeutic Class: Antihypertensive Indications: Treatment of hypertension as monotherapy or in combination with other antihypertensives; & slowing the progression of nephropathy in patients with hypertension and type-2 diabetes Contraindications: Hypersensitivity to the drug; bilateral renal artery stenosis; & pregnancy (second and third trimester) Pharmacokinetics: Route P.O Onset Unknown Peak Within 2 hours Duration 24 hours

Metabolism: Hepatic; T: 11-15hr Distribution: Crosses placenta; enters breast milk Excretion: Feces, urine

Pharmacodynamics: Selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle and adrenal gland; this action blocks the vasoconstriction effect of the renin-angiotensin system as well as the release of aldosterone, leading to decreased BP. Adverse Effects: -CNS: dizziness, fatigue, headache, syncope -CV: orthostatic hypotension, chest pain, peripheral edema -EENT: sinus disorders, dental pain -GI: nausea, diarrhea, constipation, abdominal pain, dry mouth -GU: albuminuria, renal failure

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-Metabolic: hypokalemia, gout -Musculoskeletal: joint pain, back pain, muscle weakness -Respiratory: upper respiratory tract infection, cough, bronchitis

Nursing Responsibility: -Monitor vital signs, especially blood pressure. -Watch blood pressure closely in situations where volume depletion may cause hypotension (such as diaphoresis, nausea, vomiting, diarrhea, and postoperative period). -Assess for signs and symptoms of orthostatic hypotension. -Monitor blood urea nitrogen and creatinine levels. -Tell patient that he may take the drug with or without food. -Instruct patient to change positions slowly and sitting or standing and to stay well hydrated to minimize orthostatic hypotension. -Instruct the patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness.

Generic Name: amlodipine besylate Trade Name: Norvasc Drug Class: Calcium channel blocker Therapeutic class: Antianginal, Antihypertensive

Indications: Angina pectoris due to coronary artery spasm (Prinzmetals variant angina); Chronic stable angina, alone or combination with other drugs; Essential hypertension, alone or in combination with other antihypertensives Contraindications: Contraindicated with allergy to amlodipine, impaired hepatic or renal function, sick sinus syndrome, heart block (second or third degree, lactation; use cautiously with heart failure, pregnancy.

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Pharmacokinetics: Route Oral Onset Unknown Peak 6-12 hours

Metabolism: Hepatic; T: 30-50hr Distribution: Crosses placenta, may enter breast milk Excretion: Urine

Pharmacodynamics: Inhibits the movement of calcium ions across the membranes of cardiac and arterial muscle cells; inhibits transmembrane calcium flow, which results in the depression of impulse formation in specialized cardiac pacemaker cells, slowing the velocity of conduction of cardiac impulse, depression of myocardial contractility, and dilation of coronary arteries and arterioles and peripheral arterioles; these effects lead to cardiac oxygen consumption, and in patients with vasospastic (Prinzmetals) angina, increased delivery of oxygen to cardiac cells. Side effects: Nausea, vomiting, headache Adverse Effects: -CNS: dizziness, lightheadedness, headache, asthenia, fatigue, lethargy -CV: peripheral edema, arrhythmias -Dermatologic: flushing, rash -GI: nausea, abdominal discomfort Nursing Responsibility: -Monitor BP very carefully if patient is on nitrates. -Monitor cardiac rhythm regularly during stabilization of dosage and periodically during long-term therapy. -Administer drug without regard to meals -Instruct client to report for irregular heartbeat, shortness of breath, swelling of the hands or feet, pronounced dizziness, constipation.

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Generic Name:clonidine Trade Name: Catapres, Catapres-TTS, Dixarit (CAN), Duracion, Novo-Clonidine (CAN), Nu-Clonidine (CAN), Apo-Clonidine (CAN) Drug Class: Centrally acting sympatholytic Therapeutic Class: Antihypertensive Indications: Hypertension, used alone or as part of combination therapy; Treatment of severe pain in cancer patients with opiates; epidural more effective with neuropathic pain Contraindications: Hypersensitivity to drug, to components of adhesive layer, infection at epidural injection site, bleeding problems, concurrent anticoagulant therapy. Pharmacokinetics: Route P.O. Epidural Transdermal Onset 30-60 minutes Rapid Slow Peak 2-4 hours 19 minutes 2-3 days Duratiion 8-12 hours Variable 7 days

Metabolism: Hepatic; T: 12-16 hr, 19 hr(transdermal system); 48hr(epidural) Distribution: Crosses placenta, enters breast milk Excretion: Urine

Pharmacodynamics: Stimulates alpha-adrenergic receptors in CNS, decreasing sympathetic outflow and inhibiting vasoconstriction. Prevents transmission of pain impulses to CNS by stimulating alpha-adrenergic receptors in spinal cord.

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Side effects: Nausea, vomiting Adverse Effects: -CNS: drowsiness, depression, dizziness, nervousness, nightmares -CV: hypotension, palpitations, bradycardia -GI: nausea, vomiting, constipation, dry outh -GU: urinary retention,impotence, nocturia -Metabolic: sodium retention -Skin: rash, sweating, pruritus, dermatitis -Others: weight gain, withdrawal phenomenon Nursing Responsibility: -Monitor patient for signs and symptoms of adverse cardiovascular reactions. -Frequently assess vital signs, especially blood pressure and pulse rate. -Monitor patient for drug tolerance and efficacy. -Instruct patient to move slowly when sitting up or standing to avoid dizziness or light-headedness caused bysudden blood pressure decrease. -Tell patient not to stop taking drug abruptly.

Generic Name: lactulose Trade Name: Cephulac, Cholac, Chronulac, Constilac, Constulose, Dupalac, Enulose, Evalose, Heptalac, Lactulax,PMS-Lactulose, Portalac Drug Class: Osmotic Therapeutic Class: Laxative Indications: Treatment of constipation; Prevention and treatment of portal-systemic encephalopathy Contraindications:Contraindicated with allergy to lactulose, low-galactose diet; use cautiously with diabetes, pregnancy, and lactation

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Pharmacokinetics:

Route Oral

Onset Varies

Peak 20 hours

Duration 24-48 hours

Pharmacodynamics: Produces osmotic effect, causing increased water content in the colon and increased peristalsis. Breakdown products in colon lead to acidification of colonic contents and softening of feces, and prevent reabsorption ofammonia. Ammonium ions are poorly absorbed from colon to circulation, leading to reduced blood ammonia level in portal-system encephalopathy. Adverse Effects: -CNS: fatigue, headache, insomnia, malaise, asthenia, depression, dizziness, paresthesia, peripheral neuropathy, seizures -GI: nausea, vomiting, diarrhea, anorexia, abdominal discomfort, dyspepsia, splenomegaly, pancreatitis -Hematologic: anemia, neutropenia -Hepatic: increased liver function test results, hepatomegaly with steatosis -Metabolic: hyperglycemia, lactic acidosis -Musculoskeletal: muscle, joint or bone pain, muscle weakness, myalgia, rhabdomyolysis -Respiratory: cough, abnormal breath sounds, wheezing -Skin: alopecia, rash, urticarial, erythema multiforme -Other: lymphadenopathy, body fat redistribution, hypersensitivity reactions including Stevens-Johnson syndrome, anaphylaxis Nursing Responsibility: -Monitor vital signs regularly. -Monitor complete blood count, and platelet count frequently. -Assess neurologic and mental status; report signs and symptoms of depression. -Tell patient that he may take the drug without food.

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-Advise the patient to minimize GI upset by eating small frequent servings of healthy food and drinking plenty of fluids.

Generic Name: isosorbide mononitrate Trade Name: Imdur, ISMO, Isotrate ER, Sorbitrate, Monoket Drug Class: Nitrate Theraeutic Class: Antianginal Indications: Treatment and prevention of angina pectoris; Contraindications: Contraindicated with allergy to nitrates, severe anemia, head trauma, cerebral hemorrhage, hypertrophic cardiomyopathy, narrow-angle glaucoma, orthostatic hypotenssion Pharmacokinetics: Route Oral Oral SR SL Onset 15-45 minutes Up to 4 hours 2-5 minutes Duration 4-6 hours 6-8 hours 1-2 hours

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Metabolism: Heaptic;T: 5 min, then 2-5 hr Distribution: May cross placenta, may enter breast milk

Pharmacodynamics: Releases vascular smooth muscle with a resultant decrease in venous return and decrease in arterial BP, which reduces left ventricular workload and decreases myocardial oxygen consumption. Side effects: Dizziness, lightheadedness, headache, flushing of the neck and face Adverse Effects: -CNS: dizziness, headache, apprehension, asthenia, syncope -CV: orthostatic hypotension, tachycardia, paradoxical bradycardia -EENT: sublingual burning -GI: nausea, vomiting, abdominal pain -Skin: flushing Nursing Responsibility: -Monitor ECG and vital signs closely. -Check arterial blood gas values and methemoglobin levels. -Teach patient to take drug 30 minutes or 1-2 hours after every meal. -Instruct patient to move slowly ehn changing positions.

Generic Name: captopril Trade Name: Capoten, Apo-Capto (CAN), Gen-Captopril (CAN), Novo-Captopril (CAN), Nu-CApto (CAN) Drug Class: ACE inhibitor Therapeutic Class: Antihypertensive Indications: Treatment of hypertension alone or in combination with thiazide type-diuretics; Treatment of heart failure in patients unresponsive to conventional therapy; Treatment of diabetic nephropathy; Treatment of left ventricular dysfunction after MI

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Contraindications: Contraindicated with allergy to captopril, history of angioedema, second or third trimester of pregnancy; use cautiously with renal impairment, heart failure, salt or volume depletion, lactation.

Pharmacokinetics:

Route Oral

Onset 15 minutes

Peak 30-90 minutes

Metabolism: T: 2hr Distribution: Crosses placenta, enters breast milk Excretion: Urine

Pharmacodynamics: Inhibits conversion of angiotensin I to angiotensin II (a vasoconstrictor); inactivates bradykinin and other vasodilatory prostaglandins. Increases plasma renin levels and reduces aldosterone levels, resulting in systematic vasodilation. Side effects: dizziness, fainting and light-headedness Adverse Effects: -CV: tachycardia, angina pectoris, heart failure, MI, hypotension in salt- or volume-depleted patients -Dermatologic: alopecia, rash, pruritus, scalded mouth sensation, pemphigoidlike reaction, exfoliate dermatitis, photosensitivity -Gi: nausea, vomiting, anorexia, altered taste -GU: proteinuria, impotence, decreased libido, renal failure Nursing Responsibility: -Administer 1hr before meals.

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-Monitor drop in BP secondary to reduction in fluid volume. -Monitor hematologic, kidney, and liver function test results. -Advise patient to report fever, rash, sore throat, mouth sores, fast or irregular heartbeat, chest pain, or cough. -Instruct patient not to discontinue without physicians approval.

Generic Name: omeprazole Trade Name: Losec, Prilosec Drug Class: Proton Pump Inhibitor Therapeutic Class: Antiulcer Indications: Treatment for gastroesopharyngeal disease, Duodenal ulcers associated with helicobacter pylori, Gastric ulcers, and pathologic hypersecretory conditions Contraindications: Hypersensitivity to drug or its components Pharmacokinetics:

Route Oral

Onset Varies

Peak 0.5-3.5 hours

Pharmacodynamics: Reduces gastric acid secretion and increases gastric mucus and bicarbonate production, creating a protective coating on the gastric mucosa; relieves discomfort from excessive gastric acid. Side effects: Dizziness, headache, nausea, vomiting, diarrhea, cough

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Adverse Effects: -CNS: headache, dizziness, asthenia, vertigo, insomnia, apathy, anxiety, paresthesias, dream abnormalities -Dermatologic: rash, inflammation, urticarial, pruritus, alopecia, dry skin -GI: diarrhea, abdominal pain, nausea, vomiting, constipation, dry mouth, tongue atrophy -Respiratory: URI symptoms, cough, epistaxis -Other: Back pain, fever, cancer in preclinical studies Nursing Responsibility: -Administer before meals. -Administer antacids with, if needed. -Advise patient to have regular medical follow-up visits. -Instruct to report severe headache, worsening of symptoms, chills, fever.

Generic Name: Trimetazidine Trade Name: Vastarel Drug Class: Anti-anginal Indications: Preventive treatment of episodes of angina pectoris. Adjuvant symptomatic treatment of vertigo & tinnitus. Adjuvant treatment of visual disorders of circulatory origin. Contraindications: Lactation, Children Pharmacokinetics:

Bioavailability Protein binding Metabolism

completely absorbed at around 5 hours, steady state is reached by 60th hour low (16%) minimal

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Half-life Excretion

7 to 12 hours mainly renal (unchanged), exposure is increased in renal impairment - on average by 4fold in subjects with severe renal impairment (CrCl <30 ml/min)

Pharmacodynamics: Inhibits beta-oxidation of fatty acids by blocking long-chain 3-ketoacyl-CoA thiolase, which enhances glucose oxidation.[7] In an ischemic cell, energy obtained during glucose oxidation requires less oxygen consumption than in the betaoxidation process. Adverse Effects: Rare case of GI disorders Nursing Responsibility:- Should be administered with food. - Swallow whole, do not chew/crush .

Generic Name: Citicoline Trade Name: Nicholin Drug Class: Psychostimulants Indications: Disturbances of consciousness due to head injury or brain surgery, disturbances of consciousness in acute stage of cerebral infarction, hemiplegia, Parkinsons disease, pancreatitis Contraindications: Hypersensitivity.

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Pharmacokinetics: Limits the amount of choline available to synthesize phosphatidylcholine. When the availability of choline is low or the need for acetylcholine increases, phospholipids containing choline can be catabolized from neuronal membranes. It increases glucose metabolism in the brain and cerebral blood flow. Side effects: Sleeplessness, headache, diarrhea, low or high blood pressure, nausea, blurred vision, chest pain, and others. Adverse Effects: Hypotension, insomnia, excitement

Nursing Responsibility: - Should be administered with food. - Swallow whole, do not chew/crush.

Generic Name: Piracetam Trade Name: Nootropil Drug Class: Nootropics & Neurotonics/Neurotrophics Indications: Cerebral circulatory insufficiency& chronic manifestations of CVA or Cerebral atherosclerosis, aphasia, post-traumatic syndromes, severe mental cloudiness, coma, chronic alcoholism, addiction Contraindications: cerebral hemorrhage, hepatic and severe renal impairment., pregnancy and lactation. Pharmacokinetics: Oral formulations of piracetam have a bioavailability of close to 100%. Following an oral dose of 3.2 grams, peak

concentration is around 84 igmL. Piracetam is rapidly absorbed and it takes roughly 30 minutes to reach peak plasma concentrations. Food does not impact the extent of absorption of piracetam, but it does decrease the maximal plasma concentration of it by 17% and prolongs peak plasma by 1 and hours. The drug is excreted in the urine and remains unchanged, where no metabolites of piracetam have been discovered. Piracetam crosses

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bloodbrain and placental barriers and is found in all tissues, except adipose tissue. The uptake into the brain is less rapid than into the circulation, and, at nearly 8 h, half-life in cerebrospinal fluid is longer than in plasma (about 5 h)
Excretion: Urine

Pharmacodynamics: Protects the cerebral cortex against hypoxia. It also inhibits platelet aggregation and reduces blood viscosity. Side effects: Headaches, Nausea, Fatigue, Insomnia, Gastrointestinal Issues, Depression Adverse Effects: Hyperkinesia, weight gain, anesthenia, nervousness, agitation, irritability, anxiety and sleep disturbances, fatigue, drowsiness, GI disturbances

Nursing Responsibility: -Administer to client with or without food. -Take w/ a glass of water or soft drink after taking the undiluted solution to mask bitter taste.

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Functional Health Pattern

USUAL FUNCTIONAL PATTERNS (07/03/2013) 1.Health-perceptionHealthmanagement pattern INITIAL APPRAISAL (07/03/2013) ONGOING APPAISAL -Vital signs: T=35.8C. PR= 63bpm, RR=20cpm, BP= 150/90 mmHg -Laboratory results: Normal Value: FBS= 16mg/dl 70110mg/dl -Admitted on June 27, 2013; 10:40AM -Vital signs: T=35.5C, PR= 72bpm, -Has a high blood pressure (highest: RR=22cpm, BP=140/90mmHg 200/100mmHg) -Laboratory results: -Doesnt smoke for 13 years now (before, Normal takes 5 sticks per day) Value:

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-Drinks two alcoholic beverages occasionally -Has experienced having cold for the past year and managed it by taking in Neozep.

FBS= 16mg/dl SGPT= 53U/L MCH=33.8pg MPV=7.2um RBC=4.49 10^2/mm 10^2/mm MCV=101um RDW=10.3%

70-110mg/dl 0-45U/L 27.0-32.0pg 8.0-12.0um 4.50-6.50 76-96um 11.0-16.0%

SGPT= 53U/L MCH=33.8pg MPV=7.2um 12.0um RBC=4.49 10^2/mm 10^2/mm MCV=101um RDW=10.3%

0-45U/L 27.0-32.0pg 8.04.50-6.50 76-96um 11.0-16.0%

-Medications: Irbesartan 300mg 1 tab OD Amlodipine 10mg 1 tab OD Clonidine 75mg 1 tab OD Lactulose syrup 15cc OD Trimetazidine 35mg 1 tab BID ISMN 30mg 1 tab Captopril 25mg 1 tab PO q6H PRN for BP160/90mmHg Omeprazole 40mg IVTT OD Piracetam 3gms IVTT q6H Citicholine 1gm IVTT q6H

-Medications: Irbesartan 300mg 1 tab OD Amlodipine 10mg 1 tab OD Clonidine 75mg 1 tab OD Lactulose syrup 15cc OD Trimetazidine 35mg 1 tab BID ISMN 30mg 1 tab Captopril 25mg 1 tab PO q6H PRN for BP160/90mmHg Omeprazole 40mg IVTT OD Piracetam 3gms IVTT q6H Citicholine 1gm IVTT q6H

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2.Nutritional-metabolic pattern -Consumes the whole serving, usually 2 cups of rice, fish and meat (if available) -With good appetite -No discomforts in eating -No diet restrictions -No food supplements -No skin problems -Full, low fat, low sodium with asp precaution -No weight loss or weight gain noted -Regaining back good appetite by consuming the whole meal served (1 cup of rice and a bowl of soup) -No discomforts in eating -Good fluid intake -Laboratory results: Normal values: FBS=116mg/dl 70-110mg/dl -Full, low fat, low sodium with asp precaution -No supplements -No discomforts in eating -PA: Skin- no rashes/ lumps, no itching, with relative dryness of skin, no color changes, capillary refills back < 3 seconds Mouth- complete set off teeth, no dentures, no bleeding gums, no dry mouth, doesnt remember last dental examination -No trouble in defecating -No excessive perspiration -No unusual odor -Frequent light yellow or urine elimination of about 2 glasses

3.Elimination pattern -Defecates always but in small amounts of hard bowel -No discomforts in voiding and defecating -No unusual odor -Urine is light yellow in color and clear in transparency -No excessive perspiration -Had trouble defecating upon admission due to the use of diapers -Was able to defecate yesterday, 07/02/2013, brown hard stools, twice and once for today in soft, brown stools -No discomforts in voiding and defecating -No unusual odor, no excessive perspiration -Laboratory results: (Urinalysis) Color= light yellow Transparency= clear Specific gravity= 1.030 pH=6.0 Negative for glucose and protein

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4.Activity-exercise pattern -Client stays at home when he doesnt have job -Goes roaming around the city in his leisure time -Unable to walk -Has been lying since admission -Alert -No difficulty in breathing, not restless -Has moderate amount of energy, not high nor not too low -Diagnostic results: Chest PA: clear lung parenchyma. There is a 1.2 nodule in the mediastinum on the right paratracheal area which could be due to lymphadenopathy, cardiomegaly, left ventricular in contour. -Has been having difficulty in sleeping when experiencing severe headache. Rates 5 from the scale of 1-10 where 1 is the least pain and 10 as the most painful. Manages it by touching his head with the significant other -Has been waking up several times at night because of sleep disturbances like noisy environment because of external factors such as location: alley, and taking of vital signs -Hasnt taken 5 hours straight of sleep -Unable to walk -Takes physical therapy -Been able to sit down, positions leaning left and right but not more than 10 minutes --PA: Cardiac: BP= 150/90mmHg, no heart murmurs, no chest pains, no palpitation, no dyspnea Respiratory: no wheezing, no asthma, coughs with no sputum, no tuberculosis, no pneumonia -Still doesnt get 5 hours of sleep -Has been having difficulty in in sleeping when experiencing headache, as well as the noisy location and taking of vital signs

5.Sleep-rest pattern -Sleeps well, straight, to 8 hours, or more if there is no work -Sleeps after watching TV shows -Wakes up at 7:00 if there is work

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6.Cognitive-perceptual pattern -He wears reading eyeglasses if necessary -No hearing problem -Has good memory -Attained high school education level -Learn things through experience

-Forgets things a week before admission -He wears reading eyeglasses if necessary -No hearing problem -Claims to have a good memory but observed that he forgets some things -Has been remembering things happened before he was admitted.

-He wears reading eyeglasses if necessary -No hearing problem -PA: Eyes- watery eyes with slight redness, no blurred vision, no spots, no glaucoma nor cataracts Ears: no infection, no discharges, no use of hearing device Nose: no colds, no nasal stuffiness, no discharges

7.Self-perception-self-concept pattern -Remembers/ Thinks of his past memories, what he has been through and how he passed through trials -Thinks less about his past -Paralyzed right body part -Worries about his admission -Sad about condition -He has been thinking of several things that -Worries about his admission are not like his usual doings -Doesnt get angry or annoyed easily -Doesnt get angry easily

8.Role-relationship pattern -Happily married to wife, Lorna -Has 2 children; 1 girl, 1boy -Feels part of the neighborhood and knows them well -No family problem -Has several friends -He isnt lonely -Family members feels worried especially about Efrens medications, that is associated with financial problems -Family members present, wife and children and nephew -Family roles were substituted due to his condition -Family members feels worried especially about Efrens medications, that is associated with financial problems -Family members present, wife and children and nephew -Family roles were substituted due to his condition

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9.Sexuality-reproductive pattern -No gestures of intimacy between partners -Has used contraceptives twice -No change in sexual relations -No history of operations involving reproductive organs -Has not done TSE. -No change in sexual relations -No gestures of intimacy between partners

10.Coping stress tolerance pattern -Lost his mother in the past year -Coped up by making himself busy at all times -Been taking in prescribed medications, no illegal drugs or alcohol -Family has the big role in taking things over as well as the good support system -Been taking in prescribed medications, no illegal drugs or alcohol -Family as the good support system

11.Value-belief pattern -Classified religion (Roman Catholic) as very important -Prayer is powerful as verbalized -No beliefs -Classified religion (Roman Catholic) as very important -Observed having prayer novenas and rosary on the bed, beside him -Classified religion (Roman Catholic) as very important -Observed having prayer novenas and rosary on the bed, beside him

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NURSING CARE PLANS

COLLEGE OF NURSING Silliman University Dumaguete City NURSING CARE PLAN CUES & NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

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EVIDENCES SUBJECTIVE: Verbalized dili ko gusto mu lihok kay dili ko comportable. Verbalized lisod man ilihok OBJECTIVE: Brought in via wheelchair Lying in a supine position since admission Unable to ambulate by himself Range of motion functionality mobility scale is 3 from the scale of 3-4 where 0 is completely independent and 4 as dependent Hemiplegia on the right side

DIAGNOSIS Impaired physical mobility related to hemiplegia secondary to hemorrhagic stroke

At the end of our nursing care, the patient will have improved physical mobility as evidenced by: Show willingness and cooperation by following patiently instructions to be given.

INDEPENDENT: Explain the importance of the procedures to be done with his condition. To allow the client understand the importance of the procedures and its expected outcomes. According to Dorothea Orems Self Care Theory, Compromise s activities performed independentl y by an individual to promote and maintain persons well being. Therefore, to exercise the

At the end of our nursing care, the patient was able to meet the objectives as evidenced by:

Showed cooperation by following the instructions given. Able to participated and tolerated the procedures done.

Participate in the procedures that will help him recover from the condition.

Encourage to ambulate independentl y if possible, or with bantay if unable to do alone.

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of the body. Attain highest mobility level (0) as determined by the health team Perform range of motion exercises unless contraindicat ed.

Understand the purpose of physical therapy

Provide health teaching about proper range of motion exercises to the client and family members regarding the patients condition.

client regains strength to the paralyzed body part. Change in position reduces chances of getting bed sores and breakdown of the skin. To prevent joint contracture and muscle atrophy.

Range of motion functionality mobility is 2 from the scale of 3-4 where 0 is completely independent and 4 as dependent.

According to Lydia E. Hall, patients achieve their maximal potential through a learning process; therefore the chief therapy they need is teaching.

Verbalized the purpose of the use of proper range of motion exercises and physical therapy.

COLLABORATIVE:

Endorsed to nurse on shift.

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Refer to charge nurse any deviation from the normal

According to Virginia Henderson, the nurse functions as a member of the medical team.

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COLLEGE OF NURSING Silliman University Dumaguete City NURSING CARE PLAN CUES & EVIDENCES SUBJECTIVE: Verbalized putol-putol akong tulog diri day Verbalized Lisod ikatulog kay daghan man mag agi-agi diri day. OBJECTIVE: Rubbed his eyes several times Restlessness Watery and redness of the eyes Presence of black circles around the eyes Frequent NURSING DIAGNOSIS Disturbed sleeping pattern related to environmental discomfort OBJECTIVES At the end of our nursing care, the patient will have improved sleeping pattern as evidenced by: Verbalized relief from restlessness Allow to express any concerns that may disturb him from sleeping According to Sr. Callista Roy, a person is an open adaptive system. Therefore, active listening helps determine causes of difficulty in sleeping which can be used to help the client INTERVENTIONS RATIONALE EVALUATION At the of our nursing care, the patient was able to have improved sleeping pattern as evidenced by: Able to segregate things that prevent him from sleeping.

Attain at least 6 hours of

Provide patient with usual sleep

Slept for only 4 hours

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yawning Bed is located in the alley

sleep

aids such as bath before sleeping. Provide calm and quiet environment

adapt. Personal hygiene routine precedes sleep in many patients

Manifest absence of the signs of sleep deprivation such as rubbing of eyes, watery and redness of eyes Identify personal habits that disrupt sleep pattern and strategies to improve quality of sleep as measured

Obtain a sleep-wake history including history of sleep problems, changes in sleep patterns, and use of medications and stimulants

Help promote conducive atmosphere for restful sleep

Verbalized Salamat kaayu day sa imong pag tarong sa akong higdaanan.

Assessment of sleep behaviour and patterns are an important part of any health status examination

Verbalized mag pa trapo nako sa akong asawa usa ko matulog sa gabii para comportable ko

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COLLEGE OF NURSING Silliman University Dumaguete City CUES & EVIDENCES NURSING DIAGNOSIS NURSING CARE PLAN OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

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SUBJECTIVE: Risk for impaired skin, integrity Verbalized breakdown dili ko gusto mu lihok kay dili comportable Verbalized lisod man ilihok OBJECTIVE: Hemiplegia on the right side of the body Lying in a supine position since admission Unable to ambulate by himself Range of motion functionality mobility scale is 3 from the scale of 3-4 where 0 is completely independent and 4 as dependent

Within my nursing care, the patient will have improved skin integrity as evidenced by: Being able to show willingness and cooperation Educate the patient & caregiver about the changes to skin According to Jean Watsons Caring Theory, Promotion of interpersonal teaching learning done by allowing the client to be informed and thus shifts the responsibility for ones welfare and health to the client.

At the end of my nursing care, the patient showed improved skin integrity as evidenced by: Showed cooperation and willingness by verbalizing importance of his skins health.

Being able to change positions in bed

Cite different positions that could be done without significant other

Understand the reason for changing positions at

Reduces chances of bed sores and damage of the skin integrity

Changed his positions independently

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least 2 hours Demonstrate different positions

Help the patient and significant other to implement daily routine in changing positions.

To balance the skins integrity in either side of the body

Demonstrated different positions

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RELATED READINGS

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STROKE- the HumanTime Bomb

Mass media reports that everyday many young and middle-aged Filipinos succumb to sudden attack of stroke. Stroke or brain attack is Asias third leading cause of death (behind cancer and heart disease) and one of the leading causes of adult disability. Reports estimate that victims are much younger than 65 including adolescents and even children. There are around 2 million death is Western Pacific region each year, according to the WHO report. Many may be saved if people recognize the warning signs of stroke. Stroke is medically known as cerebrovascular (CVA) or brain attack. it occurs when a blood vessel(artery) supplying blood to the brain bursts or becomes blocked by a blood clot. Within minutes, the brain cells in the area if the brain is damaged for lack of oxygen supply. As a result, the part of the body controlled by the cells (nerves & blood vessels) cannot function properly (paralyzed). Generally, each side of the brain controls the motor and sensory function of the opposite side of the body. So, damaged cells on the left side of the brain will impair function on the right side of the body. Stroke can be caused by high blood pressure, diabetes, high amount of fat in the blood (cholesterol0, excess weight, smoking and heredity (may play a role), and other idiosyncratic causes. A history of mild stroke called Transient Ischemic Attack (TIA) essentially clears up within 24 hours, leaving no residual effects. About 75% of strokes are ischemic strokes. This is due to clotted blood that obstructs circulation. A thrombotic stroke occurs when a blood clot forms in the artery in the brain or neck. An embolic stroke occurs when a small clot known as embolus forms elsewhere in the body is carried through the bloodstream leading to brain and lodges there, The 25% of the stroke is hemorrhagic stroke. This occurs when a weakened or defective artery in the brain bursts, cutting off blood flow and damaging the area. Statistics show that 50% of hemorrhagic stroke patients die, as compared to 20% of ischemic stroke patients. Warning symptoms of stroke are: Sudden severe headache with no known cause. Dizziness; loss of vision especially on one eye.

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Loss of speech, or trouble talking, or swallowing. Numbness,; weakness, paralysis of face, arm or leg especially on one side of the body. Unsteadiness, sudden falls, confusion, unconsciousness. A mini-stroke(TIA) nay betreated with blood thinners. Up to 80% of stroke may be prevented through lifestyle changes. Treatment modalities: Immediate hospitalization (ICU). Drug therapy of hypertension, diabetes, anti-cholesterol agents, plasminogen activator, anticoagulant, etc.

Rehabilitation through occupational therapy after the acute period. Follow-up by a competent neurologist. Pray hard for GOD for another lease of life. SUMMARY: Stroke or brain attack is now Asias third leading cause of death and one of the leading causes of adult disability. But the much alarming is that the recent reports estimate victims younger than 65, even young adults and children are stroke victims. Stroke is medically knows as cerebrovascular (CVA) or brain attack. This results when a blood vessel (artery) bursts or becomes blocked by a blood clot. With this, brain is deprived from oxygen. Risk factors include high blood pressure, DM, high cholesterol, obesity, smoking, genetics and other idiosyncratic causes. Types of stroke are Ischemic stroke which is due to the clotted blood that obstructs the circulation, thrombotic stroke which occurs when a blood clot forms in an artery in the brain or neck, embolic stroke which occurs when an embolus forms elsewhere in the body and is carried through the bloodstream and leads to the brain and lodges there, and hemorrhagic stroke when a weakened or defective artery in the brain bursts, cutting off blood flow and damaging the area. Symptoms include sudden headaches, dizziness and loss of vision, loss of speech, numbness, and unsteadiness. Treatments include immediate hospitalization, drug therapy, rehabilitation, and prayers.

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REACTION: Stroke is a condition who chooses no one. It could attack anyone including those in the younger age. As a student nurse, these can be prevented by getting rid of the said risk factors. These includes practicing a well balanced diet without too much fats and sodium content, disciplined attitude in exercising daily, smoking cessation and living a healthy lifestyle. In situations of having a patient who is experiencing the symptoms of stroke, proper education and teaching should be provided. Life is really unpredictable. Death can be a result of stroke. If stroke is not properly managed, it can lead to complications that can cause much more discomfort and struggle not only to the patient but also to his/her family and loved ones. A persons ability to move freely will be diminished. Proper treatment and interventions should be given in order to prolong life. But above all, nothing is impossible with God. Prayers are stronger than any drug. With this, a strong faith and trust in God is needed.

WHEN STROKE STRIKES Strokes kill five million people each year and are considered as the second leading cause of death worldwide. At least 15million patients have non-fatal strokes annually, and about a third is significantly disabled as a consequence. In the Philippines, it is one of the leading cause of death together with other vascular diseases. A stroke is similar to a heart attack. It is caused by the malfunction or death of a part of the brain where there is lack of blood supply to that certain part due to a clot or a ruptured vessel. When stroke strikes, time lost is considered brain lost. The faster the patient is able ti receive medical intervention, the greater the chance for him to recover from stroke. But before a stroke happens, one needs to understand its risk factors so that medical intervention is administered early and aggressively. The non-modifiable risk factors for stroke include age, sex, family history, race, ethnicityfactors that we cannot control. However there are modifiable risk factors for stroke which when eliminated or controlled reduce the risk for stroke significantly. These are hypertension, cardiac disease (particularly atrial fibrillation), diabetes, hyperlipidemia or

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elevated cholesterol, cigarette smoking, alcohol abuse, physical inactivity, asymptomatic carotid stenosis, and transient ischemic attack. There is a growing concern that because of lifestyle and diet of Asians, particularly Filipinos, cholesterol levels are rising, resulting in an increased risk for stroke (brain attack). In addition to being a leading cause of heart attacks, high cholesterol is emerging as a major risk factor for what is known as ischemic stroke. In this type of stroke, the blood supply to part of the brain is cut off because atherosclerosis or a blood clot has blocked a blood vessel. Atorvastatin, a medicine from the worlds number one research-based pharmaceutical company Pfizer, has also been proven effective among diabetic patients in preventing the occurrence of non-hemorrhagic strokes. The Collaborative Atorvastatin Diabetes Study (CARDS) showed that type 2 diabetic patients given Atorvastatin 10mg daily reduced their risk of developing non-hemorrhagic stroke by a significant 50%. It is important for patients to be more aware of their disease and its possible risks for better health management. A sensible lifestyle and high quality medication for ailments such as cardiovascular diseases and diabetes would be the key in making sure that healthcare needs are addressed sufficiently, says Dr. James Wee, Pfizer Philippines cluster physician for lipids and metabolics. It is also highly important that patients communicate with their doctors regularly so that they are given ample information about their disease. This will greatly help in making the patient understand his condition.

Summary

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Stroke is a disease that results to death worldwide. Stroke is similar to heart attack which is caused by a malfunction or "death" of a part of the brain where there is lack of blood supply to that certain part of a clot ruptured vessel. Non modifiable factors of stroke are: age, sex, family history, race, and ethnicity, while the modifiable factors are: hypertension, cardiac disease, DM, hyperlipidemia or elevated cholesterol cigarette smoking, alcohol abuse and physical inactivity. There is growing concern that is because of the lifestyle and diet if Asians.

Reaction

In stroke, time lost is considered brain lost. This is because of the time lost of blood flow to the brain which kills the function of the cells in it. The faster the patient is able to receive medical attention the greater the chance for him to survive. One must know stroke in order to prevent it. Without knowing it, a person will not be able to know the risk factors that can lead to stroke. Proper instructions for drug therapy should be provided. It is better for patients to be more aware of stroke to reduce the risk of having it. It is also to know what management and interventions can be given to patients with stroke. Proper communication with the health team is required. This is for better understanding of stroke.

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HYPERTENSION KILLS

Hypertension is a personal tsunami. not ball symptoms are well-defined and so victims are not likely to know they have a problem until it is too late- just like a tsunami. Defined, hypertension is blood pressure that is too high for one person. Doctors look at 120/80mmHg as a normal blood-pressure: 120 refers to the force of blood vessel walls exerted by the heart when pumping blood (the systolic) and80 is the force of the blood between beats, when the heart is filling (the diastolic). A person, with blood pressure equal to or greater than 140/90 mmHg on two separate occasions, is hypertensive. more recently, cardiologists have begun identifying and treating prehypertensives. Why is hypertension dangerous? Firstly, the heart will have to work harder to pump into inelastic vessels. A heart is already weakened by a fat clogged blood supply can be damaged and parts of it can die. What follows is your heart attack. Secondly, the vessels themselves are injured. The so called end organs like the kidney, liver, brain, and the retina of the eyes are at risk of damage as well. And so, hypertension is the disease that makes other diseases possible. Types. Close to 90%-95% of hypertensive cases are essential. This just means there are no identifiable underlying causes for the condition. it is however associated with several risk factors. It is found more often in men than in women. Postmenopausal women are affected as well. It tends to run in families. Most importantly, essential hypertension responds well to positive changes in lifestyle such as quitting smoking, eating less fatty foods, and exercising. in secondary

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hypertension, there causes to point a finger to. The most common type is due to problems with the kidney. other conditions that may lead to hypertension are pregnancy, use of hormones like estrogen (found in birth control pills), and tumors that secrete hormones that raise blood pressure (for example, the adrenal glands). Cant wait to see the doctor. A regular executive checkup should be able to screen hypertension. So whos into denial here? If you eat like meat will run out tomorrow, if you smoke like a chimney, and if your definition of exercise is walking from one end of the office to the other, chances are youve been a very bad boy (or girl). A little suspicion will do a lot of good. On the matter of symptoms, these are definitely not good: Headaches, nape pains, chest pain or tightness, nosebleeds, blurring of vision, confusion, memory loss may be warnings of severe hypertension. Palpitations or the sensation of the heart jumping, too much perspiration, muscle cramps, weakness, and frequent urination may point to secondary hypertension.

The Weigh-in Wake-up Call. Long term-weight gain is known risk for hypertension. If you can kindly step on your bathroom scale and find out how much youve gained since you were 18 please? An increase of 10 to 20 pounds puts you in danger. A US Nurses Health study of 82.000 who packed on 11 to 22 pounds since been age doubled their risk of hypertension. Those who gained more than 50 pounds had five times the risk. The risks are the same in men following similar studies. Its not that bleak. A Harvard Medical School study showed that losing the weight reduced the risk. Among obese men, blood pressure was significantly reduced with a modest weight loss of 5-10%. This means, rightly, that weight gain is a wakeup call. Its no longer just about vanity and the instinct to strut like a peacock that you should be concerned about your weight. Its about staying alive, period. Treatment. Such is the wisdom of reformed living after getting the cardiologists verdict of hypertension. The good doctor will first attempt to treat you non-pharmacologically. That means no drugs yet. he will prescribe healthier eating ( we all know that by now: Less meat, less fat, more vegetables, fruits, and whole grains and less salt, approximately not more than 2.4 grams of sodium in daily diet, less alcohol) and regular exercise (we all know that by now, too: 30 minutes of aerobic

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exercise three to four times a week). (Note: if you need 4 breaths to recite the last long, stylistically wrong sentence, you may be in trouble). Alternatively, there is meditation, hypnotherapy, or yoga or tai chi. Only when lifestyle changes dont work or if your blood pressure is quite high to begin with will the doctor include medication in his treatment plan. A whole arsenal of drugs has been developed and your doctor may give one or a combination of: Diuretic, beta blockers, calcium channel blockers and Ace inhibitors. Maybe to say hypertension is a medical tsunami is inaccurate. It implies that victims were caught unaware. The wellinformed is not a victionun less theres the inertia to do nothing at all. Thats no different from rushing toward the tsunami.

Summary

Hypertension is like a tsunami. It implies that victims were caught unaware. A "normal" blood pressure is at 120/80 mmHg. Whereas, a person with blood pressure of 140/90mmHg in different occasions. It is dangerous because of two reason, first, the heart will have to work harder to pump into inelastic vessels. Secondly, the vessels themselves are injured. Therefore, hypertension is the disease that makes other diseases possible. Men are more prone to women. But menopausal women are also affected. There are things to be avoided and to be reduced. Eating meat like there is no tomorrow or smoking like a chimney must be avoided. It is better to lose up weight and eat fruits, vegetables, less in meat, less in sodium and less in fat. Symptoms like headache, chest pain or tightness, nosebleed, palpitations, muscle cramps, frequent urination are not so good. A visit to the doctor for the first time will attempt to treat the client nonpharmacologically, which means without medications. But if so, the high blood pressure can't be lowered with no medications, physician will have to treat the client with medications and most likely have it for maintenance. Reaction We agree that hypertension is or can be called tsunami, symptoms may arise but many victims are unaware. Regular exercise keep or lower blood pressure down, gaining enough strength for every day, losing weight is beneficial too, it makes you look good and feel right. There are two inexpensive treatments for high blood pressure. It is even much more do-able. The thing about taking medicines, is that if you forget to take a pill, you'll probably increase your blood

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pressure again. It is also advisable to eat health food like fruits and vegetables, exercise and or a combination of it with medications. Not only will you stabilize your blood pressure but it will also make you look fit, health and energized for everyday living.

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SUMMARY OF NURSING DIAGNOSIS

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 Impaired physical mobility related to hemiplegia secondary to hemorrhagic stroke Disturbed sleeping pattern related to environmental discomfort Impaired physical mobility related to hemiplegia secondary to hemorrhagic stroke Fatigue related to hemiplegia secondary to hemorrhagic stroke Altered growth and development related to hemiplegia secondary to hemorrhagic stroke Self Care deficit related to immobility secondary to hemorrhagic stroke Altered role performance related to hemorrhagic stroke secondary to hypertension

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BIBLIOGRAPHY

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 Marieb, E.(2006).Essentials of Human Anatomy and Physiology.Singapore: Pearson Education South Asia Pte Ltd. Black, J. and Hawks, J.H.(2005).Medical-Surgical Nursing.Singapore:Elsevier Ptd Ltd. Kozier, B. et. al.(2010).Fundamentals of Nursing.Singapore: Pearson Education South Asia Pte Ltd. Doenges, M. et. al.(2010).Nursing Care Plan.Thailand:Book Promotion and service Ptd Ltd. Lewis. et. al. (2007).Medical-Surgical Nursing.Missouri: Mosby Elsevier Westline Industrial Drive. http://lrrpublic.cli.det.nsw.edu.au/lrrSecure/Sites/LRRView/7700/documents/5657/5 657/5657_02.htm http://sehati.org/index/patientresources/normalanatomy.html

Negros Chronicle Vol.38,No.4, July 3,2011 p.11 Philippine Daily Inquirer June 26 2009 E-3 Manila Bulletin April 3, 2005 p.25

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