I.

INTRODUCTION

Cerebrovascular disease or stroke refers to brain disorders. It is any disorder

that affects the disease in the blood vessels that feed oxygen- rich blood to the face
and brain. Stroke is the primary cerebrovascular disease in the country.

In the year 2000, cerebrovascular diseases ranked as the fifth leading cause
of mortality in the Philippines. Statistical data on stroke is still very meager. With the
present on-going study on hypertension and stroke, the epidemiological status of
cerebrovascular diseases will improve. Based on the data collected by the author,
cerebral infarct is the most common type of cerebrovascular disease; hypertension
is the leading predisposing factor for stroke in the Philippines; and the other risk
factors are cardiac abnormalities, diabetes, hypertriglyceridemia and
hypercholesterolemia. (THE FIRST ASIAN-PACIFIC SYMPOSIUM ON STROKE: SESSION
I. PANEL DISCUSSION PRESENTS STATUS OF STROKE PROBLEMS IN EACH COUNTRY).

The only statistical data on cerebrovascular diseases on a national level is that

of the Philippine Health Statistics which is preparerd annually by the Disease
Intelligence Center of the Ministry of Health. They notify the 10 leading cause of
morbidity and mortality. Cerebrovasvular diseases are not include among the
notifiable diseases, hence, there is no national statistics on the frequency of
cerebrovascular diseases.

Top 5 Leading Causes of Mortality Philippines, 2003

Causes Male Female Total Rate^ Perce

nt

38,677 29,019 67,696 83.5 17.1

1. He
art
Diseases

2. Vascular 29,054 22,814 51,868 64.0 13.1

System
Diseases

3. Malignant 20,634 18,664 39,298 48.5 9.9

Neoplasm

4. Accidents 27,720 6,246 33,966 41.9 8.6

5. Pneumoni 15,831 16,224 32,055 39.5 8.1

a
In the US, 80% of strokes are due to Ischemia the remainders are
due to hemorrhagic. Advance age, hypertension, diabetes, high
cholesterol, thrombophilia (a tendency of thrombosis) and
smoking are the risk factors of this disease. Cerebrovascular
disease are also the 3rd leading cause of US mortality in the year
2005. (http://www.upibalonbicol.com/2008/12/top-10-leading-
causes-of-death.html)

II. OBJECTIVES
III. NURSING ASSESSMENT

I. PATIENT DEMOGRAPHIC PROFILE

Name: Regina Ferolino Ewayan Age/Gender: 74 / F Status:

Married
Home Address: Sobusteha Kalunasan Cebu City

Religion: Roman Catholic Nationality: Filipino 0ccupation:

Housewife

II. HEALTH HISTORY PROFILE

A. Past Medical History

1. Pediatric and Adult Illness

Date Illness Medication Remarks
Patient -Cough -Patient Cured
can’t -Chicken pox can’t Cured
recall recall
1984 -Hypertension Pt. is
experiencing
the illness up to
the present.

2. Immunization
Immunization Doses Dates Remarks
Patient Patient Patient Patient
can’t can’t can’t can’t
recall recall recall recall

3. Hospitalization
Date/Year Hospital Diagnosis Duration
1984 Perpetual Motor-Vehicular Patient can’t
Succour Accident recall

Patient can’t Hemorrhage

recall CCMC due to 1 week
miscarriage

2000 CCMC Motor-Vehicular 5 days

Accident

4. Injuries and Accidents

Twenty- six years ago, Mrs. Regina was about to cross the street
to buy her favorite native delicacy “biko” when she was
accidentally hit by a motorcycle which caused an wound on her
forehead.
 5. Transfusions

The patient had been transfused with 6 bags of type O blood

when she was hospitalized due to hemorrhage.

6. Allergies (specify)

The patient claimed that she is allergic in dried fish.

Family History

Alejandra
Abunito
Kardyo,
Ferolino,
72, ,
67, , HP
ARTH, HP

Abelino
Benjam
Regina HP Ferolino
in
Ferolino , 60,
Ferolino
Ewayan, ARTH
, 56, HP
74, CVD,

Legend:

- Siblings ARTH – arthritis Roque

Ferolino
, 48
- Parents HP - hypertension

- deceased CVD – cerebral vascular

disease

C. Social and Personal History

1. Occupation
Pt. R.E. is a housewife.
2. Number of children
Pt. had miscarriage on her first pregnancy. Since then, she never
had children.
3. Military experience, foreign travel
N/A
4. Habits (tobacco, alcohol, non-prescription drugs, others)
N/A
5. Diet
She eats vegetables, fish as well as fruits e.g. banana and
mangoes.
6. Type of Family
Pt. and her husband live with her niece.
7. Cultural and Religious Beliefs
 Roman Catholic.
8. Brief Description of average day:

5:00 am waking up
5:00-6:00 preparing breakfast
6:00-7:00 breakfast
7:00-8:00 taking a bath
8:00-9:00 watching TV
9;00-10:00 doing some home chores
10:00-11:00 preparing for lunch time
12:00-1:00 Lunch Time
1:00-3:00 nap time
3:00-4:00 snack time
4:00-5:00 preparing for dinner
6:00pm Dinner Time
7:00-5:00 Sleeping Time

A. Review of System (for the past 6 months). Physical

Assessment
General Weight Loss Fatigue anorexia night sweats
Chills Fever weakness
The patient suffered from weight loss due to loss of
appetite. Loss of appetite affects the production of energy
that is acquired from dietary sources.

Skin Itch rash lesions bruising

Bleeding color change
The patient stated that she suffered from allergies when
she ate dried fish. Food allergies occur when the immune
system mounts an attack on certain proteins in certain
foods. The substances in the food that trigger this immune-
system response are called allergens.
Eyes Pain discharge itch vision loss
Excessive Tearing diplopia glasses/ contact lens
Date of last exam:

The patient does not have any problem with her eyes.

Ears Earaches discharges tinnitus hearing loss

The patient experienced hearing loss in her left ear due to

production of excessive earwax related to poor hygiene.
Aging is a related factor of hearing loss due to organ
deterioration.

Nose Obstruction discharge epistaxis

The patient does not have any problem with her nose

Throat and Sore Throats bleeding gums toothache dentures

Mouth

The patient does not practice proper oral hygiene. Although

systemic factors and general health can modify the tissue
reactions to local irritants, gingivitis at all ages is caused
primarily by local irritants.
Neck and Swelling dysphagia hoarseness
Head

The patient didn’t experience any problems involving the

indicated system.

Chest Cough sputum: amount and character

hemoptysis
Wheeze pain on respiration dyspea
Cough due to mucous secretions of the bronchial tree. The
sputum is markedly yellowish and thick.

Cardio Precordial pain palpitation dyspnea on exertion

Vascular Paroxysmal nocturnal dyspnea orthopnea
Edema Heart Murmur thrombophlebitis
claudication

The patient didn’t experience any CV problem.

Gastrointesti Heartburn nausea vomiting bloating

nal Diarrhea food intolerance excessive gas or
indication
Constipation change in bowel movement
Jaundice melena hemmorhoids hernia
The patient experienced nausea and vomiting which
resulted from a coordinated sequence of abdominal muscle
contractions and reverse esophageal peristalsis and
constipation because of indigestion.

Genitourinary Heartburn nausea vomiting bloating

Diarrhea food intolerance excessive gas or
indication
Constipation change in bowel movement
Jaundice melena hemmorhoids hernia
The patient experienced nausea and vomiting which
resulted from a coordinated sequence of abdominal muscle
contractions and reverse esophageal peristalsis and
constipation because of indigestion.

Extremities Joint pains varicose veins claudication

Back pain edema stiffness deformities
The patient experienced back pain and joint pains because
of instability of the lower spine and old age.

Endocrine Hot Flashes hair loss temperature intolerance

Polydipsia goiter
The patient experienced hair loss because of old age and
unhealthy lifestyle. It is also because of the gradual
thinning of the hair.

Neurology Numbness tingling tremor fainting

 Headaches muscle weakness ataxia
Unconsciousness paralysis/ paresis memory loss
Dizziness seizure
The patient experienced tremor, muscle weakness and
memory loss because of aging that results to physical
dysfunctioning.

Psych Anxiety depression sexual problems

Insomia nightmares
The patient did’nt experience any psychological problem.

Others There are no other problems noted.

III. CURRENT HEALTH PROFILE

A. Presenting complaints and medical diagnosis to include intervention

done prior to hospitalization

Patient was apparently well until morning prior to admission, patient

complained of headache and dizziness after which family members claimed that she
fell down on the floor unsupported. After she fell down, her niece let her take a rest.
While she was resting, vomiting times 5 episodes was noted by the significant
others and the patient were immediately rushed to CCMC – ER was subsequently
admitted.
No medication was taken prior to hospitalization.

B. APPLICATION OF NURSING PROCESS:

1. ASSESSMENT FINDINGS (head-to-toe)

GENERAL OBSERVATION:

Patient was seen lying in bed, very weak, unable to move freely, conscious
with IV infusion PNSS on her left hand, with nasal canula, and very thin. She
responds sometimes when asked but in a whisper.

V/S:

TEMPERATURE: 37.2 C
RESPIRATORY RATE: 34 cpm
PULSE RATE: 74 bpm
BLOOD PRESSURE: 140/90 mmHg

SKIN:

The skin of the patient is uniform brown. A bruise was seen at her left
antecubital caused by the CBC examination. The skin surface is warm but is dry.
The patient’s skin is wrinkled, saggy and has a poor skin turgor.

HAIR:

The hair is black in color with terminal hairs distributed. A lesion was seen
near her forehead and the scalp is light brown in color with dandruff. There were no
signs of any infestations.
NAILS:

The patient’s nails have brown crest. Presence of beaus’ line was noted on
her nail surfaces. When conducted with capillary refill test, its color returned to
normal with 2-3 seconds approximately. Nail thickness are uniform but have brittle
edges and is very dirty.

FACE:

There is symmetry in the patient’s facial features. The shape of her face is
oval and there were no signs of edema there were no involuntary movements
present and no disproportionate structure. A scar was noted on the right part of the
forehead.

EYES:

The patient’s eyelids appear symmetrical with no drooping, infections, or

lumps. There were no enlargement, swelling or tenderness and no redness that is
visible. Bulbar conjunctiva appears pale with small blood vessels visible. Lacrimal
glands have no enlargement and no discharges. She can raise both eyelids.

EARS:

The ears of the patient matched the flesh color of her skin and are
symmetrical. No tenderness was felt when palpated and there were no redness and
lesion present. Some discharges were seen on both ears. The left ear cannot
perceive any sound anymore.

NOSE AND SINUSES:

The shape of the external nose is located symmetrically in the middle of the
face without swelling, bleeding or lesions and masses. There is a nasal canula
present. The patient experienced no discomfort.

MOUTH AND PHARYNX:

The lips of the patient are dry but there were no evidence of lesions or
inflammation, and the breath has a foul odor, however the tongue is in midline of
the mouth. The ventral surface of the tongue has prominent blood vessels, and
without lesions. The numbers of teeth are less than normal and are yellowish in
color.

NECK:

No masses present when palpated. The patient was able to move her head
slowly in right and left direction. No masses or tenderness on the thyroid. The color
of her neck is a little bit darker than the rest of the skin with a red rash because of
excessive sweating.

BREAST:

The patient refused to allow us to assess her breast as well as her axillae
since she have a difficulty in moving.

ABDOMEN:
 The patient’s abdomen is uniform in color and symmetric in contour. Aortic
pulsation in the epigastric area was assessed. Abdominal wall is thinner and muscle
wasting is present.

MUSCULOSKELETAL:

Presence of tremor was noted on left hand due to aging since muscle tissues
become reversely rigid and deteriorated structure develops. The patient is
hemeplegic on the right sid of the body.

HEART AND CENTRAL VESSEL:

S4 is present upon auscultation of the apical area of the heart. A decrease

pulsation was noted on the left carotid artery.

PERIPHERAL AND VASCULAR SYSTEM:

Peripheral pulses on the right part of her body are weak compared to the left.
Superficial veins are noted on her both hands and feet.

NEUROLOGICAL:

The patient was conscious and responds weakly to some of our questions.
She has difficulty in speaking and cannot recall some necessary information.

EXTERNAL GENITALIA:

The patient refused to allow us in assessing her genitalia.

RECTAL AND ANUS:

The patient refused to allow us in assessing her rectum and anus.

Laboratory / Diagnostic Results

Date Lab. Exam Patient Results Normal Findings Interpretation/

Significant Findings
April 21, CT- Scan (Brain Acute hemorrhage
2010 Plain- CT 16) in the left thalamic It has no presence There is presence of
area with of blood, brain blood due to an acute
surrounding injury and skull hemorrhage caused by
perifocal edema fractures the patient’s accident
and mass effect
estimated volume
is 4 cc.
Electrolytes Normal
April 21, Sodium =142.3 135- 148mmoL/L Normal
2010 Potassium = 3.77 3.5 – 5.3 mmoL/L
Blood Chemistry Normal
FBS = 95 mg/dL 75 – 115 mg/Dl

Urinalysis
Within Normal Range
Color = yellow Amber/yellow
Transparency = Clear Normal
Microscopic clear Normal
 Exam
Puss cells : 0-1 0-5 In the urine there may
RBC : 0-1 be a sign of a tumor.
Epithelial Cells : few But, more often, they
few indicate that the urine
sample was
contaminated during
the test, and a new
sample is needed.

May indicate an
infection.

Bacteria : Rare Rare Normal

Chemistry
Examination Within normal range
PH : 6.0 PH 5-7

Spec. Gravity : 1.002-1.030

1.020

CBC Within the normal

range

WBC:11.5 x10/ L 5.0- 10.0 Within normal range

Hgb : 125 g/L 120 – 160
Within normal range
Hct : .376 37 - .47

Platelet : 283 x 150 - 450 Normal

Segmenter 10/L Normal
Lymphocytes Normal
Monocytes .63 0.50 – 0.65
.09 0.25 – 0.35
.02 0.02 – 0.06

IV. ANATOMY AND PHYSIOLOGY

 The heart is the most vital organ in the circulatory system. It is
composed of 4 main sections: the right and left ventricle and the right and
left atrium. The heart acts like a pump that forces the blood through an
interconnecting system of vessels which eventually return to the heart. Blood
leaves the left side of the heart and travels through arteries which gradually
divide into capillaries. The blood then travels in veins back to the right side
of the heart, where it is pumped directly to the lungs. In the lungs, carbon
dioxide is exchanged for oxygen, and this renewed blood flows back to the
left side of the heart, and the whole process begins again.

On its way back to the heart, the blood travels through a system of veins. As
it reaches the lungs, the carbon dioxide (a waste product) is removed from
the blood and replace with fresh oxygen that we have inhaled through the
lungs. The vascular system is important in supplying blood systemically,
pulmonary and most especially to the brain, where it passes the jugular vein.

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

cells called neurons that coordinate the actions of an animaland transmit signals
between different parts of its body. In most animals the nervous system consists of
two parts, central and peripheral. The central nervous system contains
the brain, spinal cord, and retina. The peripheral nervous system consists of sensory
neurons, clusters of neurons called ganglia, and nerves connecting them to each
other and to the central nervous system.

These regions are all interconnected by means of complex neural pathways.

The enteric nervous system, a subsystem of the peripheral nervous system, has the
capacity, even when severed from the rest of the nervous system through its
primary connection by the vagus nerve, to function independently in controlling the
gastrointestinal system.

Neurons send signals to other cells as electrochemical waves travelling along

thin fibres called axons, which cause chemicals calledneurotransmitters to be
released at junctions called synapses.
VI. NURSING CARE PLAN
UNIVERSITY OF SAN CARLOS
COLLEGE OF NURSING

NAME: REGINA FEROLINO EWAYAN PATIENT’S HEALTH PROFILE: Received patient lying in bed,
SEX: Female with nasal canula, IV infusion on her left hand, very thin
and weak.
OCCUPATION: housewife INITIAL COMPLAINT: Dizziness, loss of conscious control,
headache and vomiting
DATE OF ADMISSION: April 16, 2010
STATUS: married DIAGNOSIS/IMPRESSION: Cerebrovascular Disease
Needs/ nursing Scientific analysis Objectives Nursing intervention Rationale Evaluation
diagnosis
I. Physiologic I. Scientific Analysis: After 8 hours of  Observe  To note The goal was not
needs: client-nurse movement when any met since we were
Cerebrovascular disease interaction, the client is unaware incongruencies not able to go
Impaired Physical is a group of brain patient will be able of observation with reports of back to implement
Mobility related dysfunctions related to to participate in  Change positions abilities. our planned
to weakness, disease of the blood nurse initiated at least every 2 interventions.
limited range of vessels supplying the activities that hours (supine,  Affecte
motion, brain. Hypertension would promote side lying) and d side has poorer
hemiplegia, damages the blood mobility. possibly more circulation and
vessel lining, often if placed on reduced
S: “ maglisud lge endothelium, exposing affected side. sensation and is
ko ug lihok.” the underlying collagen  Support affected more predisposed
where platelets part using pillows/ to skin
O: aggregate to initiate a rolls. breakdown.
 hemiplegic repairing process which  To
 weak is not always complete maintain position
 Difficulty and perfect. It  Encourage of function and
in permanently changes adequate intake reduce risk of
speaking the architecture of the of fluids/ pressure ulcers.
 Limited blood vessels making nutritious foods.  Promot
range of them narrow, stiff, es well being and
 Observe affected
motion deformed, uneven and maximizes
side for color,
more vulnerable to energy
 Slowed edema, or other
movement fluctuations in blood production.
signs of
 v/s: pressure. compromised  Edema
BP:140/70m REFERENCE: circulation. tous tissue is
mHg  Encourage more easily
TEMP:37.2 C  http://www.omnim participation in traumatized and
RP: 34 cpm edicalsearch.com/c self care, heals more
PR:74 bpm onditions- diversional or slowly.
diseases/cerebrov recreational
ascular-disease- activities.  Enhanc
symptoms.html es self concept
 http://nursingcrib.c and sense of
om/nursing-care- independence.
plan/nursing-care-
plan-
cerebrovascular-
accident-cva/
 Textbook of
Medical-Surgical
Nursing 11th
edition by Joyce
Young Johnson

OWN ANALYSIS:
Cerebrovascular Disease
is a functional
abnormality of the brain
caused by hypertension
which ruptures the blood
vessels that carries
oxygenated blood to the
brain. CVD can then
result to ischemic stroke
in which blood supply to
a certain part of the
brain is decreased,
leading to dysfunction of
the brain tissue in that
area.
VIII. DISCHARGE PLAN

DISCHARGE PLAN AND INSTRUCTION FORMAT

(Revised 2007)

Name: Regina Ferolino Ewayan Age: 74 Sex: Female

Religion: Roman Catholic

Diagnosis: Cerebral Vascular Disease

Surgery undergone, if any: N/A

Hospital: CCMC RM\m/Ward-Bed No.: Female Medical Ward

Physician: Dr. Vidad

A. OBJECTIVES: (SMART /KSAV)

After 8 hours of nurse – patient interaction, the patient will be

able to:

1.) Verbalize understanding of situation and individual treatment

regimen and safety measure.
2.) Demonstrate techniques or behaviors that enable resumption of
activities
3.) Shows appreciation of the given assistance and interventions.

B.

1. Medications

Name of Drug Dosage and Route Curative Effect Side Effect

Frequency

Rosuvastati 1 tab OD Per Orem Lipid Lowering CNS:

n 5mg/day Agent dizziness,
(Crestor) headache,
insomnia
CV: chest
pain
EENT:
sinusitis
GI: abdominal
pain
GU: UTI
Respiratory:
1 tab BID Per Orem antihypertensiv increased
Amlodipine 5mg/day e cough
(Norvasc)
CNS: anxiety,
dizziness,
fatigue,
headache
CV:
peripheral
edema
EENT: dry
mouth
GI : diarrhea
 GU: urinary
frequency
Respiratory:
dyspnea

2. EXERCISE / ACTIVITY

Type of Activity allowed/ to be continued:

The patient can be allowed to do exercise like walking,
balanced with sleep and rest.

Procedure or Steps: NONE

Use of equipments (if any): NONE

Restrictions: NO RESTRICTIONS WERE NOTED

3. TREATMENT (Prescribed treatment to be continued at home or

to a referred institution.
1. Continue taking medications for the prescribed number of
days.
2. Adhere to the prescribed diet to regain health, strength, and
energy.
3. Drink 8 to 10 glasses of water everyday and maximum intake
of food based fluid such
as soup and rice water.
4. Monitor blood pressure every now and then.
5. avoid strenuous activities.

4. HEALTH TEACHING (Provide a separate sheet on specified

health teachings)

( / ) clinic appointment schedules ( ) use of alternative

medicines
( / ) follow-up laboratory examination ( ) relapse
prevention measures
 ( / ) understanding and knowing what to do with side effects of
medications
( ) others

• Clinic appointment schedules: a month after discharge

together with laboratory examinations.
• Explain the side effects of the medication to be taken at
home and to follow it according to prescribed direction.

5. a.) Observed signs and symptoms that need reporting:

 Severe headaches

 Fatigue or confusion

 Dizziness

 Nausea

 Problems with vision

 Chest pains

 Breathing problems

 Irregular heartbeat

b.) Interventions/Home remedies that may be done

immediately prior to seeking consultation:

• Taking a rest maybe done if the patient continued signs

and symptoms of hypertension.
 6.) DIET (Prescribed by the doctor/dietician)

a.) Prescribed Diet:

• Fiber-rich food such as green leafy vegetable and fruits (banana,

pineapple)
• Low sodium diet – low fat diet

6.) DIET (Prescribed by the doctor/dietician)

b.) Prescribed Diet:

• Fiber-rich food such as green leafy vegetable and fruits (banana,

pineapple)
• Low sodium diet – low fat diet

c.) Restrictions:

• Avoid foods that are high in fats and sodium

• Avoid drinking of alcoholic beverages

7.) SPIRITUAL AND PSYCHOLOGICAL NEEDS

( ) spiritual counseling ( ) confession (/)

supportive counseling
( ) grief work ( / ) family therapy ( ) join
organizations/church activities
( ) anger management ( ) reconciliation of conflicted
relationships

C. DISCHARGE DETAILS

A. Date and time of discharge: April 30, 2010

B. Accompanied by : Husband

C. Mode of Transportation : Ambulance provided by the hospital

D. General condition upon discharge: patient appeared alert with no

reports of headache and dizziness for the past 2-days and able to eat well.
THESE DISCHARGE INSTRUCTION WERE EXPLAINED TO THE PATIENT
AND/ OR RELATIVE
Read and Understand: (translated according to patient's convenience)
: If all measures fail, an interpreter is asked.

Mr. Abelino Benjamin Roque

PATIENT / RELATIVE
(Signature over printed name)

Validated:

Mikhael Denn C. Layese

STUDENT NURSE
(Signature over printed name)

Ms. Estrobo
CLINICAL INSTRUCTOR
(Signature over printed name)