A CASE PRESENTATION OF CEREBROVASCULAR

ACCIDENT INFARCT

Presented to the Faculty of School of Nursing

Adventist Medical Center College
Brgy.San Miguel, Iligan City

In Partial Fulfillment
of the Requirements for the Degree
BACHELOR OF SCIENCE IN NURSING

PANGCOGA, AISHA RESSAN A.

DECEMBER 2019 1
 TABLE OF CONTENT

I. TITLE PAGE

II. TABLE OF CONTENTS

III. OBJECTIVES

A. General Objective
B. Specific Objectives

IV. INTRODUCTION

V. NURSING HEALTH HISTORY

A. Vital Information (Personal Data)

B. History of Present Health Concern
C. Past Health History
D. Family Health History (Genogram)
VI. PHYSICAL ASSESSMENT AND REVIEW OF SYSTEM

VII. GENOGRAM

VIII. NORMAL ANATOMY AND PHYSIOLOGY

IX. DIAGNOSTIC TEST

X. MEDICATIONS

XI. NURSING CARE PLAN

XII. MEDICAL/ SURGICAL MANAGEMENT

XIII. DISCHARGE PLAN

XIV. REFERENCES

2
 DEFINITION OF TERMS

Agnosia- inability to recognize one or more subjects that were previously familiar

Aphasia - Inability to use or understand language

Apraxia - inability to carry out some motor pattern (e.g., drawing a figure, getting
dressed)

Expressive aphasia - a motor speech problem in which one can understand what is being
said but can respond verbally only in short phrases; also called Broca’s aphasia.

Hemiparesis - weakness of the left or right half of the body

Hemiphlegia- paralysis of the left or right half of the body

Hemorrhagic stroke - when a blood vessel ruptures, spilling blood into spaces
surrounding neurons

Ischemic stroke. Deficient supply of blood to a body in which is a part of the heart or
brain.

Cardiogenic embolic stroke. is obstruction of blood or struking of any foreign matter in

blood vessels while travelling through the blood stream.

Cryptogenic stroke. is defined as cerebral ischemia of obscure or unknown origin. 

3
 INTRODUCTION

A cerebrovascular disorder or CVA is damage to part of the brain when its blood supply

suddenly reduced or stopped. A CVA may also be called stroke. The part of the brain

deprived of blood dies and can no longer function. Blood is prevented from reaching

brain tissue when a blood vessel leading to the brain becomes blocked, ischemic or burst

(hemorrhagic). the symptoms of a stroke differ, depending on the of the brain affected

and the extent of the damage. Symptoms following a stroke come on suddenly and may

include: weakness, numbness, or tingling in the face, arm or leg, especially on one side of

the body trouble walking, dizziness, loss of balance,aphasia,expressive aphasia,

confusion or hemiparesis, such as swallowing, hemiplegia , severe headache with no

known cause, and loss of consciousness.

Ischemic stroke, cerebrovascular accident (CVA) or “brain attack” is a sudden loss of

the blood supply to a part of the brain. Ischemic strokes are subdivided into five different

types based on the cause: large artery thrombosis stoke (20%), small penetrating artery

thrombotic stokes (25%), cardiogenic embolic strokes (20%) cryptogenic strokes (30%)

and other (5%).

Hemorrhagic stroke account for 15% to 20% of cerebrovascular disorders and are

primarily caused by intracranial or subarachnoid hemorrhage. Hemorrhagic stroke are

caused by bleeding in the brain tissue, the ventricles, or the subarachnoid space. Primary

intracerebral hemorrhage from a spontaneous rupture of small vessel accounts for

approximately 80% of hemorrahgic stroke and is caused chiefly by uncontrolled

hypertension. Subarachnoid hemorrhage results from ruptured intracranial aneurysm in

about half the cases.

Every year, more than 795,000 people in th USA have a stroke. About 610,000 of

these are first or new strokes. About 185,000 strokes nearly

4 1 of 4 are in people who have

had a previous stroke. About 87% of all strokes are ischemic strokes, in which blood flow

to the brain is blocked.

Tackling different aspects of cerebrovascular accident such as; the cause, precipitating

factors, predisposing factor, and its prevalence throughout the world as one of the top ten

leading causes of morbidity.The severity associated with cerebrovascular accident can

best be demonstrated by the following facts: CVA is the leading cause of adult disability

in the world.

5
 VITAL INFORMATION
NAME:Macawadib, Dimapinto B.
ROOM #: 246
AGE: 73
GENDER: Male
CIVIL STATUS: Married
DATE OF BIRTH: 01/11/1946
PLACE OF BIRTH: Mulondo, Lanao Del Sur
CULTURAL GROUP:
PRIMARY LANGUAGE: Meranao
RELIGION: Islam
HIGHEST EDUCATION ATTAINMENT: 3rd year college
OCCUPATION: Businessman
USUAL HEALTH CARE PROVIDER: Family
REASON FOR HEALTH CONTACT: Headache and body weakness
DATE OF CONFINEMENT: October 20, 2019
SOURCE OF HISTORY: 50% SO and 50% Chart
ATTENDING PHYSICIAN: Dr. Diamla
IMPRESSION/FINAL DIAGNOSIS: Cerebrovascular accident infarct

6
Present history:

Days prior to admission, Mr. P always experienced severe headache and body

weakness. On october 20, the family decided to have Mr P a check-up at Adventist

Medical Hospital. After being admitted on october 20 the patient experienced seizure and

was admitted to the ICU and undergone craniotomy due to intracnial hemorrhage. After

operation, he was under obsercation by nurses in ICU for 17days.

Past history:

Mr.P was born on January 01, 1946 at Mulundo, LDS. He did not experience having

any childhood illness like mumps, chicken pox and etc. according to his wife. Mr. P was

hospitalized at Mercy hospital due to fever many years ago. He has no any food allergies

according to the SO.

7
 GENOGRAM

LEGEND:

- male

- Female

-Patient CV K CV
A F A
-Deceased
- HPN

KF- Kidney Failure

CVA-Cerebrovascular
accident infarct
 PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS
Areas Assessed Subjective Objective Findings Problem
Findings Identified
General Health Survey  Needs assistance  No problems
 Left body identified
paralysis  Risk for
 Unconscious injury
 Poor skin turgor  Altered LOC
 Appears weak
 No signs of
respiratory
distress
 No deformities
 BP- 140/90

Integumentary System  Dry skin  Pain

 Skin is warm to
touch
 Nails are hard
and basically
immobile
 Bed sore
HEENT  Appears weak  Risk for
a. Head and face  Craniectomy infection
b. Eyes defect
c. Ears  Paleness is
d. Nose noted
e. Oral Cavity  No mucosal
discharge
 Lips are pale
without lesions
or swelling
 No unusual or
foul odor is noted

• Nasal flaring is not

observed
Neck  The jugular vein No problems
is not distended. identified
 No blowing or
swishing or other
sounds are heard
upon auscultating
 Lymph nodes:
there is no
swelling or
enlargement
noted
Respiratory System  Client does not
use accessory No problems
muscles to assist identified
breathing.
 Equal chest
expansion
 Clients reports
no tenderness,
pain or unusual
sensations.
 Nasal flaring is
not observed.

Cardiovascular System  No murmurs are No problems

heard identified
 No shortness of
breath noted.
 BP:140/90
 (-) jugular vein
distention

Breast and axilla • Breast are No problems

symmetrical with no identified
signs of dimpling or
retraction
• No masses palpated
 No discharges
noted.
Gastrointestinal System and  No striae  No problems
the Abdomen  No scars identified
 Abdomen is free
of lesions or
rashes
 Umbilicus is
midline at lateral
line
 Abdomen is
symmetric, does
not bulge when
client raises head
Genitourinary/Reproductiv  Urine output No problems
e system 600cc identified

Musculoskeletal System  Shoulders are

symmetrically  Self-care
round, no deficit
redness, swelling
or deformity or  Impaired
heat physical
 Elbows are mobility
symmetric,  Risk for
without injury
deformities,
redness or
swelling
 Bed ridden
 Weak muscle
strength
 Left side
paralysis
(hemiplegia)
 Legs are free of
lesions or
ulcerations
 No edema
present in the
legs
 Toes, feet and
legs are equally
warm bilaterally
 Lower leg in
alignment with
the upper leg
 Symmetric,
without redness
or swelling
 no signs of
tingling on the
hands noted

Neurologic System  Unconscious  Altered LOC

 Can raise arms
side hand
 Poor muscle
strength
 Altered LOC
Lymphatic/Hematologic • Paleness not noted
System • No signs of
bleeding in the
different areas of the
body including the
nose and rectal
bleeding.
NV:
 RBC-4-6 x 10
12/L
 Hematocrit-
0.40-0.54
Hemoglobin
 130-160 g/L
WBC
 5-10 x 10 9/L
Result:
RBC-3.08
Hematocrit
 0.28
Hemoglobin
 93.0
WBC
 5.36

Endocrine System  No abnormal  No problems

pigmentation identified
 No excessive
sweating or
flushing
 Skin warm to
touch
 NORMAL ANATOMY AND PHYSIOLOGY

ANATOMY FUNCTIONS

BRAIN DIVISIONS

1. FOREBRAIN  Responsible for a variety of function including receiving and

processing sensory information, thinking, producing, and
understanding language and controlling motor function.
2. MIDBRAIN  Is the portion of the brain stem that connects the hindbrain and
the forebrain. Thisn region of the brain is involved in auditory
and visual responses as well as motor function.
3. HINDBRAIN  Alsocalledrhombencephalon,region of the developing
vertebrate brain that is composed of the medulla
oblongata, the pons, and the cerebellum. The
hindbrain coordinates functions that are fundamental to
survival, including respiratory rhythm, motor activity, sleep,
and wakefulness
BRAIN STRUCTURES
 Involved in cognition and voluntary movement. Diseases
1.BASAL GANGLIA related to damages of this area are Parkinson's and
Huntington's
2.BRAINSTEM
 Relays information between the peripheral nerves and
spinal cord to the upper parts of the brain. Consists of the
midbrain, medulla oblongata, and the pons

3.BROCA'S AREA
 Speech production, Understanding language

4.CENTRAL SULCUS
 (Fissure of Rolando)Deep grove that separates the parietal
5.CEREBELLUM and frontal lobes

 Controls movement coordination, Maintains balance and

equilibrium

 The part of the brain at the back of the skull in vertebrates. Its
function is to coordinate and regulate muscular activity.

 Outer portion (1.5mm to 5mm) of the cerebrum. Receives

6.CEREBRAL CORTEX and processes sensory information

*Divided into cerebral cortex lobes

Cerebral Cortex Lobes

1. Frontal Lobes -involved with decision-making, problem

solving, and planning
2. Occipital Lobes -involved with vision and color recognition
 3. Parietal Lobes - receives and processes sensory information
4. Temporal Lobes - involved with emotional responses, memory,
and speech
7. CEREBRUM
 Largest portion of the brain. It Consists of folded bulges
called gyri that create deep furrows
8. CORPUS CALLOSUM

 Thick band of fibers that connects the left and right brain
hemispheres
9. MEDULLA OBLONGATA

 Lower part of the brainstem that helps to control autonomic

functions Meninges. Membranes that cover and protect the
brain and spinal cord.
 The medulla oblongata helps regulate breathing, heart and
blood vessel function, digestion, sneezing, and swallowing.
This part of the brain is a center for respiration and
circulation. Sensory and motor neurons (nerve cells) from
the forebrain and midbrain travel through the medulla

DIAGNOSTIC TEST
DIAGNOSTIC NORMAL RESULT INTERPRETA SIGNIFICANCE NURSING
TEST VALUES TION RESPONSIBIL
ITIES
RBC  4-6 x 10  3.08  Decreased  If the number 1. Explain
Hematocrit 12/L  0.28  Decreased of RBCs is lower  test
Hemoglobin  0.40-0.54  93.0  Decreased than normal, it procedure.
WBC  130-160 g/L  5.36  Increased may be caused by: Explain that
Segmenters  5-10 x 10  0.76  Decreased anemia. bone slight
Lymphocytes 9/L  0.16  Decreased marrow failure. discomfort
Stabs  0.50-0.65  0  Decreased erythropoietin may be felt
Monocytes  0.25-0.35  0.03 deficiency, which when the
Eosinophils  0.05-0.10  0.05 is the primary skin is
Basophils  0.03-0.07  0 cause of anemia in punctured.
Platelet counts  0.01-0.03  128 patients with 2. Encoura
 0-0.01 chronic kidney ge to avoid
 140-450 x disease. stress if
10 9/L hemolysis, blood possible
loss (hemorrhage) because
Creatinine  71-115  207.  A lower than altered
umol/L 21 normal hematocrit  physiologic
Potassium  3.5-5.3  4.17 can indicate: An status
Sodium mmol/L  142. insufficient supply influences
 135-148 9 of healthy red and
mmol/L blood cells changes
SPECIMEN: (anemia) A large normal
Wound number of white hematologi
discharge blood cells due to c values.
long-term illness, 3. Explain
ORGANISM infection or a that fasting
ISOLATED: white blood cell is not
Pseudomonas disorder such as necessary.
aeruginosa leukemia or However,
lymphoma. fatty meals
COLONY Vitamin or may alter
COUNT: mineral some test
Light growth deficiencies. results as a
 Elevated result of
creatinine level lipidemia.
signifies 4. Apply
impaired kidney manual
function or kidney pressure
disease. As the and
kidneys become dressings
impaired for any over
reason, the puncture
creatinine level in site on
the blood will rise removal of
due to poor dinner.
clearance of 5. Monitor
creatinine by the the
kidneys. puncture
Abnormally high site for
levels of oozing or
creatinine thus hematoma
warn of possible formation.
malfunction or 6. Instruct
failure of the to resume
kidneys. normal
activities
and diet.
Drug name Route/Freque Mechanism of Indication Contraindication Nursing
ncy/Dose Action responsibilities
Generic Route:IV Ihibits protein Indicated for the Hypersensitivity  Assess for
name: synthesis by treatment of to hypersensitivi
Amikacin binding directly infections of; aminoglycoside ty to
Frequency: to the 30S CNS,biliary and antibiotics, aminoglycosi
Brand: ribosomal intestinal tracts, pregnancy. de.
Amikin subunit skin and  Obtain
Dose: 350mg bactericidal subcutaneous specimen for
tissues. culture and
sensitivity
test.
 Correct
dehydration
before
therapy
begins
because of
increased risk
of toxicity
 Monitor renal
function;
urine
output,specifi
c gravity,
urinalysis,
BUN and
creatinine
clearance.
 Watch for
signs and
symptoms of
incessant
infection.

Drug name Route/frequenc Mechanism of Indication Contradication Nursing

 y/ and dosage Action responsibilities
Generic name: Route: Inhibits influx Hypertension, Sick sinus  Assess cardio
Amlodipine of calcium ion chronic stable syndrome; respiratory
across cell angina, second or third status. BP,
Brand name: Dosage:5mg membranes to vasospatic agina degree pulse,
Amvasc, produce antrioventricula respiration
norvasc relaxation of r and ECG.
Frequency: coronary  Assess
OD vascular hydration and
smooth fluid volume
muscle. status, I & O
Decrease ratio presence
peripheral of edema,
vascular distended
resistance of neck veins,
smooth adequate
muscle pulses and
(decrease BP) skin turgor.

Drug name Route/freque Mechanism of Indication Contraindicati Nursing

ncy/dose Action on responsibility
Meropenem Route: Antiinfective; Prescribed for Contraindicate  Determine
IV carbapenem bacterial d with history of
Brand name: antibiotic infections like hyoersensitivit hypersensi
Merrem Dose: skin and skin y to tivity
1g structure carbapenem reactions
Frequency: infections, antibiotics to other
bacterial beta-
meningitis, lactams,
serious cephalosp
nosocomial orins,
infections like penicillins,
septicaemia, or other
febrile drugs.
neutropenia. the  Discontinu
medication e drug and
inhibits cell wall immediate
synthesis in ly report
bacteria. S&S of
hypersensi
tivity.
 Monitor
for
seizures
especially
in older
adults and
those with
renal
insufficien
cy.

Drug Route/frequenc Mechanism of Indication Contraindicati Nursing

y/dose Action o responsibility
Generic: Route: IV drips
The precise Indicated as Hypersensitivi  Instruct the
levetiraceta mechanism by adjunctive ty to patient to
m Dose: 500mg which therapy in the levetiracetam. take
levetiracetam treatment of medication
Brand: Frequency: Q exerts is partial onset as directed.
Keppra 12 hrs antiepileptic seizures.  Do not
effect is discontinue
unknown. abruptly;
may cause
increase in
frequency
of seizures
 Assess
patient for
CNS
adverse
effects
throughout
therapy.

Drug Route/dose/fre Mechanism of Indication Contraindicat Nursing
quency Action ion responsibility
Generic: Route: Stimulates alpha- It is indicated Hypersensitiv  Monitor BP
Clonidine adrenergic in the treatment ity carefully
Dose:150mg receptors in the of hypertension Disorder of when
Brand: CNS; which Cardiac discontinui
Catapres results in Pacemaker ng
decreased acitivity clonidine.
sympathetic and Hypertensi
outflow inhibiting conduction on usually
cardio returns
acceleration and when
vasoconstriction 48hrs.
centers.  Instruct the
patient to
consult
prescriber
if dry
mouth or
drowsiness
becomes a
problem.
 During oral
clonidine
therapy. To
minimize
these
effects,
prescriber
may
suggest
taking most
of dosage
at bedtime.

Drug Route/dose/fre Mechanism of Indication Contraindicati Nursing

quency action on responsibility
 Generic: Route:  Valproic acid is Sole and Contraindicat  Give drug
Valproic sometimes used  adjunctive ed with with food to
acid Dose: together with therapy in hypersensitivi prevent GI
500mg other seizure simple and ty to valproic upset.
Brand: medications. Val complex absence acid, hepatic  Monitor
Depakote Frequency: proic acid is seizures; acute disease, or ammonia
1/2 tab OD also used to treat treatment of significant levels and
manic episodes manic episodes heaptic discontinue
related to associated with impairment. if there is
bipolar disorder bipolar clinicallt
(manic disorder;prophyl significant
depression), and axis of migraine elevation in
to prevent headaches; level.
migraine adjunctive 
headaches. therapy for
multiple seizure
disorders.

Drug Route/freque Mechanism of Indication Contraindicati Nursing

ncy/dose action on responsibility
Generic: Route: Increase and/or -Sedative or Known hypers  Document
Phenobarbit Dose:60g mimic the inhibitory hypnotic,anticon ensitivity to indication for
al sodium 1/2 tab activity of GABA vulsant,emergenc valproate or therapy, type,
Frequency:O on nerve synapses y control of acute any of the onset, and
Brand: D seizure disorders ingredients characteristic
Luminal used in the s of
sodium preparation. symptoms.
 Assess V.
reduce dose
with
impairment
and in
debiliated/eld
erly clients.
 Be alert for
adverse
reactions and
drug
interactions.

Drug Route/frequen Mechanism of Indication Contraindication Nursing

 cy/dose action responsibility
Generic: Route: Gastric acid- Short-term Contraindicated  Arrange for
Omeprazol pump inhibitor: treatment of with further
e Dose:40g 1 suppresses active hypersensitivity evaluation of
cap gastric acid duodenal to omeprazolear patient after
Brand: secretion by ulcer; first line its components 8weeks of
Prisolec Frequency: specific therapy in therapy for
OD inhibition of treatment gastro reflux
the hydrogen gastroesophag disorders; not
potassium ATP eal reflux intended for
as enzyme disease maintenance
systemm at the (GERD). therapy.
secretory  Administer
surface of the antacids with
gastric parietal omeprazole,
cells. if needed.
 Take the drug
before meals.

Drug Route/freque Mechanism of Indication Contraindication Nursing

ncy/dose action responsibility
Generic: Route: Produce analgesia  Relief  Contraindica  If there is
Paracetamol IV by blocking mild pain ted in fever,
generation of pain or fever patients with assess
Brand: Frequency: impulses, hypersensiti patient’s
Biogesic Every 4hrs probably by vity to the for fever or
inhibiting drug. pain.
Dose: prostaglandin  Avoid
300mg synthesis in the giving
CNS. aspirin or
aspirin-like
analgesics
because it
inhibits
platelet
aggregation
.
 Teach
client/SO
warning
signs that
needs
immediate
attention of
the
physician.
 Evaluate
therapeutic
effect.

Drug Route/frequenc Mechanism of Indication Contraindication Nursing

y/dose action responsibility
Indapamid Route:Oral Increases Mild moderate Hypersensitivity;  Monitor BP,
e excretion of hypertension.. cross-sensitivity I&O, and
sodium and edema with daily weight.
Frequency:OD water by associated and sulfonamides  Assess patient
inhibiting other causes. especially if
Dose:1 tab sodium taking
reabsorption in digoxin , for
the distal tubule. anorexia,
nause,
vomiting,
muscle
cramps and
paresthesia.
 Assess patient
for allergy to
sulfonamides.

CUES NURSING PLANNING NURSING RATIONALE EVALUAT

DIAGNOSIS INTERVENTIO
N
 Altered Ineffective LTO:  Determine  Deterioration After NI th
LOC cerebral tissue Within the 12hrs factors in patient will
 Sensory, perfusion r/t shift of nursing related to neurological manifest an
language, hemorrhage; intervention individual signs and sign of
intellectual, cerebral edema patient will not: situation, symptoms or deterioratio
and manifest or cause for failure to
emotional display any signs coma, improve after
deficits of further decreased initial may
deterioration or cerebral reflect
recurrence of perfusion,an decreased
deficits. d potential intracranial
for ICP. adaptive
 Monitor & capacity,
document which
neurological requires the
status client to be
frequently admitted to
and compare critical area
with for
baseline. monitoring
 Monitor vital of ICP.
signs noting:  Assess trends
hypertension in LOC and
or potential for
hypotension: increased
compare BP ICP and is
readings in useful in
both arms. determining
 Monitor location
heart rate ,extend, and
and rhythm; progression
auscultate or resolution
for murmurs. of CNS
 Assess damage.
higher  Fluctuations
functions, in pressure
including may occur
speech, if because of
patient is cerebral
alert pressure or
injury in
vasomotor
area of the
brain.

CUES NURSING PLANNING NURSING RATIONALE EVALUAT

DIAGNOSIS INTERVENTIO
N
Subjective: Impaired LTO:  Provide  Provides After NI th
verbal Within the 12hrs alternative communicati patient will
Objective: communication shift of nursing methods of on needs of manifest an
Aphasia r/t intervention communicati patient based sign of
neuromuscular patient will not: on by on individual deterioratio
impairment as manifest or providing situation and
manifested by display any signs visual cues underlying
aphasia of further such as deficit.
deterioration or gesture.  Reduces conf
recurrence of  Talk directly usion and
deficits. to client , allays
speaking anxiety at
slowly having to
distinctly. process and
Use yes/no respond to
questions to large amount
begin with of
progressing information
in at one time.
complexity As retraining
as a client progresses,
respond. advancing
 Speak with complexity
normal of
volume and communicati
avoid talking on stimulates
too fast. memory and
 Encourage further
visitros/SO enhances
to persist in word and
efforts to idea
communicate association.
with client.  Patient is not
 Consult and necessarily
refer hearing
patient to impaired, and
speech raising voice
therapist. may irritate
or anger
patient.
 It is
important for
family
members to
continue
talking to
patient to
reduce
patient’s
isolation,
promote
establishment
of effective
communicati
on, and
maintain
sense of
 connectednes
s with
family.
 Assesses
individual
verbal
capabilities
and sensory,
motor, and
cognitive
functioning
to identify
deficits/thera
py needs.

CUES NURSING PLANNING NURSING RATIONALE EVALUAT

DIAGNOSIS INTERVENTIO
N
Subjective: Disturbed LTO:  Review  Awareness After NI th
Sensory Within the 12hrs pathology of on the type patient will
Objective: Perception r/t shift of nursing individual and areas of manifest an
unconscious Altered intervention condition. involvement sign of
sensory patient will not:  Eliminate aid in deterioratio
reception, manifest or extraneous assessing
transmission, display any signs noise and specific
integration of further stimuli as deficit and
(neurological deterioration or necessary. planning of
trauma or recurrence of  Assess care.
deficit)a deficits. sensory  Reduces
awareness: anxiety and
dull from exaggerated
sharp, hot emotional
from cold, responses
position of and
body parts, confusion
joint sense. associated
 Stimulate with sensory
sense of overload.
touch. Give  Diminished
patient sensory
objects to awareness
touch, and and
hold. Have impairment
patient of kinesthetic
practice sense
touching negatively
walls affects
boundaries. balance and p
 Note ositioning
inattention to and
body parts, appropriatene
segments of ss of
environment, movement,
lack of which
recognition interferes
of familiar with
objects/perso ambulation,
ns. increasing
risk of
trauma.
 Aids in
retraining
sensory
pathways to
integrate
reception and
interpretation
of stimuli.
Helps patient
orient self
spatially and
strengthens
use of
affected side.
 Agnosia, the
 loss of
comprehensi
on of
auditory,
visual, or
other
sensations,
may lead
result to
unilateral neg
lect, inability
to recognize
environmenta
l cues,
considerable 
self-care defi
cits, and
disorientation
or bizarre
behavior.

CUES NURSING PLANNING NURSING RATIONALE EVALUAT

DIAGNOSIS INTERVENTIO
N
Subjective: Risk for injury STO:  Establish  To promote STO:
(none) r/t left After 4 hrs of NI, rapport cooperation. Pt shall hav
hemiplegia pt will be able to  Monitor vital  To have seek help to
Objective: secondary to seek help to signs baseline data. promote tas
Left hemiplegia CVA infarct perform tasks  Keep the  To protect that are bey
that are beyond side rails of from falling capabilities
capabilities. the bed out of bed. LTO:
LTO: raised.  To prevent Pt shall hav
After 3 days of  Remind injury. remained fr
NI, pt will be client to  For from
able to remain walk slowly, continous injury/falls
free from injury rest monitoring
absence of adequately
and guidance
abrasions/falls between
intervals of to the client..
walking use
effective
lighting.
 Inform pt’s
SO not to
leave
her/him in
the
bathroom..

CUES NURSING PLANNING NURSING RATIONALE EVALUAT

DIAGNOSIS INTERVENTIO
N
Subjective: Self Care Short Term:  Monitored  To have a Short Term
(none) Deficit related After 4 hrs of vital signs baseline data Were abl
to nursing  Assessed for  Provides data identified
Objective: musculoskeleta intervention, SO type and regarding personal
 Inability to l impairment will be able to severity of mobility and resources
ambulate secondary to identify personal immobility ability to can pr
CVA resources that impairment, perform assistance.
can provide muscle activities
assistance and be flaccidity, with in Long Term
able to verbalize spasticity limitations Patient able
knowledge of and without safely perfo
health care coordination, injury or self-care
practices. ability to frustrations. activities.
walk, sit,
Long Term: move in bed
After 3 days of perform
nursing  promotes
intervetion, SO  Passived circulation,
will safely ROM to all muscle tone,
performs self- limbs and joint
care activities to progress to flexibility,
the patient assistive and prevents
then active contractures
ROM in all and
joints four weakness
times a day
 Provides safe
 use assistive support for
devices as immobility
appropriate
and other self
for
ambulation. care
activities to
promote
independence
.

MEDICAL/SURGICAL TREATMENT
Emergency IV medication. Therapy with drugs that can break up a clot has to be given
within 4.5 hours from when symptoms first started if given intravenously. The sooner
these drugs are given, the better. Quick treatment not only improves your chances of
survival but also may reducecomplications.

Emergency measures. If you take blood-thinning medications to prevent blood clots,

you may be given drugs or transfusions of blood products to counteract the blood
thinners' effects. You may also be given drugs to lower the pressure in your brain

(intracranial pressure), lower your blood pressure, prevent spasms of your blood vessels
and prevent seizures.

Surgery. If the area of bleeding is large, your doctor may perform surgery to remove
the blood and relieve pressure on your brain. Surgery may also be used to repair blood
vessel problems associated with hemorrhagic strokes. Your doctor may recommend one
of these procedures after a stroke or if an aneurysm, arteriovenous malformation
(AVM) or other type of blood vessel problem caused your hemorrhagic stroke.

Surgical clipping. A surgeon places a tiny clamp at the base of the aneurysm, to stop
blood flow to it. This clamp can keep the aneurysm from bursting, or it can keep an
aneurysm that has recently hemorrhaged from bleeding again.

Coiling (endovascular embolization). Using a catheter inserted into an artery in your

groin and guided to your brain, your surgeon will place tiny detachable coils into the

aneurysm to fill it. This blocks blood flow into the aneurysm and causes blood to clot.

Craniotomy with open surgery: The neurosurgeon removes a portion of the skull and
conducts open surgery to drain the hematoma and repair the ruptured blood vessel.

DISCHARGE PLAN
 A. OBJECTIVES

1. Summarizes a simple and productive discharge plan

2. Be able to initiate treatment for patients who have CVA

3. Demonstrate effective teaching strategies for individuals and groups`

4. Demonstrate how to use and maintain medication delivery devices
5. Explain how to educate clients who have special needs or difficulty with self-
management

METHODS
Medications:
Medications Dosage/Frequency Nursing Intervention
Amlodipine Dose: 5mg  Assess cardio
respiratory status. BP,
Frequency: OD
pulse, respiration and
ECG.
 Assess hydration and
fluid volume status, I
& O ratio presence of
edema, distended neck
veins, adequate pulses
and skin turgor

1. Exercise/Activity and Home Environment

Type of Activity Allowed/To be continued:

2. Exercise/Activity and Home Environment

Type of Activity Allowed/To be continued:
 Exercise 30-60 minutes a week as prescribed.
 Advise the patient to have complete bed rest until strength regained. Have the
patient turn side to side every 2 hours to prevent bed sores.
 Avoid strenuous activity and allow time for rest periods.
 Have ROM exercises to enhance body function.

Restrictions:
a) 1.) Avoid strenous activity that triggers stress

THERAPY
 Physical therapy
 Speech therapy

HEALTH TEACHING
Health Prevention/Promotion
 Maintain a healthy diet such as eating vegetables and fruit
 Emphasize that BP within the recommended ranges.
 Instruct patient to refrain from smoking, and drink in alcohol moderation
 Maintain normal blood pressure
 Maintain a healthy weight

Preparing diet:

 Avoid fatty food

 Eat a low salt, low fat, and high-fiber diet
 Sodium ranges from 60-90 mEq.
 Eat a diet rich in vegetables and fruit
 Limit cholesterol intake

OPD VISITS/ REFERRALS

 Follow up chek up
 Physical therapist rehab.

DIET
b) Prescribed diet: Soft diet
Day 1 Day 2 Day 3
Breakfast Breakfast Breakfast
 Steamed broccoli
 1 cup of white rice  mashed potatoes  1 cup of rice
 1 pouched egg
 Baked potato
 Apple
 1 glass of water  pureed fruit (such as
applesauce)
 Banana

Lunch Lunch Lunch

 1 cup of rice  1 glass of water
 1 cup white of rice
 Steamed broccoli  1 orange
 Fish
and carrots  1 cup of rice
 Banana
 Chicken  Fried egg with
 1 glass of Water ampalaya

Dinner Dinner

 pureed fruit (such as
 applesauce)
 1 cup of white rice
 Fish

1. Spiritual Care and Psychological or Sexual Needs (Give special

consideration to religious and cultural practices)
Spiritual and Psychological Needs
( ) Spiritual Counseling
( ) Grief Work
( ) Anger Management
( ) Confession
( ) Family Therapy
( ) Reconciliation of Conflicted Relationships
( ) Supportive Counseling
( ) Join Church Organizations/Activities
( ) Prayer
( ) Meditation, Reflection, and Spiritual Devotion
( ) Religious Rituals
( ) Religious/Spiritual Materials

Sexual Needs
( ) Marriage Counseling
( ) Sex Therapy
( ) Sexual Violence
( ) Referral to Appropriate Agencies

C.DISCHARGE DETAILS
a. Date and Time of Discharge:
b. Accompanied by:
c. Mode of Transportation:
d. General Condition upon Discharge:

References:
 Nursing Diagnosis Handbook, Judith Wilkinson, 8th Edition
 Lippincott Manual of Nursing Practice series Diagnostic Tests

 Nursing 2008 Drug Handbook

 Lemone, P & Burke, K (2014). Medical-Surdical Nursing critical thinking

in client care. Singapore: Pearson Education

 Roger T. Malseed,Phd., Lippincott Williams & Wilkins. (2005).

Springhouse Nurses Drug Guide 2005, 6th ed. ( 1-58255-321-1)

 Doenges, M. E., Moorehouse, M. F., Murr, A. C. (2009). Nursing Care

Plans: Guidelines for Individualizing Client Care Across the Life Span,
8th ed. ( 651-652)
 Weber, Janet and Kelley, Jane. (2014) Health Assessment in
NURSING(5th edition). Quezon City, Philippines. C&E publishing inc
 McPherson, Richard and Pincus, Matthew. (2012). Henry’s (22nd edition).
Clinical diagnosis and management by laboratory methods. Singapore.
Elsevier, inc.
 Lppincott Williams & Wilkins. (2007). Lippincott manual of Nursing
Practice series: Diagnostic Tests, 8th ed. ( 651-652)