STI College of Nursing

Sta. Cruz, Laguna

College of nursing

Submitted to:
Mrs. Aurea Celino, RN
Clinical Instructor

Submitted by:
GROUP III

Members:
Avanzado, leonel
Dawinan, Paullette Edilyn
Del Rosario, Jason
Mallari, Kim
Miras, Roxanne
Napiza, Charlene Diane
Salvador, Leomar
Valenzuela, Abrelaine

December 6, 2010

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 TABLE OF CONTENTS

I. Introduction --------------------------------------------------------------------------------3
A. Objectives -------------------------------------------------------------------------------5
B. Background of the Study ------------------------------------------------------------5
C. Rationale for Choosing the Case -------------------------------------------------6
D. Significance of the Study -----------------------------------------------------------7
E. Scope and Limitations ---------------------------------------------------------------8

II. Clinical Study ------------------------------------------------------------------------------9

A. Demographic Data --------------------------------------------------------------------9
B. Physical Assessment -----------------------------------------------------------------10
C. System Affected -----------------------------------------------------------------------13
D. Laboratory and Diagnostic Exam -------------------------------------------------13

III. Clinical Discussion -----------------------------------------------------------------------16

A. Anatomy and Physiology -------------------------------------------------------------16
B. Pathophysiology ------------------------------------------------------------------------19
C. Nursing Care Plan ----------------------------------------------------------------------20
D. Drug Study -------------------------------------------------------------------------------26
E. Course in the Ward --------------------------------------------------------------------35
F. Discharge Plan --------------------------------------------------------------------------37
G. Evaluation --------------------------------------------------------------------------------38
H. Summary ---------------------------------------------------------------------------------38
I. Recommendation -----------------------------------------------------------------------39

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I. INTRODUCTION

CEREBROVASCULAR ACCIDENT
A stroke, previously known medically as a cerebrovascular accident (CVA), is the
rapidly developing loss of brain function(s) due to disturbance in the blood supply to the
brain. This can be due to ischemia (lack of blood flow) caused by blockage
(thrombosis, arterial embolism), or a hemorrhage (leakage of blood). As a result, the affected
area of the brain is unable to function, leading to inability to move one or more limbs on one
side of the body, inability to understand or formulate speech, or an inability to see one side of
the visual field.
A stroke is a medical emergency and can cause permanent neurological damage,
complications, and even death. It is the leading cause of adult disability in the United States
and Europe and it is the number two cause of death worldwide.

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.

 Worldwide, one-quarter of all strokes are fatal.
 Stroke is the third leading cause of death in the United States and the leading cause
of disability.
 It is estimated that four of every five families in the United States will be affected by
stroke in their lifetime,
 More than half a million people in the United States experience a new or recurrent
stroke each year.
 Stroke kills about 150,000 Americans each year, or almost one out of three stroke
victims.
 Three million Americans are currently permanently disabled from stroke.
 In the United States, stroke costs about $43 billion per year in direct costs and loss of
productivity.
 Two-thirds of strokes occur in people over the age of 65.
 Strokes affect men more often than women, although women are more likely to die
from a stroke.
 Strokes affect African Americans more often than Caucasians, and are more likely to
be fatal among African Americans.

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  The incidence of strokes among people ages 30 to 60 is less than 1%. This figure
triples by the age of 80.
 The rate of occurrence for strokes in the United States fell by 15.52% between 1988
and 1998. But the number of deaths from stroke actually rose by 5%.
 According to the World Health Organization, one in ten of the 55 million deaths that
occur every year worldwide are due to stroke and two-thirds of which occur among
people living in developing countries). In the Philippines, stroke remains to be a
leading cause of disability, afflicting 400,000 Filipinos yearly
 (Manila Bulletin, 13 September 2004). 

What Are the Risk Factors for Developing Stroke?

1) smoking
2) excessive alcohol intake
3) uncontrolled high blood pressure
4) high cholesterol 
5) overweight/unhealthy diet
6) illegal drugs/abuse of Rx drugs
7) known or unknown heart problems
8) diabetes
9) known or unknown vascular brain defects - aneurysm, etc.
10)family history of stroke

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A. OBJECTIVES

GENERAL OBJECTIVE
This study aims to:

 Have a further study about cerebrovascular accident (CVA) or stroke.

 Perform physical assessment to the patient with this kind of ailment.
 Understand the pathophysiology of the disease, and how it affects our body
system.
 Formulate nursing care plan for this patient with CVA.
 Have further knowledge about the different medicines and treatment modalities
about this disease.
 Give proper information through health teaching, rendering appropriate nursing
interventions to the patient about his present conditions are the main objectives of
this study.

B. BACK GROUND OF THE STUDY

MR. CVA is a 68 years old tricycle driver from Mabitac, Laguna. The patient was
rushed to the Emergency Room last November 25, 2010 at 12:30am with complaints of
chilling, chest pain, nausea and vomiting. The patient has been diagnosed with
cerebrovascular accident (CVA) or stroke and was admitted at the hospital.
We decided to present this case for the reason that we want to learn and explore
new knowledge and information about this type of condition. Our group wants to improve
our skill in rendering care with this kind of client.

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 C. RATIONALE FOR CHOOSING THE CASE

Nurses in all settings perform a cruical role in assessing the patient, helping prevent

the occurence of possible complications and rendering supportive nursing care. Thus, it is

vital that we, as future nurses be enlighten with significant information that we may use, as

we render health encouraging services to our client.

This presentation has been chosen by the group under the following reasons:

1. Assess the patient’s family history and identify risk factors for developing the disease.

2. Apply a nursing process to the patient under the students care and resolve problem,

implement the plan and evaluate the progress of the plan.

3. Identify the appropriate nursing care interventions in managing the clinical signs and

symptoms that manifest in patient.

4. Utilize effective communication techniques for educating the client and the family.

5. Determine factors and conditions that may influence to the development of the disease.

Further enhance knowledge and understanding regarding the nature of the disease.

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 D. SIGNIFICANCE OF THE STUDY

This would serve as an important source to the following sectors:

To the students:

This study discusses Cerebrovascular Accident, its definition, causes,

manifestation and proper treatment which will broaden our understading of the

disease.

This would also improve our knowledge in the anatomy and physiology of the

Nervous system and how its directly affected by the disease.

To the Family and Patient:

This study can also benefit the patient through better understanding of the

underlying causes of the diseases and to have knowledge on proper managament of

the illness.

This can also provide the patient on how to deal with the possible signs and

symptoms and other noticeable changes might observed.

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D. SCOPE AND LIMITATION

This research study primarily focused on the different nursing intervention and health

teaching that we students nurses can give/advice our patients to help alleviate pain and

discomfort. This study also focused on the nature and occurances of the diagnosis, as

well as the primary factors present in the environment that may worsen the situation.

We, as student nurses are limited in formulation of the best nursing care plan

for our patient. We also focused on the the different types of medication prescribed by the

physician,for us to know and understand its effect to our patient. Therapeutic nurse

patient interaction was also established to be able to render the best possible care.

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II. CLINICAL STUDY

DEMOGRAPHIC DATA

Patient Name : MR. CVA

Age : 68 years old
Sex : Male
Birth Date : April 15, 1942
Address : Mabitac, Laguna
Date of Admission : November 25, 2010
Time of Admission : 12:30am
Admitting Diagnosis: Cerebrovascular Accident

Source of Information

Secondary Source : Patient’s Relative

Chief Complaint: “nanginig, nagsuka at sumakit ang dibdib ng pinsan ko kaya namin sya
dinala sa hospital.” As verbalized by the patient’s relative.

History of Present Illness

Few days prior to admission according to his cousin MR. CVA was complaining of
experiencing dizziness, headache and mild chest pain. When MR. CVA was rushed to the
hospital he was having chills, nausea, vomiting, and mild chest pain. The Physician on duty
who have seen and examined MR. CVA decided to admit him in Medicine Ward.

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History of Past Illness

MR. CVA has suffered from stroke previously; he had his first stroke last 2000. His
cousin said that MR. CVA had recovered from the first accident without any permanent
damage or complication and then eight years after the first accident he had his second attack
on the year 2008. Fortunately MR. CVA recovered fully after hospitalization and treatment.
His third attack of stroke happened last November 25, 2010 and he was then admitted at the
Medicine ward.

Dietary History

Prior to the episode of his first stroke, MR. CVA was fond of eating fatty foods like pork
chop, meat viands and chicken skin. He loves to eat rice and fried foods. After suffering from
stroke MR. CVA began to regulate his diet. His relatives also prepared for him healthy foods
such as vegetables and fish and set a limit with their intake of meat and fried foods.

History of Elimination pattern

Output: 900 cc level of urine at urine bag for 24 hours. (Nov. 30, 2010)
400 cc level of urine at urine bag @ 12 noon.
Color: Amber Red.

B. PHYSICAL ASSESSMENT

Levels of consciousness: Glasgow coma scale

Faculty measured
Eye opening: 3
Motor response: 3
Verbal responses: 2
Total: 8

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 - With flushes, dry skin
General Appearance - Medium body built
- With IVF of @ right metacarpal vein
- With oxygen therapy regulated @ 10 LPM delivered by
face mask
- With NGT ( Nasogastric tube)
- Normocephalic
Head - symmetrical in shape
- no masses, no lesions, no tenderness
Hair - evenly distributed over the scalp
- no dandruff
- Hair with few gray hairs.
Eyelids - with water eyelids
- no edema, and no discharges
Sclera - yellowish
Iris - symmetrical in size
- round and black
- Symmetrical in size
Pupils - round and dark brown in color
- PERRLA (Pupils Equally Round And React To
Light and Accommodation)
Lower conjunctiva - Moist
- equal in size
Ears - auricles are smooth and symmetrical
- pinna recoils after it is folded
- the external nose is symmetrical and straight
- color is the same with the entire face
- lesions and tenderness were both absent
- nasal septum is intact and in midline without
Nose deviations
- cilia present in internal nares
- absence of nasal discharge
- with oxygen mask

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 - with cyanotic lips
Mouth - dry oral mucous membrane
- dentures are removed
- free from lumps and no tenderness
Neck - at the center and midline
- skin color was not evenly distributed
Thorax - no masses and tenderness upon palpation
- with wheezing sounds
- With irregular lub-dub sound * cannot be distinguished.
- round in shape, no lumps, no masses
Breast - areola dark brown in color
- nipples round, equal in size
- skin color evenly distributed
Abdomen - no lumps , masses and tenderness
- skin uniform in color
Upper extremities - with IVF @ right metacarpal vein
- Left arm paralyzed ( limb ataxia)
- Capillary refill: 2-3 seconds
- Skin uniform in color
- Left leg paralyzed
Lower extremities - Sole of the foot is pale
- No Deep tendon reflex
- With indwelling catheter
Genitalia

C. SYSTEM AFFECTED

 Cardiovascular system
 Increased BP

 Nervous system

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  Hemiplagia
 Limb ataxia
 Dysarthia
 Numbness

 Respiratory system
 Increased RR

D. LABORATORY AND DIAGNOSTIC EXAM

HEMATOLOGY

COMPONENT RESULT NORMAL SIGNIFICANCE INTERPRETATION

VALUES
WBC (x109/L) 23.2 4.5 – 10.5 x 109 High Increased due to
/L infection.
SEGMENTED 87 45 – 65% High
NEUTROPHIL
S
MONOCYTES 18 2 – 10% High Increased in viral
infections.
RBC (x1012/L) 4.16 5.5 – 6.5 x Low Decreased in
1012/L anemia.
MCH (pg) 22 27 – 32 pg Low Decreased in iron
deficiency anemia.
MCHC (g/L) 24.4 32.0 – 36.0 g/L Low Decreased in iron
deficiency anemia

Evaluation of Blood Smear: TROPONIN E – NEGATIVE

BLOOD ANALYSIS REPORT

COMPONENT RESULT NORMAL INTERPRETATION SIGNIFICANCE

VALUES
PH 7.51 7.35 – 7.45 High Indicates
alkalosis.

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PCO2 25 mm Hg 35 – 45 Low Indicates
respiratory
alkalosis (hyper
or over
ventilation).
PO2 90 mm Hg 80 – 100 Normal Normal
HCO3 20 mmol/L 22 – 26 Low Indicates
metabolic
acidosis.
TCO2 21 mmol/L 23 – 27 Low Indicates
respiratory
alkalosis
BE ecf -3 mmol/L (-2) – (+2) Low A negative
base excess
indicates
metabolic
acidosis
(primary or
secondary to
respiratory
alkalosis).
SO2 92% 95 – 100% Low Indicates that
the hemoglobin
is
deoxygenated.

Readings: Uncompensated Respiratory alkalosis with unconnected oxygenation.

COMPONENT RESULT NORMAL INTERPRETATION SIGNIFICANCE

VALUES
BUN kinetic UV 9.8 mmo/L 2.5 – 6.4 High The BUN level
(Blue) is significantly
above the
normal limits
which denotes
an impairment
in renal
functions.
Creatinine 133.7 umo/L 35.4 – 123.8 High The creatinine
Kinetic (2 * level is
significantly
above the

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 normal limits
which is a
result of renal
impairment
related to the
client’s active
renal disease.
Direct HDL 0.214 mmo/L 0.700 – 2.200 Low Indicates
heightened risk
for heart
disease.

ECG ANALYSIS RESULT

819 Undefined Tachycardia
81 A Undefined Arrhythmia
303 High Voltage (Right Ventricular)
701 Poor R Progression
401 Short P-R Internal
618 Unspecified ST – T Abnormalities

III. CLINICAL DISCUSSION

A. ANATOMY AND PHYSIOLOGY

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 Circulatory system

NORMAL BLOOD CIRCULATION

 BLOOD from the superior and inferior vena cava enters to the right atrium and

passed the tricuspid valve.

 After the blood passed the tricuspid valve it flows to the right ventricle and

enters the pulmonary valve then flows to the pulmonary artery into the lungs.

 The blood that enters the lungs will be oxygenated and by passing the

pulmonary vein it goes to left atrium.

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 And then it will passed the bicuspid valve to the left ventricle and pass the

aortic valve through aorta then the blood is ready for distributing and collecting

carbon dioxide to the tissues and organs.

 Nervous system

FUNCTIONS OF THE NERVOUS SYSTEM

1. Sensory input- sensory receptors monitor numerous external and internal

stimuli that may be

interpreted as touch,

temperature, taste, smell,

sound, blood pressure and

body position. Action potential

from the sensory receptors

travel along nerves to the

spinal cord and brain, where

they are interpreted.

2. Integration- the brain and the

spinal cord are the major organs processing sensory input and initiating

responses. The input may produce an immediate response, may be stored as

memory, or may be ignored.

3. Homeostasis- the nervous system plays an important role in maintenance of

homeostasis. This function depends on the ability of the nervous system to

detect, interprets, and responds to the changes in the internal and external

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 conditions. In response, the nervous system can stimulate or inhibit the

activities of other system to help maintain a constant internal environment.

4. Mental activity- the brain is the center of the mental activity, including

consciousness, memory and thinking.

5. Control of muscles and glands- skeletal muscle normally contract only when

stimulated by the nervous system. Thus, through the control of skeletal muscle,

the nervous system controls the major movement of the body. The nervous

system participates also in controlling cardiac muscle, smooth muscle, and

many glands.

Organization of the nervous system

STIMULUS

Sensory division conducts action potentials from the periphery to the CNS

CNS processes and integrates information, initiates response, and carries out mental activity

Motor division conducts action potentials to the periphery

Somatic nervous system Autonomic nervous system

Parasympathetic division Sympathetic division

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 B. PATHOPHYSIOLOGY OF CVA
PREDISPOSING FACTOR PRECIPITATING FACTOR
Age: 68 yrs.old, Hypertension
Sex: male Lifestyle: Lack of Exercise
Family history of hypertension Diet: Eating Foods Rich in Cholesterol
2 times Hx of stroke accident.

Deposition of fats in the artery of the brain or neck

Narrowing of the vein occurs

Occlusion of the artery in the brain or neck

Disruption of the blood flow

Ischemic cascade occurs * cellular metabolic events

Dizziness Oxygen on the neurons (aerobic respiration of the neurons fails)

Switching of the mitochondria into anaerobic respirations

Production of the lactic acid Insufficiency in the production of ATP

Electrolyte ion imbalance occurs

pH is changed
Depolarization of the cells
Acidosis occurs

Intracellular calcium increased Body temperature Depolarization of the cell

Increased of glutamate

Cell membrane and protein breakdown, formation of free radicals, protein production

Cell injury and death occurs

Carotid or vertebral artery dissection occurs Headache Numbness,

Occlusion of the small vessel supplying the lateral thalamus, pons, or renticular region

Disturbance of the upper motor neuron on Hemiplagia

one side / Hemipharesis
Paralysis of the muscle producing sounds and someSome brain
muscle functions are affected
airways

19 Damaged of the brain reached the frontal lobe

Infraction in the cerebral hemisphere Limb ataxia

Dysarthria, DOB Limited attention span, difficulty in comprehension

Cyanotic lips
CEREBROVASCULAR ACCIDENT

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 C. NURSING CARE PLAN

HYPERTHERMIA

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Subjective: Hyperthermia After 8 hours 1. Monitor vital 1. Regular After 8 hours of

“Nilalagnat ang related to of nursing signs. temperature nursing
pinsan ko.” As increased interventions monitoring interventions the
verbalized by the intracellular the client body will identify clients body
patient’s relative. calcium as temperature adequate temperature
evidenced by will be thermoregulat remain 37.7 0 C.
Objective: elevated body decreased ion. GOAL UNMET.
temperature. from 37.7 0C 2. Noted body 2. Noting the
- Febrile to the normal temperature body
- Warm to range. temperature
touch indicates and
- Flushed show the
skin progress of
- Temp: 37.7 the client’s
0
C condition

3. Provide tepid 3. To promote

sponge bat (if not cooling of
contraindicated). body surface.

4. Promote 4. To maintain
ventilation of stable
skin by means of body
undressing or temperature
unclothing of

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 (heat loss by the clients
radiation and
conduction).

5. Administered 5. Medication
medication such as
(antipyretics) e.g antipyretics
paracetamol, as can decrease
prescribed. and
normalized
body
temperature.

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IMPAIRED PHYSICAL MOBILITY

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Subjective: Impaired After 8 hours of 1. Determine 1. To identify After series of

“Hindi physical mobility nursing diagnosis causative/contribu nursing
makagalaw ang related to interventions that ting factors. intervention the
lolo ko simula disturbance of the patient’s: contributes to patient relatives:
noong ma- upper motor immobility.
stroke siya” as neuron in one  S/O will  Relatives can
verbalized by part of the brain demonstrate 2. Assist or 2. To prevent demonstrate
the patient’s (neurovascular techniques have S/O complications like d techniques
relative. impairment) as that will reposition bedsore. that will
evidenced by enable safe client on a enable safe
hemiplagia. repositioning regular repositioning.
Objective: . schedule by GOAL MET.
turning to
 (+) general side every 3
body hours (as
weakness ordered by
 (+) Paralysis the
of left side of physician).
the body
(hemiplagia) 3. Provide 3. To provide safety.
 (+) lethargy safety
 Functional measure
level scale: 0 such as
(completely putting side
independent) rails up, or
 Inability to using pillows
perform to support
gross/fine body part.
motor skills

23
4. Involve S/O 4. To impart health
in care, teaching to the
assisting patient’s family.
them to learn
ways to
managing
problems of
immobility.
5. Teach 5. To enhance blood
relatives to circulation and
perform prevent
passive contractures
Range of
Motion
Exercises

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IMPAIRED VERBAL COMMUNICATION

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Subjective: Impaired verbal After 1 hr. of 1. Provide 1. Provide After 1 hr. of

“Hindi communication nursing alternative communicati nursing
makapagsalita ng related to loss of intervention, the methods of on needs intervention, the
maayos ang lolo facial or oral patient will communicati or desires patient was able
ko” as verbalized muscle establish on, like based on to
by the patient’s tone control as method of pictures or individual establish method
relative. evidenced by communication in visual cues, situation or of
difficulty speaking. which needs can gestures or underlying communication in
be demonstratio deficit. which needs can
Objective: expressed n and Hand be
gestures expressed.
 Difficulty
producing
speech 2. It reduces
 Dysarthria 2. Talk directly confusion
 Presence of to patient. or anxiety
face mask Speaking and having
slowly and to process
directly. Use and
yes or no respond to
question to large
begin with. amount of
information
at one
time.

3. Patient is not
3. Speak in necessary
normal tones hearing

25
 and avoid impaired and
talking too raising
fast. voice may
Give patient irritate or
ample time anger the
to respond. patient

4. It is
4. Encourage important for
family family
members members to
and visitors continue
to talking to
persist the patient to
efforts to reduce
communicate patients
with the isolation,
patient. promote
establishmen
t of
effective
communicati
on and
maintain
sense of
connectedne
ss or
bonding with
the
family

26
 D. DRUG STUDY

GENERIC BRAND CLASSIFICA MECHANISM INDICATION CONTRAINDICATIO ADVERSE NURSING

NAME NAME TION OF ACTION N REACTION RESPONSIBLIT
Y

Acetyl ASA, Pharmacolo Reduces pain Mild pain or Hypersensitivity EENT: Tell to
Salicylic Aspergum, gic Class: and fever to salicylates, hearing loss relatives of
Acid Aspercin NSAIDs inflammation other NSAIDs the patient to
by inhibiting Mild to GI: nausea, report
Dosage: Therapeutic prostaglandin moderate Renal impairment vomiting ototxicity
80mg Class: production. pain caused symptoms,
tab Non opioid Fever by Severe hepatic Hematologic: unusual
Once a Analgesic, reduction inflammation impairment thrombocytop bleeding and
day Antipyretic, mechanism enia, bruising
Anti platelet unknown; Acute Vitamin K leukopenia
drug may be linked rheumatic deficiency caused Instruct the
to decrease fever by dehydration Hepatic: relative of the
in hepatotoxicity patient to tell
endogenous To reduce the Pregnancy or all prescribers
pyrogens in risk of breastfeeding Respiratory: he’s taking
hypothalamu transient wheezing the drug
s resulting ischemic Concurrent because it
from attacks or anticoagulant use Skin: rash, may cause
prostaglandin cerebrovascu urticaria serious
inhibition. lar accident in interactions
Exerts anti men with a with many
platelet effect transient common
by inhibiting ischemic medicines
synthesis of attack caused
prostacyclin by emboli Tell patien’s
and relative not to
thromboxane To reduce the take over the
A2. risk of counter
myocardial preparations

27
 infarction in containing
patients with aspirin
history of MI
or unstable
angina

Thromboemb
olic disorders.

GENERIC BRAND CLASSIFICATION MECHANISM INDICATION CONTRAINDICA ADVERSE NURSING

NAME NAME OF ACTION TION REACTION RESPONSIBLIT
Y

Isordil Isosorbide Pharmacologic Promotes Treatment and Hypersensitivit CNS: Teach patient
Dinitrate Class: peripheral prophylaxis in y to drug dizziness, relative to give
Dosage: Nitrate vasodilation situations headache oral drug 30
5 tablets and reduces likely to Severe mins. before
sublingual Therapeutic preload and provoke acute anemia CV: or 1 to 2 hours
Class: afterload, angina tachycardia, after a meal
Anti anginal decreasing pectoris. Acute orthostatic
myocardial myocardial hypotension Inform patient
oxygen Prophylaxis of infarction relative that
consumption angina GI: nausea , drug may
and cardiac pectoris. vomiting cause
output. Also headache.
dilates SKIN:
coronary flushing Advise his
arteries, relative to treat
increasing headache as
blood flow usual and not
and improving to alter drug
collateral schedule.
circulation

28
GENERIC BRAND CLASSIFICATION MECHANISM INDICATION CONTRAINDICATION ADVERSE NURSING
NAME NAME OF ACTION REACTION RESPONSIBLITY

Acetamin PARACE Pharmacologic Unclear. Mild to Hypersensitivity to HEMATOL Tell patient,

ophen TAMOL Class: Pain relief moderate drug. OGIC: parents, or
Synthetic non may result caused thrombocyt other
DOSAGE: opioid p- from byheadache openia, caregivers not
Ampule IV aminophenol inhibition of , muscle neutropeni to use drug
q4h derivative prostaglandi ache, a, concurrently
n synthesis backache, hemolytic with other
Therapeutic in cns, with mild anemia acetaminophen
class: subsequent arthritis, -containing
analgesic, blockage of common HEPATIC: products.
antipyretic pain cold, Jaundice,
impulses. toothache, hepatotoxi Advise patient ,
Fever and fever. city parents or
reduction other
may result SKIN: caregivers to
from rash. contact
vasodilation urticaria prescriber if
and fever or other
increased METABOLI symptoms
peripheral C: persist despite
blood flow hypoglyce taking
in mic coma recommended
hypothalam amount of
us, which OTHERS: drug.
dissipates hypersensi
heat and tivity Inform patient
lowers body reaction with chronic
temperature alcoholism that
. drug may
increase
severe liver
damage.

29
 As appropriate,
review all other
significant and
life threatening
adverse effect
and
interactions
and behaviors
mentioned
above.

GENERIC BRAND CLASSIFICATION MECHANISM INDICATION CONTRAINDICATION ADVERSE NURSING

NAME NAME OF ACTION REACTION RESPONSIBILITY

30
Berodual Ipratropium Anti cholinergic It blocks the Prevention Hypertrophic Nervousness. Instructed the
Bromide drug, Anti muscarinic and obstructive Restlessness, clients relative
Dosage: asthmatic cholinergic treatment of cardiomyopathy, tachycardia, on how to use
Nebule receptors in symptoms tachyarrythmias. palpitations, of inhaler,
q6h the smooth in chronic hypersensitivity to dizziness, nebulizer.
muscles of obstructive atropine like headache. dry
the bronchi airway substance. mouth and Advised the
disorders cough. patients
in the lungs.
with relative to use
This opens
reversible dry cotton and
the bronchi, bronchospa tap the lips to
and provides sm (eg avoid dryness.
relief in bronchial
chronic asthma and Instructed the
obstructive chronic clients relative
pulmonary bronchitis. to do back
disease and tapping or
acute vibration after
asthma. the medication.

GENERIC BRAND CLASSIFICATI MECHANISM INDICATION CONTRAINDICATION ADVERSE NURSING

NAME NAME ON OF ACTION EFFECTS RESPOSIBILITY

31
 Digoxin Lanoxin Antiarrythmic, Increase Heart failure; Hypersensitivity to CNS: fatigue, Check PR
inotropic force of and tachyarrythmia drugs headache, regularly, if it’s
Dosage: velocity of s; atrial asthenia below 60 or
20 g mayocardial fibrillation and Uncontrolled CV: above
OD. contraction flutter; ventricular bradycardia, 110bpm/min, tell
and prolongs paroxysmal arrhythmias ECG changes, him to withhold
refractory atrial arrhythmias dose and notify
period of AV tachycardia. AV block EENT: blurred the prescriber.
node by or yellow
increasing Tab.20mg OD Idiopathic vision Instruct patient
calcium hypertropicsubaort GU: relative not to
entry into ic stenosis gynecomastia take OTC drugs
myocardial GI: n/v, without
cells. Slows Constrictive diarrhea prescribers
conduction pericarditis approval
through
sinoatrial Teach patient
and AV relative on how
nodes and to recognize and
produces report signs and
antiarrythmic symptoms of
effect. digoxin toxicity

GENERIC BRAND NAME CLASSIFICA MECHANISM INDICATION CONTRAINDI ADVERSE NURSING

NAME TION OF ACTION CATION EFFECTS RESPOSIBILIT
Y

32
Mannitol Osmitrol, Diuretics Enhance To prevent acute Active CNS: Teach
resectisol water flow renal failure intracranial dizziness, patient
Dosage: from various during bleeding headache, relative
100 cc tissues and cardiovascular seizure about
every q6 ultimately and other Anuria CV: chest importance
hours. decrease surgeries 50-100g secondary pain, of monitoring
intracranial I.V. infusion as to severe hypotension, exact urinary
and 5%-25% solution. renal hypertension, output.
intraocular disease tachycardia,
pressure. To reduce thrombophlebi Advise
Also protects intracranial Progressive tis, heart patient
kidneys by pressure and heart failure, relative to
preventing brain mass. 0.5- failure, vascular report
toxins from 2g/kg I.V infusion pulmonary overload adverse
forming and as 15-25% given congestion, EENT: blurred reaction,
blocking over 30-60 mins. renal vision, rhinitis such as
tubules. damage or GI: n/v, increase
To promote renal diarrhea, dry shorthness
dieresis in drug dysfunction mouth of breath or
toxicity 25g I.V. after GU: polyuria, back
infusion as mannitol urinary
loading dose, therapy retention Tell patient
followed by begins Respi: relative that
infusion of 5-25% pulmonary drug may
solution given Severe congestion cause thirst
continuously to dehydration Skin: rash, or dry mouth.
maintain high urticaria
urine output.

GENERIC BRAND NAME CLASSIFICA MECHANISM OF INDICATION CONTRAINDI ADVERSE EFFECTS NURSING
NAME TION ACTION CATION RESPOSIBILITY

33
Furosemide Furoside, Diuretics, Unclear. Edema Hypersensiti CNS: dizziness, Take the drug
lasix, antihyperte Thought to caused by vity to drug headache, vertigo in the morning
Dosage: novosemide nsive inhibit sodium heart failure, or other weakness, with foods to
20 mg IV and chloride hepatic sulfonamide lethargy, prevent
reabsorption cirrhosis, or s restlessness, light nocturia.
from ascending renal headedness
loop of Henle disease Anuria CV: hypotension, Instruct S/O
and distal renal Adults: tachycardia to report s/sx
tubules, initially, 20- EENT: blurred of ototoxicity.
promoting renal 80 mg/day vision,
excretion of PO as a xanthopsia,
water, sodium, single dose; hearing loss, Caution
chloride, may tinnitus patient relative
magnesium, increase 20- GI: n/v, not to give any
hydrogen and 40mg constipation, alcohol
calcium increments dyspepsia, content
PO q 6-8 hrs cramping, beverages and
until desired anorexia, dry herbs while
response mouth taking this
occur. GU: excessive drug.
and frequent
urination,
nocturia.
Musculoskeletal:
muscle pain and
muscle cramps

34
GENERIC BRAND CLASSIFIC MECHANISM OF INDICATION CONTRAINDICATI ADVERSE NURSING
NAME NAME ATION ACTION ON EFFECTS RESPOSIBILITY

Ceftazidime Ceptaz, Anti- Interferes with Skin Hypersensitivity CNS: Instruct patient
portaz, inffective bacterial cell wall infection, to headache, relative to
Dosage: tazidime synthesis and bone and cephalosporins lethargy, report reduced
IV q8 hours division by joint infection and penicillin confusion, urine output,
binding to cell urinary tract syncope persistent
wall, causing cell and seizures diarrhea,
to die. Active gynaecologic CV: bruising and
against gram infection; hypotension, bleeding
negative and adults and palpitation,
gram positive children chest pain
bacteria, with ages 12 and vasodilation
expanded older: 500mg EENT: hearing
activity against to 2 g. IV or loss
gram negative IM q 8- GI: n/v,
bacteria. Exhibits 12hrs. UTIs abdominal
immunosuppress 500mg q 8- cramping
ant activity. 12hrs. IV or GU: vaginal
IM candidiasis
Respi:
dyspnea
Skin: urticaria,
maculopapular
rash

35
E. COURSE IN THE WARD

November 30, 2010

 Received client on a bed lying down asleep with IVF of 200cc of 0.9

NaCl in SS level of 70cc of mannitol and with oxygen regulated at 10

LPM. IVF infusing well.

DATE TIME VITAL SIGNS NURSES OBSERVATION

November 30, 2010 8:00 am  BP: 120/ 90

- Asleep
mmHg
 PR: 62 bpm - Febrile
 RR: 30 cpm
- With flushed skin
 Temp: 37.7 O C
- Warm to touch
- With cyanotic lips
12:00 noon  BP: 120/ 90 - DOB
mmHg
- Lethargic
 PR: 62 bpm
 RR: 30 cpm - Hemiplagia
 Temp: 37.7 O C
- Limb ataxia
- Pale sole of the foot
- With indwelling
catheter
- Dysathria

36
December 1, 2010

 Received client on a bed lying down asleep with IVF of 275cc of 0.9

NaCl in SS level of 81cc of mannitol and with oxygen regulated at 10

LPM. IVF infusing well.

DATE TIME VITAL SIGNS NURSES OBSERVATION

December 1, 2010 8:00 am  BP: 140/ 100

- Asleep
mmHg
 PR: 71 bpm - Febrile
 RR: 36 cpm
- With flushes skin
 Temp: 38.0 O C
- Warm to touch
- With cyanotic lips
12:00 noon  BP: 140/ 100 - DOB
mmHg
- Lethargic
 PR: 98 bpm
 RR: 41 cpm - Hemiplagia
 Temp: 38.8 O C
- Limb ataxia
- Pale sole of the foot
- With indwelling
catheter
- Dysathria

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DISCHARGED PLAN

M-EDICATION
Patient has to take his medication on time.

E-XERCISE
The patient was advised to have complete bed rest until strength is regained. Have
turn side to side every 2 hours to prevent bed sores. Have ROM exercise on to enhance
client's body function.

T-REATMENT
Insist physical therapy for improving strength and walking. Undergo Occupational
therapy for regaining dexterity of the arms and hands. The client should go through speech
therapy to learn talking and swallowing. Oxygen inhalation should be available if necessary.

H-EALTH TEACHING
Teach the client how to have a healthy lifestyle. Teach patient the foods to eat and
the foods to avoid. Teach the family members how to prepare low sodium and low fat diet.
Encourage environmental modification to enhance safety and prevent injury.

O-UT PATIENT
The client was advised to have a follow-up check-up, as indicated by the physician.

D-IET
Patient was instructed to maintain the low salt and low fat diet. The low salt diet is
designed to induce a loss of sodium and water from the body or avoid sodium retention. A
2000 mg low sodium diet is sufficient to control blood pressure. A low fat diet help lose
weight to decrease risk of having CVA again.

S-SPIRITUAL ADVICE

The patient needs a spiritual advice by their relative to have faith in GOD that his
illness will lessen, and only GOD can cure his pain with the help of medicine.

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 F. EVALUATION

The nursing process and procedure rendered to the patient is accordingly.

Health teaching and nursing interventions were done properly and effective. In order to

provide care our group applies the knowledge, skills and right attitude for caring for our

patient. In terms of rendering and giving independent intervention, we as student nurses

believe that we have done our best to be able to provide our outmost care. The client was

admitted in the hospital because he suffered from chills, dizziness, nausea and vomiting. The

Physicians diagnosis was Cerebral Vascular Accident (CVA) or stroke. He is confined in the

hospital for more than seven days. We assisted this patient and made some independent

nursing interventions to help alleviate his conditions and to be of assistance to the client’s

relatives.

G. SUMMARY

This study focused on Cerebral Vascular Accident (CVA). The condition is caused by

the interruption of the blood supply to the brain, usually because a blood vessel bursts or is

blocked by a clot. This cuts off the supply of oxygen and nutrients, causing damage to the

brain tissue.

The most common symptom of a stroke is sudden weakness or numbness of the face, arm

or leg, most often on one side of the body. Other symptoms include: confusion, difficulty

39
speaking or understanding speech; difficulty seeing with one or both eyes; difficulty walking,

dizziness, loss of balance or coordination; severe headache with no known cause; fainting or

unconsciousness.

The effects of a stroke depend on which part of the brain is injured and how severely it

is affected. A very severe stroke can cause sudden death.

After choosing this case, we researched about CVA to know the cause, clinical

manifestation and nursing intervention that we are going to perform. After doing procedures

such as physical assessment and assessing the vital signs, along with our research, this

helped us to gain more knowledge and understanding about the disease.

H. RECOMMENDATION

As a student nurse we recommended the following:

To the patient:

1. Continue his medication with the help of the relatives

2. Eat healthy and nutritious foods avoid cholesterol that trigger his condition

3. Initiate physical therapy after discharged in the hospital

4. Teach the relatives how to monitors patients vital signs, frequently specially blood

pressure because patient is unstable in her condition.

5. The relatives should always pray for the fast recovery of their love ones.

6. Be patient in caring for his, who suffering from this kind of disease.

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