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Transcript of body
As an overview about perception and coordination concept, mainly it focuses the normal
functioning of the body which is important in our daily living. It is a mental process by which the
brain selects organization and interpretation of the sensory stimuli that serve as a basis for
understanding learning and knowing or for the motivation of a particular action and the
appropriate response to a stimulus which is the movement of the body parts together through
skilful and balanced movement.
A stroke, previously known medically as a Cerebrovascular Accident (CVA), is the
rapidly developing loss of brain functions due to disturbance in the blood supply to the brain.
This can be due to lack of blood flow caused by blockage or a haemorrhage. As a result, the
affected area of the brain is unable to function, leading to inability to move one or more limbs or
one side of the body, inability to understand or formulate speech, or an inability to see one side
of the visual field.
Stroke can soon be the most common cause of death worldwide. The incidence of
stroke increases exponentially from 30 years of age, and etiology varies by age. Advance age is
one of the most significant stroke risk factor. 95% of strokes occur in people age 45 and older,
and two-thirds of strokes occur in those over the age of 65.
According to the World Health Organization (WHO), 15 million people suffer stroke world
wide each year. One of these, 5 million die, and 5 million are permanently disabled. There were
many risk factor of Cerebrovascular Accident and high blood pressure is a risk factor which
contributes to over 12.7million strokes worldwide. According to the Department of Health, the
disease of the heart was top 7 leading cause of death, out of 100,000 per population of the
Philippines in the year 2006, the mortality rate is 49.3 and hypertension was the top 4 cause of
death and the mortality rate is 522.8. According to the City Health Office, in year 2010 the
Cerebrovascular Accident was the top 2 leading cause of the death, out of 100,000 per
population of the Davao city in the year 2010, the mortality rate is 78.91.
The group had chosen L.S.P., a 70 year old female, who was diagnosed with
Cerebrovascular Accident. Pondering upon these presented facts, the proponents are certain
that they have chosen the right patient. Aside from broadening our knowledge about
Cerebrovascular Accident and challenging ourselves with this very complicated yet interesting
case, the proponents also thought that they can make a difference in the life of the patient
suffering from this dreaded disease through health teachings and nursing interventions.
This case study will let researchers know about Cerebrovascular Accident. We student
nurses must be well educated and up-to-date not only in nursing knowledge and skills but also
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in research findings such as perception and coordination. This will serve as an instrument for us
to develop an effective and efficient health care provider representing our quality of care to the
patient.
In addition, the study will be a significant tool for and will acquire new information to the
other student nurses who will encounter the same case and would open more researches about
the illness to give better and fast recovery of patients. At the same time, the management
rendered can also be used in other countries.
In Nursing Education, apparently, it directly benefits the proponents for they have
acquired another set of knowledge which would be very vital in their journey as student nurses.
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That within the three weeks of clinical exposure at San Lorenzo Ward, the group will be
able to integrate our learning from the lecture of the Perception and Coordination Concept to the
clinical area there by resulting to a comprehensive case study that will allow the student nurses
to apply and widen up their knowledge, improve the skills and attitude towards the care of
patients.
Specifically, the group will be able to:
a. Select a client who is applicable for the area of exposure;
b. establish a good working relationship to our patient including her family;
c. present a rationale that will give an overview of the case;
d. formulate a specific, measurable, attainable, realistic, time-bounded objectives;
e. collect all pertinent data such as client’s personal data, clinical data, past health history
and history of present condition;
f. obtain genographic data that traces all the diseases of the patient’s family in both the
maternal and paternal lineage;
g. compare the development of the patient to the Psychosocial Stages of Development
theory of Erik Erikson and Developmental Tasks theory of Robert Havighurst;
h. conduct a systematic cephalocaudal physical and neurological assessment;
i. define the complete diagnosis of the patient from different medical educational sources;
j. discuss the anatomy and physiology of the system that is affected by the disease;
k. trace the pathophysiology of Cerebrovascular Accident in a schematic diagram form and
in narrative form, with its etiology and symptomatology;
l. discuss the medical management including the actual and possible diagnostic
examinations undergone by the patient and also the therapeutic management rendered;
m. discuss all the different medications prescribed to the client;
n. formulate efficient nursing care plans from the identified problems based on the patient’s
condition;
o. provide the patient a well-organized discharge plan which are essential for her condition;
p. evaluate the client’s prognosis with regards to her condition; and
q. list down the references used in the study.
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Biographical Data
Name : L. S. P.
Gender : Female
Age : 70 years old
Birthday : March 27, 1940
Place of birth : Mati, Davao Oriental
Nationality : Filipino
Address : Mapantao, Brgy. Sainz,Mati Davao Oriental
Religion : Roman Catholic
Educational level : Second year High school
Occupation : Barangay Official (Retired)
Source of Income : Boarding House
Income : Php 6,000/ month
Number of Dependents: None
Number of Siblings : 6
Marital Status : Married (Widow)
Clinical Data
Chief Complaint : Right sided weakness
Date of Admission : January 24, 2011; Time: 10:45am
Ward : San Lorenzo Ward 307- 3
Admitting Diagnosis : Cerebrovascular Accident Infarct
: Diabetes Mellitus Type II
Attending Physician : Dr. Cyrus Estera, MD
: Dr. Anabelle Y. Lao, MD
: Dr. Santos- Carpio, MD
Date of Discharge : January 27, 2011; Time: 4.49pm
Final Diagnosis : Cerebral Infarct Left MCA
: Diabetes Mellitus Type II, Hypertension Type II
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Genogram
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FAMILY HEATLH HISTORY
It is of great importance to get the family health history of the client in order to have a
greater view on the occurrence of the illness whether it’s hereditary or affected by her lifestyle
and environment. Having a precise taking of the family health history will be able us to trace and
acquire more knowledge and understanding on how the disease process started.
Our client namely LSP gave us an opportunity to gather significant information and
details to trace the inherited disease in their family. Through this schematic diagram, it identifies
and explains how these diseases linked together and passed from one member of the family to
another member. Not all diseases cannot be acquired by genetic means.
In the illustration of the previous page, it shows that Melinda, LSP’s grandmother on the
paternal side, had no known serious disease or illness and died but the family doesn’t know the
cause of death. Mr. Juanito, his grandfather, died due to old age. Sir Venancio, LSP’s father,
had a history of hypertension and died due to old age.
On the other hand, LSP’s grandparents on the maternal side are Mr. Pedro and Mrs.
Corazon. Mr. Pedro died because of stroke and had a history of hypertension which wasn’t
properly managed which in the end caused of his death but her grandmother on the other hand
died due to old age. Mrs. Leonila, LSP’s mother, also died due to old age.
Mr. Venancio and Mrs. Leonila were blessed with 6 children. Among them, 4 out of 6
have a history of hypertension namely (Obaldo 83, Teofila 82, Binacio 73, and Lolita 70). The
eldest child, Euphracia, 84 years of age has no known acquired disease. Teofila had a history of
asthma and Binacio also had a history of stroke. On the other hand, Romeo, the youngest
among them, died because of bone cancer in the age of 68.
Our patient is the 5th child among the 6 children in the family. She had been diagnosed
to have diabetes mellitus and stroke. According to our client, she is a smoker in her 30’s, one
pack per day then one to three sticks per day when she reached 60.
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Past Health History
According to Ma’am X (daughter- in- law), Ma’am LSP had a history of being a smoker
when she was 30 years old. She consumes 1 pack of cigarette per day but she’s not fun of
drinking alcoholic beverages. Ma’am LSP was hospitalized and was diagnosed of having
hypertension and Diabetes Mellitus type II when she was on her 40’s. She had already
maintaining antihypertensive drug (amlodipine) since then. She was also advised to look after
her diet by avoiding foods which are high in fats, salt and sweets, as well as to stop her vices.
Ma’am LSP stopped smoking; however she was not able to maintain her drugs as prescribed.
She had negligence on taking her medications most of the time and was not cautious about her
diet, she eat anything most especially those that was prohibited to her due to her condition.
Moreover, Ma’am LSP had also a sedentary life due to her old age and doesn’t do follow up
check-ups to her doctor. Furthermore, last 2009 Ma’am LSP was hospitalized because of
increased blood pressure. It was considered as a mild stroke. She was given amlodipine
sublingual and she was advised by Dr. Catbagan same as before on how to manage her
condition. However, Ma’am LSP still doesn’t comply with her treatment regimen.
In addition, according to Ma’am X, Ma’am LSP can’t remember if she had completed
her immunizations. Moreover, Ma’am LSP does not experience any surgeries. Besides from
that, Ma’am LSP had experienced simple coughs and colds, but can be managed at home. The
recent condition of Ma’am L.P caused her current hospitalization.
Present health History
Two weeks prior to admission at SPH. Ma’am LSP experienced weakness and sudden
immobility of her right lower extremities. Her condition was associated with slurring of speech
and facial asymmetry. According to Ma’am X (daughter –in- law) the night after that incident
Ma’am LSP ate “lechon”, then in the morning Ma’am LSP complained to her grandchild who
lives with her, a feeling of pain at the back of her neck, however her grandchild does not take it
seriously, because according to Ma’am LSP the pain is not that worst so she opted to take a
rest on her room, but as she stand to walk she grabbed something to balance herself because
she was to fall down since she lost her sensation on her lower extremities, then suddenly
Ma’am LSP couldn’t talk clearly and her face was quite deformed . Due to this reason, she was
admitted at Davao Oriental Provincial Hospital. She was then diagnosed of having
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Cerebrovascular accident (CVA). Ma’am LSP’s condition was managed by giving her
medications of citicholin, amlodipine, sinuvastatin, pioglituzer. However, she was referred by
Dr. Pisano (her Attending Physician) to SPH for further supervision of her condition, since she
was advised to have a CT scan for further assessment as well as for physical therapy session
for her rehabilitation.
E.6. Developmental Tasks Erik Erikson – Psychosocial Theory
PSYCHOSOCIAL CRISIS: INTEGRITY VS. DESPAIR (65 years to death)
Erik Erikson emphasizes that life is a succession of levels of achievement. An individual
must undergo and achieve each task. Erikson extends the idea that development is a continued
process throughout the lifespan of a human being. Each task may possibly be completed as
successful, partially successful or unsuccessful. Erikson believes that the greater the task
achievement, the healthier the personality of a person can be. This development task can be
viewed as a series of crises and successful resolution of these crises is supportive to the
person’s ego. Failure to resolve the crises is damaging to the ego.
The final stage of Erikson's theory is maturity stage (age 65 years- death). Erikson
proposes that this stage will have a positive resolution if the elder person already reflects upon
acceptance of one’s own worth and uniqueness of one’s own life, in as much as the idea of
his/her incoming death. Moreover, a sense of withdrawal and denial of death shows anegative
resolution in this stage.
Ma’am LSP a 70 year old widow achieved a sense of integrity. Ma’am LSP had already
adjusted to her aging body, she refrains from doing things which requires her to exert more
efforts. She is quite dependent to her grandchild in terms of doing the household choirs,
because she easily gets tired in doing so. According to Ma’am X (daughter- in- law), Ma’am LSP
is already fulfilled and satisfied as a mother to see her children grown up and have their own
families to live with, without experiencing many difficulties in life, in as much as seeing her
grandchildren grow up as well. Ma’am LSP had already achieved her self- worth as wife who
proved her love to her husband for almost 52 years of marriage and even until her death. Ma’am
LSP had no regrets and frustrations in life, she only make used to recall those happy moments
when she still young and continues share her wisdom of her own experiences to her grand
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children and let them learned from her values she used to instill to her children before. As of
now, Ma’am LSP is already accepted and prepared herself to face her end at any time God will
take away her life and confident enough to face a new life eternally in heaven.
Robert Havighurts – Developmental Task Theory
Stage: Later Maturity
Robert Havighurst believed that learning is basic to life and that people continue to learn
throughout life. He described growth and development as occurring during 6 stages, each
associated with 6 to 10 tasks to be learned. For Havighurst, developmental tasks is a task which
arises at or about a certain period in the life of an individual, successful achievement of which
leads to his happiness and to success with later task, while failure leads to unhappiness in the
individual, disapproval by society, and difficulty with later tasks
a. Adjusting to decreasing physical strength and health (achieved)
Ma’am LSP had already accepted that her body is already aging and she cannot
tolerate to do things which require her to exert much effort. Thus, at this point in her life
she depend her needs on others in terms of cooking her food, doing the laundry and
cleaning her home. Ma’am LSP can no longer tolerate ambulation for a long period of
time. So Ma’am LSP usually has a sedentary life by watching television or stay on her
bed to rest. Accompanied to her age was her disease hypertension and Diabetes
Mellitus II which Ma’am LSP doesn’t take it seriously because she doesn’t cooperate
most of the time in terms of complying to the advises of her doctor because according to
Ma’am X, Ma’am LSP knows what’s good for her.
b. Adjusting to retirement and reduced income (achieved)
Ma’am LSP was able to go to secondary high school until 2nd year level. Due to
financial reasons she was not able to finish her studies. After her marriage at 18 years of
age, she stayed at home as a house wife and attends the needs of her children. Ma’am
LSP depend the financial means of their family to her husband who is a government
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employee. After her children got married and have their families, Ma’am LSP and her
husband sustained her needs through a little a little pension he got from his work, and
rent a room business in which earns 3,000 thousand per month. She was also affiliated
to Philhealth, which helped her a lot in paying her medical bills. Moreover, Ma’am LSP’s
children gave some money for her at times in order to sustain her needs, most especially
her medications.
c. Adjusting to death of spouse (achieved)
The patient is described by her children as a strong woman. Ma’am LSP lost her
husband when she was 67 years old it took her 1 year to grief her lost and adjust to go
on with her ordinary life. According to Ma’am X, (daughter- in- law) Ma’am LSP did
mentioned that she will just eventually go with her husband in heaven.
d. Establishing an explicit affiliation with one’s age group ( not achieved)
Ma’am LSP has a membership on senior citizen. However due to old age she is
not active member. She doesn’t usually go out her home because she easily gets tired.
She never goes out unless if it is not really necessary. Like, when she will be brought to
the hospital for check-ups, other than that she will not agree to go out for stroll. Since,
she’s the one being visited by her children.
e. Meeting social and civil obligations (not achieved)
Ma’am LSP doesn’t involve herself in the community organizations or activities,
because her age. On the other hand, she is being updated about what happens in their
community through her grandchild who lived with her. Moreover, she usually contributes
to the welfare of the by keeping her environment clean and following the rules imposed
on their local government.
f. Establishing satisfactory physical living arrangements (achieved)
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Ma’am LSP is happy and satisfied living in her own house with her 4
grandchildren who are teenagers, they were the one who usually took care of her.
Besides her house, is her small business of a boarding house is located. Through this,
she has a source of income her own without really exerting much effort to earn since it is
just within her residence. Furthermore, she can move easily and comfortably in her own
house because she is oriented to where things are.
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Date: January 26, 2011
GENERAL SURVEY
She was wearing a long sleeping dress and was lying in semi fowler’s position. She was
awake, and responsive to any kind of stimuli. Her body built was an endomorphic type. No body
odor or foul breath was noted. Client responds to any questions asked. She had an IVF of
PNSS liter @ 80cc/hr infusing well at right basilic vein at 600cc level.
VITAL SIGNS
Vital Signs
Actual VS
Normal Ranges
Remarks
Temperatu
re
36.2 ºC 35.6-36.7 ºC Afebrile
Pulse Rate 90 bpm 80-90 bpm Tachycardia
Respirator
y rate
21 cpm 16-20 cpm Tachypnea
Cardiac
Rate
92 bpm 80-90 bpm Tachycardia
Blood
Pressure
140/80
mmHg
110/70-130/90
mmHg
Hypertension
SKIN, HAIR AND NAILS
Upon inspection, the patient has a light brown skin tone, was soft and warm to touch and
has a good skin turgor which is appreciated when skin over the clavicle area returns
immediately to its normal position when pinched up. There were discoloration noted over the
face and extremities due to aging.
Hair on the scalp is evenly distributed, thick and is black in color. Hair is wavy and short
in length and is free from infestations upon inspection. Scalp is smooth, moist and mobile with
presence of dandruff.
Nails are of normal size and are intact but are not kept clean or trimmed. Pinkish
nailbeds are noted will a capillary refill time of 1 to 2 seconds and has a concave curvature of
approximately 160 degrees. No clubbing noted upon performing Schamroth’s test.
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HEAD AND FACE
Head is normocephalic, with no lacerations bulges or masses noted. The skull is round
in shape and is intact. No tenderness, masses and nodules noted. Facial features are
symmetric when being asked to raise eyebrows, puff cheeks, frown, close eyes tightly, smile
and show teeth. There are no signs of difficulty seen or discomfort upon assessment.
EYE STRUCTURE
Eyebrows are equally distributed and are symmetrical. Also, the eyelashes are evenly
distributed and slightly curled outward. The client has bilateral blinking. Outer canthus of the
ears aligns with the tip of the pinna. Conjunctiva is pink and sclera is opaque in color. Client has
brown colored iris. Pupils are equally round but sluggishly reactive to light stimulation and
accommodation with a pupil size of 2mm. When looking straight ahead, the client can see
objects in the peripheral fields but is not very clear according to the client. Eyes can follow the
six ocular movements. Furthermore, the client wears correction eye glasses to aid her with her
sight especially for far away objects.
EARS AND HEARING
Ears appear to be symmetric and with same color of facial skin. No lesions and
discharges were noted but there is presence of thick amounts cerumen. The tip of the auricle is
aligned with the outer canthus of the eye. Client was able to hear normal voice tones and
whispers on both ears.
NOSE AND SINUSES
Upon inspection, the nose is of average size and outer structure is free of lesions. Nasal
septum is intact and is positioned in the midline. No discharges or tenderness noted. Air moves
freely as the client breathes through the nares, patient is able to identify the smell of crackers
and alcohol. No tenderness noted upon palpating the sinuses.
MOUTH
Both upper and lower lips were pale to pinkish in color. The client was able to purse lips.
Her teeth were yellowish in color with minimal tooth decay. Both upper and lower second and
third molars were absent. Client was not using dentures to replace her missing teeth. Gums
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were moist and pinkish in color. The mouth was free from lesions. Her tongue was also pinkish,
positioned in the midline and was moving freely.
NECK
Her neck is located midline and is free from bulging masses. There were no swelling or
enlargement and no tenderness of her lymph nodes upon palpation. She can move her neck
without any discomfort and pain felt. She can flex and extend her neck as well. She was able to
resist the force applied towards the side of her face.
THORAX ANG LUNGS
There is symmetrical chest expansion and clear lung fields noted upon assessment.
Upon assessing the vocal fremitus, client was instructed to say “99” and increased vibrations
were felt over major airways and in a decreasing manner, over the lungs to the periphery of the
lungs.
HEART AND CENTRAL VESSELS
Upon auscultation, no adventitious sound was noted but has a fast rhythmic heartbeat.
The point of maximal impulse is located at the left midclavicular line at the 5 th intercostal space,
slightly below the breast. Jugular veins are not distended and visible.
BREASTS AND AXILLA
The client refused to be assessed on these parts.
ABDOMEN
Skin color is lighter in tone over the area compared to exposed parts of the body. No
lesions were noted on the area, normal bowel sounds was appreciated in all four quadrants.
EXTREMITIES
No swelling, masses or deformities were noted. Skin over the area is uniform in color.
There was a presence of right sided weakness. Client had a difficulty clenching her right hand
and raising her right leg. Patient was able to flex wrists, elbows and ankles of the unaffected
side. There was no pressure ulcers noted in the bony prominences.
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CRANIAL NERVES ASSESSMENT AND NEUROVITAL SIGNS
CRANIAL NERVE RESULTS
1- OLFACTORY We asked our client to close her eyes,
then, we held the chocolate cracker
under one nostril with the other
occluded. We asked her to identify the
scent and she was able to distinguish
it correctly (biscuit). Afterwards, we
test the other nostril and had the
same answer.
2- OPTIC We asked the client to read one
sentence from the book we offered for
a distance of 14 inches and she was
able to read it. She also said that she
uses correction glasses to see objects
from afar clearly. The client had
minimum difficulty in seeing objects in
periphery when looking straight
ahead.
3- OCULOMOTOR Pupils were equally round but
sluggishly reactive to light stimulation
and accommodation. The six
extraocular muscles are active.
4- TROCHLEAR Both eyes were coordinated with
parallel alignment.
5- TRIGEMINAL We tested this by touching her cornea
lightly with ear buds and her eyelids
blinked bilaterally. Also, we used a
plastic ruler to test client's ability to
feel light touch, dull and sharp facial
sensations on both sides of the face
at the forehead, cheek and chin
areas. She was able to identify which
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is sharp, dull and light touch
sensations.
6- ABDUCENS All extraocular muscles are active.
7- FACIAL The client was capable of smiling,
frowning, raising her eyebrows,
puffing out her cheeks and closing
eyes tightly.
8- VESTIBULOCOCHLEAR
The client was able hear normal voice
tone and even whisper.
9- GLOSSOPHARYNGEAL
Client is able to move her tongue from
side to side and up and down and was
able to swallow.
10- VAGUS Gag reflex is present since the client
was able to swallow.
11- ACCESORY Client was able to resist the force
introduced in her head and was able
to shrug shoulders against resistance.
12- HYPOGLOSSAL The client was able to protrude her
tongue at midline and move it side to
side.
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NVS LEFT RIGHT
Pupil Size 2 mm 2 mm
Pupil Reaction Sluggish Sluggish
Hand Grip Strong Weak
Leg Movement Strong Weak
Reaction Level Scale
Actual Score
Alert, Fully Conscious
1
Therefore, the client has a RLS/GCS of 1/15.
EVALUATION
Our patient was assessed in a cephalocaudal manner and found both normal and
irregular findings. She has poor hygiene and poor choices when it comes to her health. She is
unable to ambulate independently due to the weakness of the right side of her body. A fast heart
rate and elevated blood pressure was noted as a compensatory action of the body in response
to her recent accident.
CEREBROVASCULAR ACCIDENT (CVA)17| P a g e
Glasgow Coma Scale
Actual Score
Eye OpeningMotor ResponseVerbal Response
4 Eyes open
spontaneously
6 Obeys commands
5 Oriented
GC Total Score
15
Complete definition of diagnosis
A cerebrovascular accident (CVA) is also called a brain attack or stroke. It leads to
neurologic deficits from decreased blood supply to a local area of the brain.
Source: Burke,K., LeMone,P., Eby,L.(2007). Medical Surgical Nurisng Care. (2nd
ed.).Upper Saddle River, New Jersey: Pearson Education.
A cerebrovascular accident, or stroke, is a prolonged interruption in the flow of blood
through one of the arteries supplying the brain. Brain and cerebral nerve cells are extremely
sensitive to a lack of oxygen; if the brain is deprived of oxygenated blood for 3 to 7 minutes
during stroke, both the brain and nerve cells begin to die.
Source: Timbu,B., Smith,N.(2010).Introductory Medical Surgical Nursing.(10th
ed.).China:Wolters Kluwer Health/Lippincott Williams & Wilkins
A stroke is also known as a cerebrovascular accident (CVA) or a brain attack. Blood
supply is interrupted to part of the brain, causing brain cells to die; this results in the patient
losing brain function in the affected area. Interruption is usually caused by an obstruction of
arterial blood flow (ischemic stroke), such as formation of a blood clot, but can also be caused
by a leaking or ruptured blood vessel (hemorrhagic stroke).
Source: DiGuilio,M., Jackson,D.(2007).Medical-Surgical Nursing Demystified.United
States of America: McGraw-Hill Companies.
Cerebrovascular accident is the infarction of brain tissue caused by the disruption of
blood flow to the brain. It is characterized by focal neurological deficits specific to the area of the
brain involved that do not fully resolve. The patient does not return to baseline functional level.
Source: William, L. (2007). Medical Surgical Nursing. (3rd edition). F.A Davis Company
Philadelphia.
Cerebrovascular accident: The sudden death of some brain cells due to lack of oxygen
when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain. A
CVA is also referred to as a stroke.
Source: http://www.medterms.com/script/main/art.asp?articlekey=2676
NERVOUS SYSTEM
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The nervous system is the master controlling and
communicating system of the body. Every thought,
action, and emotion reflects its activity. Its signaling
device, or means of communicating with body cells, is
electrical impulses, which are rapid and specific an
cause almost immediate responses.
To carry out its normal role, the nervous system
has three overlapping functions.
1.) It uses its millions of sensory receptors to
monitor changes occurring both inside and
outside the body. These changes are called
stimuli, and the gathered information is called
sensory input.
2.) Its process and interprets the sensory input and
makes decisions about what should be done at
each moment a process called integration.
3.) It then effects a response by activating muscles
or glands via motor output.
Structural classificationThe structural classification, which includes all nervous system organs, has two
subdivisions- the central nervous system and the peripheral nervous system.
The central nervous system is consist of the brain and the spinal cord, which occupy the
dorsal body cavity and acts as the integrating and command centers of the nervous system.
They interpret incoming sensory information and issue instructions based on past experience
and current condition.
The peripheral nervous system, the part if the nervous system outside the CNS, consist
mainly if the nerves that extend from the brain and spinal cord. Spinal nerves carry impulses
toad n from the spinal cord. Cranial nerves carry impulses to and from the brain. They link all
parts of the body by carrying impulses form the sensory receptors to the CNS and form the CNS
to the appropriate glands or muscles.
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Functional classificationThe functional classification scheme is concerned only with PNS structures. It divides
them into two principal subdivisions, the sensory or the afferent division and the motor or
efferent division.
The sensory or the afferent division consists of nerve fibers that convey impulses to the
central nervous system form the sensory receptors located in various parts of the body. Sensory
fibers delivering impulses from the skin, skeletal muscles, and joints are called somatic sensory
fibers; whereas those transmitting impulses form the visceral organs are called visceral sensory
fibers or visceral afferents. The sensory divisor keeps the CNS constantly informed of events
going both inside and outside the body.
The motor or efferent division carries impulses from the CNS to effector organs, the
muscles and glands. These impulses activate muscles and glands; that is, they effect a motor
response the motor division has two subdivision, the somatic nervous system and the
autonomic nervous system. The somatic nervous system allows us to consciously, or
voluntarily, control our skeletal muscles. Hence, this subdivision is often referred to as the
voluntary nervous system. However, not all skeletal muscle activity controlled by this motor
division is voluntary. Skeletal muscle reflexes, like the stretch reflex for example are initiated
involuntarily by theses same fibers. The other subdivision, autonomic nervous system regulates
events that are automatic, or involuntary, such as the activity or smooth and cardiac muscles
and glands. This subdivision commonly called the involuntary nervous system, itself has two
parts, the sympathetic and parasympathetic, which typically bring about opposite effects.
Nervous Tissue: Structure and FunctionThe nervous tissue is made up of two principal types of cells, the supporting cells and
the neurons.
Supporting cellsSupporting cells in the CNS are “lumped together” as
neuroglia, literally, “nerve glue”. Neuroglia includes many
types of cells that generally support, insulate and protect the
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delicate neurons. Each different types of neuroglia is simply called glia or glial cells, has special
functions. The CNS glia includes:
a.) Astrocytes: abundant star-shaped cells that account
for nearly half of the neural tissue. Astrocytes form a
living barrier between capillaries and neurons and play
a role in making exchanges between the two. In this
way, they help protect the neurons from harmful
substances that might be in the blood. It also help
control the chemical environment in the brain by
picking up excess ions and recapturing released
neurotransmitters.
b.) Microglia: spiderlike phagocytes that dispose of
debris, including dead brain cells and bacteria.
c.) Ependymal cells: these glial cells line the cavities of
the brain and the spinal cord.
d.) Oligodendrocytes: glia that wrap their flat extension
tightly around the nerve fibers, producing fatty
insulating coverings called myelin sheaths.
Glias are not able to transmit nerve impulses, a function that is highly developed in neurons.
Another important difference is that glia never lose their ability to divide, whereas most neurons
do. Consequently most brain tumors are gliomas, or tumors formed by glial cells. Supporting
cells in the PNS come into two major varieties- Schwann cells and satellite cells. Schwann cells
forms the myelin sheaths around nerve fibers that are found in the PNS. Satellite cells acts as
protective, cushioning cells.
Neurons
Neurons, also called nerve
cells, are highly specialized to
transmit messages from one part of
the body to another. They all have a
cell body, which contains the nucleus
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and is the m metabolic center of the cell, and one or more slender processes extending from the
cell body.
The cell body is the metabolic center of the neuron. It contains the usual organelles
except for cenrtioles. The rough ER called Nissl substance, and neurofibrils, intermediate
filaments that are important in maintaining cell shape, are particularly abundant in the cell body.
The longest arm like processes or fibers is located at the lumbar region of the spine to
the great toe. Neuron processes that convey incoming messages toward the cell body are
dendrites whereas those that generate nerve impulse and typically conduct them away from the
cell body are exons. Neurons may have hundreds of the branching dendrites, depending on the
neuron type, but each neuron has only one axon which arises from a conelike region of the cell
body called the axon hillock.
An occasional axon gives off a collateral branch along its length, but all axons branch
profusely at their terminal end, forming hundreds to thousands of axon terminals. These
terminals contain hundreds of tiny vesicles, or membranous sac, that contain chemicals called
neurotransmitters. Each axon terminal is separated from the next neuron by a tiny gap called
the synaptic cleft. Such a junction is called synapse.
Most long nerve fibers are covered with a whitish, fatty material, called myelin which has
a waxy appearance. Myelin protects and insulates the fibers and increases the transmission
rate of nerve impulses. Axons outside the CNS are myelinated by Schwann cells, specialized
supporting cells that wrap themselves tightly around the axon jelly-roll fashion. When the
wrapping process is done, a tight coil is wrapped membranes, the myelin sheath encloses the
axon. Most of the Schwann cells cytoplasm ends up just beneath the outermost of its plasma
membrane. This part is called neurilemma. Since the myelin sheath is formed by many
individual Schwann cells, it has gaps or indentations, called nodes of Ranvier.
For the most part, cell bodies are found in the CNS in clusters called nuclei. This well-
protected location within the bony skull or vertebral column is essential to the well- being of the
nervous system. The cell body carries out most of the metabolic functions of a neuron, so if it si
damaged the cell dies and is not replaced. Small collections of cell bodies called ganglia are
found in a few fibers running through the CNS are called tracts, whereas in the PNS they are
called nerves. The term white matter and gray matter refer respectively to myelinated wersus
unmyelinated regions of the CNS. The white matter consists of dense collections of mylinated
fibers and gray matter consist mostly unmyelinated fibers and cell bodies.
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ClassificationFunctional classification groups neurons according to the direction the nerve impulse
is traveling relative to the CNS. Neurons carrying impulses from sensory receptors to the CNS
are sensory or afferent neurons. The cell bodies of sensory neurons are always found in a
ganglion outside the CNS. Sensory neurons keep us informed about what is happening both
inside and outside the body.
Neurons carrying impulses from the CNS to the viscera and or muscles and glands are
motor or efferent neurons. The third category of neurons is the association neurons, or
interneurons. They connect the motor and sensory neurons in the neural pathways.
Structural classification is based on the number of processes extending from the cell
body. Neurons with two processes-an axon and a dendrite-are called bipolar neurons. Unipolar
neurons have a single process emerging from the cell body.
The spinal cordThe spinal cord is a
long, thin, tubular bundle
of nervous
tissue and support cells that
extends from
the brain (the medulla
oblongata specifically). The
brain and spinal cord
together make up the central
nervous system. The spinal
cord begins at the Occipital
bone and extends down to
the space between the first
and second lumbar
vertebrae; it does not extend
the entire length of
the vertebral column. It is
around 45 cm (18 in) in men and around 43 cm (17 in) long in women. Also, the spinal cord has
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a varying width, ranging from 1/2 inch thick in the cervical and lumbar regions to 1/4 inch thick in
the thoracic area. The enclosing bony vertebral column protects the relatively shorter spinal
cord. The spinal cord functions primarily in the transmission of neural signals between
the brain and the rest of the body but also contains neural circuits that can independently control
numerous reflexes and central pattern generators. The spinal cord has three major functions: a.)
Serve as a conduit for motor information, which travels down the spinal cord. b.) Serve as a
conduit for sensory information, which travels up the spinal cord. c.) Serve as a center for
coordinating certain reflexes.
Nerves called the spinal nerves or nerve roots come off the spinal cord and pass out
through a hole in each of the vertebrae called the Foramen to carry the information from the
spinal cord to the rest of the body, and from the body back up to the brain. There are four main
groups of spinal nerves which exit different levels of the spinal cord. These are in descending
order down the vertebral column:
Cervical Nerves "C" : (nerves in the neck) supply movement and feeling to the arms,
neck and upper trunk.
Thoracic Nerves "T" : (nerves in the upper back) supply the trunk and abdomen.
Lumbar Nerves "L" and Sacral Nerves "S" : (nerves in the lower back) supply the
legs, the bladder, bowel and sexual organs.
The spinal nerves carry information to and from different levels (segments) in the spinal
cord. Both the nerves and the segments in the spinal cord are numbered in a similar way to the
vertebrae. The point at which the spinal cord ends is called the conus medullaris, and is the
terminal end of the spinal cord. It occurs near lumbar nerves L1 and L2. After the spinal cord
terminates, the spinal nerves continue as a bundle of nerves called the cauda equina. The
upper end of the conus medullaris is usually not well defined.
There are 31 pairs of spinal nerves which branch off from the spinal cord. In the cervical
region of the spinal cord, the spinal nerves exit above the vertebrae. A change occurs with the
C7 vertebra however, where the C8 spinal nerve exits the vertebra below the C7 vertebra.
Therefore, there is an 8th cervical spinal nerve even though there is no 8th cervical vertebra.
From the 1st thoracic vertebra downwards, all spinal nerves exit below their equivalent
numbered vertebrae.
The spinal nerves which leave the spinal cord are numbered according to the vertebra at
which they exit the spinal column. So, the spinal nerve T4, exits the spinal column through the
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foramen in the 4th thoracic vertebra. The spinal nerve L5 leaves the spinal cord from the conus
medullaris, and travels along the cauda equina until it exits the 5th lumbar vertebra.
The level of the spinal cord segments do not relate exactly to the level of the vertebral
bodies i.e. damage to the bone at a particular level e.g. L5 vertebrae does not necessarily mean
damage to the spinal cord at the same spinal nerve level.
Brain
Cerebral HemispheresThe paired cerebral hemisphere,
collectively called the cerebrum, are the most
superior part of the brain and together are a
good deal larger than the other three brain
regions combined. The entire surfac e of the
cerebral hemispheres exhibits elevated ridges
of tissue called gyri, separated by shallow
grooves called sulci. Less numerous are the deeper grooves called fissures, which separate
large regions of the brain. The cerebral hemispheres are separated by a single deep fissure, the
longitudinal fissure. Other fissures are sulci divided each cerebral hemisphere into a number of
lobes, named for the cranial bones that lie over them. Speech, memory, logical and emotional
response, as well as consciousness, interpretation of sensation, and voluntary movement, are
all functions of neurons of the cerebral cortex, and many of the functional areas of the cerebral
hemispheres have been identified. The somatic sensory area is located in the parietal lobe
posterior to the central sulcus. The somatic sensory area allows you to recognize pain,
coldness, or a light touch. The visual area is located in the posterior part of the occipital lobe,
while the auditory area is in the temporal lobe bordering the lateral sulcus, and the olfactory
area is found deep inside the temporal lobe.
The primary motor area that allows us to consciously move our skeletal muscles is
anterior to the central sulcus in the frontal lobe. The axons of these motor neurons form the
major voluntary motor tract- the corticospinal or pyramidal tract, which descends to the cord.
Most of the neurons in this primary motor area control body areas having the finest motor
control; that is the face, mouth, and hands. The body map on the motor cortex is called the
motor homunculus.
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A specialized area that is very involved in our ability to speak is the Broca’s area, is
found at the base of the precentral gryus. Damage to this area which is located in only one
cerebral hemisphere causes inability to say words properly. Areas involved in higher intellectual
reasoning and socially acceptable behavior are believed to be in the anterior part of the lobes.
Complex memories appear to be stored in the temporal and frontal lobes. The speech area is
locate at the junction of the temporal, parietal, and occipital lobes. The cell bodies of neurons
involved in the cerebral hemisphere functions named above are found only in the outermost
gray matter of the cerebrum, the cerebral cortex. Most of the remaining cerebral hemisphere
tissue the deeper cerebral white matter is composed of fiber tracts carrying impulses to or from
the cortex. One very large fiber tract, the corpus callosum, connects the cerebral hemispheres.
DiencephalonThe diencephalon or the interbrain, sits atop
the brain stem and is enclosed by the cerebral
hemisphere. The major structures of the
diencephalon are the thalamus, hypothalamus, and
epithalamus.
The thalamus which encloses the shallow
third ventricle of the brain. The hypothalamus
makes up the floor of the diencephalon. It is an important autonomic nervous system center
because it plays a role in the regulation of body temperature, water balance, and metabolism.
The hypothalamus is also the center for many drives and emotions, and as such it is an
important part of the so-called limbic system. The pituitary gland hangs from the anterior of the
hypothalamus by a slender stalk. The mammillary bodies reflex centers involved in olfaction
bulge from the floor of the hypothalamus posterior to the pituitary gland. The epithalamus forms
the roof of the third ventricle. The important parts of the epithalamus are the pineal body and the
choroid plexus.
Brain stem The brain stem is about the size of thumb in diameter and approximately 3 inches long.
Its structures are the midbrain, pons, and medulla oblongata.
The midbrain is relatively small part of the brain stem. It extends from the mammillary
bodies to the pons inferiorly. The cerebral aquaduct is tiny canal that travels through the
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midbrain and connects the third ventricle of the diencephalon of the fourth ventricle below. The
pons is the rounded structure that protrudes just below the midbrain. The medulla oblongata is
the most inferior part of the stem. It contains centers that control heart rate, blood pressure,
breathing, swallowing, and vomiting. Extending the entire length of the brain stem is a diffuse
mass of gray matter, the reticular formation. The neurons of the reticular formation are involved
in motor control of the visceral organs. Reticular activating system plays a role in consciousness
and the awake/sleep
CerebellumThe cerebellum projects dorsally from
under the occipital lobe of the cerebrum. The
cerebellum also has an outer cortex made up of
gray matter and an inner region white matter.
The cerebellum provides the precise timing for
skeletal muscle activity and controls our balance
and equilibrium.
MeningesThe three connective tissue membranes covering and protecting the CNS structures are
meninges. The outermost layer, the leathery dura mater, meaning “tough or hard mother”, is a
double- layered membrane where it surrounds the brain. The other called the meningeal layer,
forms the outermost covering of the brain and continues as the dura mater of the spinal cord.
The middle meningeal layer is the weblike arachnoid mater. It’s a threadlike extensions span the
subarachnoid space to attach it to the innermost membrane, the pia mater. The subarachnoid
space is filled with cerebrospinal fluid. Specialized projections of the arachnoid villi protrude
through the dura mater.
Cerebrospinal fluidCerebrospinal fluid is a watery similar in its makeup to blood plasma, from which it
forms. However, it contains less protein, more vitamin C, and its ion composition is different.
CSF is continually formed from blood by the choroid plexuses. The CSF in and around the brain
and cord forms a watery cushion that protects the fragile nervous tissue from blows and other
trauma. Inside the brain, CSF is continually moving. It circulates for the two lateral ventricles (in
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the cerebral hemisphere) into the third ventricle ( in the diencephalon), and then through the
cerebral aqueduct of the midbrain into the fourth ventricle dorsal to the pons and medulla
oblongata. The fluid returns to the blood in the dural sinuses through the arachnoid villi.
Cranial nerves
The 12 pairs of cranial nerves primarily serve the head and neck. Most cranial nerves are mixed
nerves; however, three pairs the optic, olfactory and vestibulocochlear nerves are purely sensory in
function.
# Name Nuclei Function
0
Cranial nerve
zero(CN0 is not
traditionally
recognized.)[1]
olfactory trigone, medial
olfactory gyrus,
and lamina terminalis
New research indicates CN0 may play a
role in the detection of pheromones [2]
[3] Linked to olfactory system in human
embryos[4]
I Olfactory nerve Anterior olfactory nucleus
Transmits the sense of smell; Located
in olfactory foramina in theCribriform
plate of ethmoid
II Optic Nerve Ganglion cells of retina [5] Transmits visual information to the brain;
Located in optic canal
III Oculomotor nerve
Oculomotor
nucleus,Edinger-
Westphal nucleus
Innervates levator palpebrae
superioris, superior rectus, medial
rectus, inferior rectus, and inferior
oblique, which collectively perform most
eye movements; Also innervates m.
sphincter pupillae. Located in superior
orbital fissure
IV Trochlear nerve Trochlear nucleus
Innervates the superior oblique muscle,
which depresses, rotates laterally
(around the optic axis), and intorts the
eyeball; Located insuperior orbital
fissure
V Trigeminal nerve Principal sensory Receives sensation from the face and
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trigeminal nucleus, Spinal
trigeminal
nucleus,Mesencephalic
trigeminal
nucleus,Trigeminal motor
nucleus
innervates the muscles of mastication;
Located in superior orbital
fissure (ophthalmic nerve - V1), foramen
rotundum (maxillary nerve - V2),
and foramen ovale(mandibular nerve -
V3)
VI Abducens nerve Abducens nucleus
Innervates the lateral rectus, which
abducts the eye; Located insuperior
orbital fissure
VII Facial nerve
Facial nucleus,Solitary
nucleus,Superior salivary
nucleus
Provides motor innervation to
the muscles of facial expression,
posterior belly of the digastric muscle,
and stapedius muscle, receives the
special sense of taste from the anterior
2/3 of the tongue, and
provides secretomotor innervation to
the salivary glands (except parotid) and
the lacrimal gland; Located and runs
through internal acoustic canal to facial
canal and exits atstylomastoid foramen
VIII
Vestibulocochlear
nerve (or auditory-
vestibular
nerveor statoacoustic
nerve)
Vestibular
nuclei,Cochlear nuclei
Senses sound, rotation and gravity
(essential for balance & movement).
More specifically. the vestibular branch
carries impulses for equilibrium and the
cochlear branch carries impulses for
hearing.; Located in internal acoustic
canal
IX Glossopharyngeal
nerve
Nucleus
ambiguus,Inferior salivary
nucleus,Solitary nucleus
Receives taste from the posterior 1/3 of
the tongue, provides secretomotor
innervation to the parotid gland, and
provides motor innervation to
the stylopharyngeus. Some sensation is
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also relayed to the brain from the
palatine tonsils. Sensation is relayed to
opposite thalamus and some
hypothalamic nuclei. Located injugular
foramen
X Vagus nerve
Nucleus ambiguus,Dorsal
motor vagal
nucleus,Solitary nucleus
Supplies branchiomotor innervation to
most laryngeal and all pharyngeal
muscles (except the stylopharyngeus,
which is innervated by the
glossopharyngeal);
provides parasympatheticfibers to nearly
all thoracic and abdominal viscera down
to thesplenic flexure; and receives the
special sense of taste from the epiglottis.
A major function: controls muscles for
voice and resonance and the soft palate.
Symptoms of
damage: dysphagia(swallowing
problems), velopharyngeal insufficiency.
Located injugular foramen
XI
Accessory
nerve(or cranial
accessory
nerveor spinal
accessory nerve)
Nucleus ambiguus,Spinal
accessory nucleus
Controls sternocleidomastoid and
trapezius muscles, overlaps with
functions of the vagus. Examples of
symptoms of damage: inability to shrug,
weak head movement; Located
in jugular foramen
XII Hypoglossal nerve Hypoglossal nucleus Provides motor innervation to the
muscles of the tongue (except for
the palatoglossus, which is innervated by
the vagus) and other glossal muscles.
Important for swallowing (bolus
formation) and speech articulation.
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Located in hypoglossal canal
The Circle of Willis
Four major arteries
and their branches supply
the brain with blood. The
four arteries are composed
of two internal carotid
arteries (left and right) and
two vertebral arteries that
ultimately join on the
underside (inferior surface)
of the brain to form the
arterial circle of Willis, or
the circulus arteriosus.
The vertebral
arteries actually join to form
a basilar artery. It is this
basilar artery that joins with
the two internal carotid
arteries and their branches
to form the circle of Willis.
Each vertebral artery arises
from the first part of the subclavian artery and initially passes into the skull via holes (foramina)
in the upper cervical vertebrae and the foramen magnum. Branches of the vertebral artery
include the anterior and posterior spinal arteries, the meningeal branches, the posterior inferior
cerebellar artery, and the medullary arteries that supply the medulla oblongata.
The basilar artery branches into the anterior inferior cerebellar artery, the superior cerebellar
artery, the posterior cerebral artery, the potine arteries (that enter the pons), and the labyrinthine
artery that supplies the internal ear.
The internal carotids arise from the common carotid arteries and pass into the skull via
the carotid canal in the temporal bone. The internal carotid artery divides into the middle and
anterior cerebral arteries. Ultimate branches of the internal carotid arteries include the
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ophthalmic artery that supplies the optic nerve and other structures associated with the eye and
ethmoid and frontal sinuses. The internal carotid artery gives rise to a posterior communicating
artery just before its final splitting or bifurcation. The posterior communicating artery joins the
posterior cerebral artery to form part of the circle of Willis. Just before it divides (bifurcates), the
internal carotid artery also gives rise to the choroidal artery (also supplies the eye, optic nerve,
and surrounding structures). The internal carotid artery bifurcates into a smaller anterior
cerebral artery and a larger middle cerebral artery.
The anterior cerebral artery joins the other anterior cerebral artery from the opposite side
to form the anterior communicating artery. The cortical branches supply blood to the cerebral
cortex.
Cortical branches of the middle cerebral artery and the posterior cervical artery supply
blood to their respective hemispheres of the brain.
The circle of Willis is composed of the right and left internal carotid arteries joined by the
anterior communicating artery. The basilar artery (formed by the fusion of the vertebral arteries)
divides into left and right posterior cerebral arteries that are connected (anastomsed) to the
corresponding left or right internal carotid artery via the respective left or right posterior
communicating artery. A number of arteries that supply the brain originates at the circle of Willis,
including the anterior cerebral arteries that originate from the anterior communicating artery.
In the embryo, the components of the circle of Willis develop from the embryonic dorsal aortae
and the embryonic intersegmental arteries.
The circle of Willis provides multiple paths for oxygenated blood to supply the brain if
any of the principal suppliers of oxygenated blood (i.e., the vertebral and internal carotid
arteries) are constricted by physical pressure, occluded by disease, or interrupted by injury. This
redundancy of blood supply is generally termed collateral circulation.
Arteries supply blood to specific areas of the brain. However, more than one arterial branch may
support a region. For example, the cerebellum is supplied by the anterior inferior cerebellar
artery, the superior cerebellar artery, and the posterior inferior cerebellar arteries.
Venous return of deoxygenated blood from the brainVeins of the cerebral circulatory system are valve-less and have very thin walls. The
veins pass through the subarachnoid space, through the arachnoid matter, the dura, and
ultimately pool to form the cranial venous sinus.
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There are external cerebral veins and internal cerebral veins. As with arteries, specific areas of
the brain are drained by specific veins. For example, the cerebellum is drained of deoxygenated
blood by veins that ultimately form the great cerebral vein.
External cerebral veins include veins from the lateral surface of the cerebral hemispheres that
join to form the superficial middle cerebral vein.
Vascular SystemComposition and Functions of blood
Among all of the body’s tissues, blood is unique. It
is the only fluid tissue. Essentially, blood is a complex
connective tissue in which living blood cells, the formed
elements, are suspended in a nonliving fluid matrix called
plasma.
Plasma
Plasma, which is approximately 90 percent water, is the liquid part of the blood. Plasma
proteins are the most abundant solutes in plasma. Except for the antibodies and protein-based
hormones, most plasma proteins are made by the liver.
Erythrocytes
Erythrocytes, or red blood cells, function primarily
to ferry oxygen in blood to all cells of the body. RBCs
differ from other blood cells because they are anucleate;
that is they lack a nucleus. Hemoglobin an iron-bearing
protein, transports the bulk of the oxygen that is carried in
the blood. Moreover, because erythrocytes lack
mitochondria and make ATP by anaerobic mechanisms,
they do not use up of the oxygen they are transporting, making them very efficient oxygen
transport.
Erythrocytes are small cells shaped like biconcave disc that provide a large surface area
relative to their volume, making them ideally suited for gas exchange. RBCs outnumber white
blood cells and the major factor contributing to blood viscosity. As the number of RBCs
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increases, blood viscosity increases. The more hemoglobin molecules the RBCs contain, the
more oxygen they will be able to carry.
LeukocytesLeukocytes are crucial to body
defense against disease. White blood
cells are the only complete cells in the
blood which means they have nuclei and
the usual organelles. Leukocytes form a
protective, movable army that helps
defend the body against damage by
bacteria, viruses, parasites and tumor
cells. WBCs can locate areas of tissue damage and infection in the body by responding to
certain chemicals that diffuse from the damaged cells. WBCs are classified into two major grou
ps, granulocytes and agranulocytes.
Granulocytes includes the:
1. Neutrophis which have a multilobed nucleus and very fine granules that respond
to both acid and basic stains.
2. Eosinophils have blue-red nucleus that resembles an old-fashioned telephone
receiver and sport large brick-red cytoplasmic granules. Their number increases
rapidly during allergies and infections by parasitic worms.
3. Basophils the rarest of the WBCs, contain large histamine-containing granules
that stain dark blue.
Agranulocytes lack visible cytoplasmic granules. The agranulocytes include the
lymphocytes and monocytes.
1. Lymphocytes havea large dark purple nucleus that occupies most of the cell
volume.
2. Monocytes are the largest of the WBCs. When they migrate into the tissues, they
change into marcophages with huge appetites.
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Platelets Platelets are not cells in the strict sense.
They are fragments of bizarre multinucleate cells
called megakaryocytes. Platelets are needed for
the clotting process that occurs in plasma when
blood vessels are ruptured or broken.
HematopoiesisNormally a blood flows smoothly past the
intact lining of blood vessel walls. But if a blood vessel wall breaks, a series of reactions is set in
motion to accomplish hemostasis or stoppage of blood flow. Hemostasis involves three major
phases which are the platelet plug formation, vascular spasms, and coagulation or blood
clotting.
CARDIOVASCULAR SYSTEM The Heart
The heart rests on the
diaphragm, near the midline of the
thoracic cavity. It lies in the
mediastinum, as mass of tissue that
extends from the sternum to the
vertebral column between the lungs.
You can visualize the heart as a
cone lying on its side. The pointed
apex is directed anteriorly, inferiorly,
and to the left. The broad base is
directed posteriorly, superiorly, and to the right. The membrane that surrounds and protects the
heart is the pericardium. It confines the heart to its position in the mediastinum, while allowing
sufficient freedom to movement for vigorous and rapid contraction.
The heart has 3 layers namely the epicardium, myocardium, and endocardium.
Epicardium is the thin, transparent outer layer of the heart wall. The middle myocardium, which
is cardiac muscle tissue, makes up the bulk of the heart and is responsible for is pumping action
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and is an involuntary muscle. The innermost endocardium is at thin layer of endothelium
overlying a thin layer of a connective tissue.
The heart has four chambers. The two chambers are the atria and the two inferior
chambers are the ventricle. On the anterior surface of each atrium is a wrinkled pouchlike
structure called an auricle. The right atrium receives blood from three veins: the superior vena
cava, inferior vena cava, and coronary sinus. Between the right and the left atrium is a thin
partition called the interatrial septum. Blood passes from the right atrium into the right ventricle
through a valve that is called the tricuspid valve. The right ventricle forms most of the anterior
surface of the heart. The right ventricle is separated from the left ventricle by a partition called
the interventricular septum. Blood passes from the right ventricle through the pulmonary valve
into a large artery called the pulmonary trunk, which divides into right and left pulmonary
arteries. The left atrium forms most of the base of the heart. It receives blood from the lungs
through four pulmonary veins. Blood passes from the left atrium into the left ventricle through
the bicuspid valve. The left ventricle forms the apex of the heart. Blood passes from the left
ventricle through the aortic valve into the ascending aorta. Some of the blood in the aorta flows
into the aorta and carry blood to the heart.
Vascular System
Arteries The wall of artery has three coast or tunics:
tunica interna, tunica media, and tuncia externa,
contains a lining of simple squamous epithelium called
endothelium, a basement membrane, and layer of
elastic tissue called the internal elastic lamina. The
endothelium is a continuous layer of calls that line the
inner surface of the entire cardiovascular system. The
tunica interna is closest to the lumen, the hollow center through which blood flows. The middle
coat, or tunica media, is usually the thickest layer. Due to the plentiful elastic fibers, arteries
normally have high compliance, which means that their walls stretch easily or expand without
tearing in response to a small increase in pressure. The outer coat which is the tunica externa is
composed mainly of elastic and collagen fibers.
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Arterioles (resistance vessels)An arteriole is a very small
artery, ranging in diameter from 10
to 100 micrometer that delivers
blood to capillaries. It has tunica
interna composed of smooth
muscle and very few elastic fibers,
and tunica externa composed
mostly of elastic and collagen fiber.
Arterioles play a key role in regulating blood flow from arteries into capillaries by regulating
resistance, the opposition to blood flow.
Capillaries (exchange vessels) Capillaries are microscopic vessels that connect arterioles to venules, they range in
diameter from 4 to 10 micrometer. The flow of blood from arterioles to venules through
capillaries is called the microcirculation. Body tissues with high metabolic requirements such as
muscles, the liver the kidney and the nervous system use more oxygen and nutrients and thus
have extensive capillary network. Tissues with lower metabolic requirements such as tendons
and ligaments contain fewer capillaries.
VenulesWhen several capillaries unite, they form small veins called venules. Venules range in
diameter from 10 to 100 micrometer, collect blood from capillaries and deliver it to veins.
VeinsThe diameter of veins ranges from 0.1mm to greater than 1mm. The tunica interna of
veins is thinner than that of arteries; the tunica media of veins is much thinner than the arteries
with relatively little smooth muscle and elastic fibers, the tunica externa of veins is the thickest
layer and consists of collagen and elastic fibers. They are distensible enough to adapt to
variations in the volume and pressure of blood passing through them, but they are designed to
withstand high pressure.
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PREDISPOSING FACTORS
Factors Present Rationale
Age Although stroke often is considered a disease of
elderly persons, one third of strokes occur in
persons younger than 65 years.
Race Race is an important risk factor. African-
Americans, Native Americans, and Alaskan
Natives are at greater risk compared to
people of other ethnicities, in part because the
African-American population has a greater
incidence of high blood pressure.
Sex Gender plays a role, too, with men being
more likely to have a stroke. However, more
stroke deaths occur in women.
Family History If someone in your family has high history of
stroke, you are more likely to have stroke.
Prior Stroke (Transient Ischemic
Attack)
A transient ischemic attack (TIA) is like a
stroke, producing similar symptoms, but
usually lasting only a few minutes and
causing no permanent damage. Often called
a ministroke, a transient ischemic attack may
be a warning. About one in three people who
have a transient ischemic attack eventually
has a stroke, with about half occurring within
a year after the transient ischemic attack.
PRECIPITATING FACTOR
Factors Present Rationale
BLOOD DISORDERS
38| P a g e
Hypertension High blood pressure is the number one
risk factor for strokes. One cause of
hypertension is a clogged blood vessel
or artery. These clogs can happen from
plaque build up along the blood vessel
walls. If a vessel is completely blocked,
then the owning organ may start to die
off. The brain is no exception. If a blood
vessel ruptures, that can directly affect
the organ that it's in by cutting off the
oxygen supply completely. Therefore,
hypertension could effectively cause a
stroke.
High Cholesterol Levels
Cholesterol is a waxy substance that
circulates, but does not dissolve, in the
blood. If a person has too much low-
density lipoprotein (LDL), also known
as bad cholesterol, it can slowly build
up in the wall of the arteries. Eventually
this buildup forms a thick, hard plaque
that narrows the arteries. If one of
these plaques ruptures, it causes a blot
clot to form, which can block normal
blood flow to the brain and lead to a
stroke.
Sickle cell disease Stroke is a devastating and potentially fatal
complication to sickle cell disease. Strokes
are difficult to explain on the basis of the
central pathological process in sickle cell
disease, namely the occlusion of small
vessels by deformed sickled cells.
Polycythemia As a result of a high concentration of red
blood cells, there would be increased risks of
39| P a g e
clotting or formation of thrombus thus
increasing the risk for stroke.
OTHER DISEASES
Diabetes Mellitus Diabetes affects 1 in 20 older people
and can increase the risk of having a
stroke. Many people with diabetes also
have high blood pressure, high blood
cholesterol and are overweight. Good
control of diabetes is important and
requires attention to diet, regular urine
tests or blood tests and probably some
medication.
LIFESTYLE
Excessive use of alcohol
Alcohol in excess (more than 2 drinks a day)
can contribute to hypertension that we all
know contributes directly to stroke. Alcohol
can cause certain heart problems that also
contribute to stroke (atrial fibrillation,
cardiomyopathy for example) There is also
evidence that alcohol can inhibit coagulation
and this might explain why alcohol tends to
directly relate to hemorrhagic stroke
(intracerebral hemorrhage, for example).
Cigarette smoking Cigarettes damage the body--gradually and
insidiously--in a number of different ways.
Cigarette smoking is the leading cause of
preventable death in the United States. It
accounts for almost 500,000 deaths per year,
or one in every five deaths. Cigarette
smoking contributes to a remarkable number
of diseases, including coronary heart
40| P a g e
disease, stroke, chronic obstructive
pulmonary disease, peripheral vascular
disease, peptic ulcer disease, and many
types of cancer.
Cocaine and illicit drug use
Years of research now show that drugs are
significant risk factors for stroke. Some drugs
can cause stroke by directly affecting blood
vessels in the brain while others do it
indirectly by affecting other organs in the
body such as the heart or the liver.
Sedentary lifestyle Lack of physical mobility is an
independent risk factor for both stroke
and heart disease.
DIET
Poor diet A poor diet may increase the risk for stroke in
a few significant ways. Eating too much fat
and cholesterol can lead to arteries that are
narrowed by plaque. Too much salt may
contribute to high blood pressure. And too
many calories can lead to obesity. A diet high
in fruits, vegetables, whole grains, and fish
may help lower stroke risk.
Obesity A person with obesity has an abnormal
amount of fatty tissue in the body so does
increases her chance of suffering from a
stroke,
Dehydration Poor oral intake of fluids can lead to
increased blood viscosity, flow stagnation and
decreased brain perfusion.
HEART DISEASES
Atrial fibrillation Atrial fibrillation causes cardioembolic strokes
41| P a g e
-- those caused by a clot that escapes from
the heart and blocks a blood vessel in the
brain. Blood clots are known to form
whenever blood remains static for prolonged
periods of time, or as a result of turbulent
blood flow, both of which are likely to occur
during the erratic and disorganized heart beat
of atrial fibrillation.
Carotid or Artery Disease
Carotid artery disease occurs when the
major arteries in your neck become
narrowed or blocked. These arteries,
called the carotid arteries, supply your
brain with blood. Your carotid arteries
extend from your aorta in your chest to
the brain inside your skull. Carotid
artery disease is a serious health
problem because it can cause a stroke.
Other heart disease People with coronary heart disease or heart
failure have a higher risk of stroke than those
with hearts that work normally. Dilated
cardiomyopathy (an enlarged heart), heart
valve disease and some types of congenital
heart defects also raise the risk of stroke
SYMPTOMATOLOGYSymptoms Present Rationale
COMMUNICATION and COGNITIVE SYMPTOMSBroca’s Aphasia Aphasia is a disorder that results from
damage to portions of the brain that are
responsible for language. For most people,
these are areas on the left side
(hemisphere) of the brain. Aphasia usually
42| P a g e
occurs suddenly, often as the result of a
stroke or head injury, but it may also
develop slowly, as in the case of a brain
tumor, an infection, or dementia.
Wernicke’s Aphasia Damage to the temporal lobe (the side
portion) of the brain may result in a fluent
aphasia called Wernicke’s aphasia. In most
people, the damage occurs in the left
temporal lobe, although it can result from
damage to the right lobe as well. People
with Wernicke’s aphasia may speak in long
sentences that have no meaning, add
unnecessary words, and even create made-
up words. As a result, it is often difficult to
follow what the person is trying to say.
People with Wernicke’s aphasia usually
have great difficulty understanding speech,
and they are often unaware of their
mistakes.
Agraphia The loss of writing ability that results from
damage to language areas of the brain.
Often, agraphia is the result of a stroke. The
loss of writing ability after stroke is often
incomplete, as many stroke survivors with
agraphia can rapidly re-learn to write some
words or sentences.
Alexia Hemianopic Alexia (HA) is a condition that
damages one half of a patient’s vision
(ahemianopia), and is usually caused by a stroke.
Alexia is an acquired disturbance in reading.
Alexias that occur after left hemisphere damage
typically result from linguistic deficits and may
occur as isolated symptoms or as part of an
43| P a g e
aphasia syndrome.
Dyslexia Dyslexia is a name for a condition where
people have difficulty with reading and
writing. People with dyslexia have normal
intelligence and are not in any way mentally
retarded or intellectually challenged. The
difficulty with certain tasks is believed to be
related to problems with perception
capability in certain parts of the brain.
According to Margaret Greenwald, PhD, assistant
professor of audiology and speech-language
pathology, stroke patients are commonly
diagnosed with acquired dyslexia as a result of
brain injury, but they rarely receive treatment for
their reading deficits.
Dysarthia Dysarthria is a motor speech disorder. The
muscles of the mouth, face, and respiratory
system may become weak, move slowly, or
not move at all after a stroke or other brain
injury. The type and severity of dysarthria
depend on which area of the nervous
system is affected. Some causes of
dysarthria include stroke, head injury,
cerebral palsy, and muscular dystrophy.
Both children and adults can have
dysarthria.
Short term memory loss
Loss of short term memory is common with
people who have had a stroke. Short term
memory is the type of memory that we use
for daily things, such as remembering why
we went to the kitchen, how to do a simple
44| P a g e
daily task or who you saw an hour ago.
PHYSICAL (SENSORY and MOTOR) SYMPTOMS
Hemiplegia Hemiplegia after stroke is common. It is the
term we use to describe paralysis of one
side of the body. The term can be broken
down into “hemi” which means “half,” and
“plegia,” which means paralysis.
The patient’s complaint was right sided
weakness.
Inability to turn eyes toward affected side
Due to the loss of control on the ocular
muscles.
Hemiattention (denial of paralyzed limb)
Due to impaired sensory and motor activities
in the affected area.
Dysphagia Due to the alterations of physiologic
functions.
Spasticity Spasticity involves an increase in the tone of
affected muscles and usually an element of
weakness. The flexor muscles usually more
strongly affected in the upper extremities and the
extensor muscles more strongly affected in the
lower extremities.
45| P a g e
46| P a g e
Precipitating Factor:
AgeSexFamily historyPrior Stroke (Transient Ischemic Attack)
Predisposing Factors:
HypertensionDiabetes Mellitus IICigarette smokingSedentary lifestylePoor diet
Atherosclerosis
Atheromatous Plaques
Emboli travel throughout the body to the narrow arteries and veins
(Thrombosis)
Occlusion in the narrow arteries and blood vessels in the brain
Sx: Hypertention
47| P a g e
If managed:
Dx: PET scan, MRI, CT scan, cerebral angiography, lumbar puncture, ECG, skull x-ray, carotid ultrasound
Tx: aspirin, thrombolytics, carotid stenting, anti coagulants, antihypertensives
If not managed:
Sx: sudden severe
headache, unconscious
ness, nausea,
vomiting, visual
disturbances
Rapture of the blood vessels in the brain
Increase intracranial pressure
Thrombus will travel into the vessels causing thickening and fragility
Cerebral hemorrhage
Sx: dizziness, confusion, headache
Cerebral ischemia
Cerebral Hypoperfusion / decreased oxygen supply
Impaired distribution of oxygen and glucose
Tissue hypoxia and cellular starvation
Formation of small and large clots
Lodges unto other arteries
Initiation of ischemic cascade
Tx:
BT
48| P a g e
Production of O2 free radicals and other reactive O2 species
Transient Ischemic Attack (TIA)
Sx: unilateral numbness, vision loss in one eye, aphasia, dysarthria Structural integrity loss of brain tissue and
blood vessel
Vascular congestion
Compression of tissue
Increased intracranial pressure
Impaired perfusion and function
Diagnostic exams:
* CT or MRI scans, angiogram. ECG, Carotid duplex (ultrasound), Blood clotting tests Blood chemistry, Complete blood count (CBC), C-reaction protein, ESR (Sedimentation rate) ,Serum lipids.
Treatment:
Surgery (carotid endarterectomy), aspirin, low-fat and low-salt dietIf managed:
Palliative careFrequent VS and NVS takingIntubationMechanical ventilationVasodilatorsOsmotic diureticsICP monitoring
If not managed:
49| P a g e
Continued insufficiency of blood flow
Further compression of tissues
Coma
Cerebral death
Dx: Blood tests, electrocardiogram and CT scan of the head
Sx: Unresponsiveness Absence of cerebral and brain stem function (Pupillary responses, corneal and gag reflex are absent)
Cessation of physiologic functions
Cardiovascular system
Pulmonary system
Loss of cardiac muscle functions
Relaxation of venous valves
50| P a g e
Sx:
Decrease cardiac output
Sx:
Hypotension
Failure of accessory muscle for breathing
Loss of lung movement
apnea
Cardiopulmonary arrest
Systemic failure
DEATH
NARRATIVE:Atherosclerosis is the strongest contributing factor to ischemic stroke. The term
atherogenesis refers to the development of the condition of atherosclerosis. The most
fundamental lesions of atherosclerosis is a fatty steak, located in the intimal layer of large
arteries. As years pass by the fatty steak becomes a fatty plaque. The patient is unaware of the
presence of plaque until the plaque starts to invade the diameter of the artery and interfere with
blood flow. The plaque disrupts the integrity of the arterial lining, there will be an increase
coagulation causing thrombus formation that will make the major vessel or artery occluded. In
some instances, embolus can also arise into cerebrovascular accident because of the different
factors that enables it to form; an embolus may form to some organs such as the heart, aorta
and carotid arteries. The embolus may break off causing it to move up and will flow upstream
going to the brain. Through the formed emboli, it can cause again occlusion resulting to cerebral
hypoperfusion or will tend to increase the effect of high blood pressure.
There will be impairment for the distribution of oxygen and glucose going to the brain
due to the cerebral hypoperfusion which will result to tissue hypoxia and cellular starvation. This
is because of the inadequate nutrients being supplied in to the brain’s cells and tissues.
Cerebral ischemia will happen wherein it is a series of biochemical reactions that take place in
the brain and other aerobic tissues after seconds to minutes of ischemia. On the other side, if
there will be an increase of blood pressure, the thrombus will lyse or move from the vessel
causing thickening and fragility, it will then initiate a rupture of the vessel wall as an outcome of
cerebral hemorrhage or also called hemorrhagic stroke. There will be formation of small and
large clots which then lodge unto other arteries causing cerebral ischemia.
Also after an ischemic cascade, there will be a production of oxygen free radicals and
other reactive oxygen as a consequence of both enzymatic and non-enzymatic reactions.
Through the production of these free radicals, endothelial lining of the blood vessel will be
damage. Both the endothelial damage and diminished energy intake will cause transient
ischemic attacks. A transient ischemic attack (TIA) is a transient stroke that lasts only a few
minutes. It occurs when the blood supply to part of the brain is briefly interrupted. TIA
symptoms, which usually occur suddenly, are similar to those of stroke but do not last as long.
Most symptoms of a TIA disappear within an hour, although they may persist for up to 24 hours.
Symptoms can include: numbness or weakness in the face, arm, or leg, especially on one side
of the body; confusion or difficulty in talking or understanding speech; trouble seeing in one or
both eyes; and difficulty with walking, dizziness, or loss of balance and coordination. If this
51| P a g e
instances remained unmanage, complete stroke will be the effect depending on what type of
stroke whether thrombotic stroke or embolic stroke.
Further compression of the brain tissue due to the continued insufficiency of blood
supply, will now cause comatose state of the patient. A cessation of physiologic functions will
also occur and will initiate multi-organ dysfunction syndrome causing shut off of function of the
different systems of the body. Cardiovascular system will lose its cardiac muscle function
leading to a loss of cardiac contractility and will decrease cardiac output. The respiratory system
will lose also its respiratory muscle function thereby losing breathing reflex. When this will
happen, it will lead to cardiopulmonary arrest then systemic failure leading to death.
52| P a g e
1. Diagnostic Exams1.1. Actual
Laboratory Tests
Date Test Definition and
Normal Range
Result Interpretation/
Significance
Nursing
Responsibilities
January 24, 2011 Cranial Computed
Tomography (CT)
Scan
Computed
tomography
(CT) of the brain is
a noninvasive
procedure used to
assist in diagnosing
abnormalities of the
head, brain tissue,
cerebrospinal fluid,
and blood
circulation. It
becomes invasive if
contrast medium is
used.
Slices or thin
sections of certain
anatomic views of
the brain and
associated vascular
Multiple plain axial
CT images of the
head were obtained.
Minute CSF
isodense change is
noted in the left
periventricular area.
No other abnormal
density changes
seen in the rest of
the brain and
brainstem
parenchyma.
Extra- axial spaces
are wide and deep.
No evident
intracranial bleed.
Midline structures
Abnormal findings in:• Abscess
• Aneurysm
• AVMs
• Cerebral atrophy
• Cerebral edema
• Cerebral infarction
• Congenital
abnormalities
• Craniopharyngioma
• Cysts
• Hematomas (e.g.,
epidural,
subdural,
intracerebral)
• Hemorrhage
Pretest
➧ Inform the patient
that the procedure
assesses the brain.
➧ Note any recent
procedures that can
interfere with test
results, including
examinations using
barium or iodine-
based contrast
medium.
Ensure that barium
studies were
performed more
than 4 days before
the CT scan.
➧ Obtain a list of
the patient’s current 53| P a g e
system are
viewed to allow
differentiations
of solid, cystic,
inflammatory,
or vascular lesions,
as well as
identification of
suspected
hematomas or
aneurysms.
Normal Findings:
Normal size,
position, and shape
of intracranial
structures and
vascular system
are not displaced.
The ventricles are
not dilated.
Sella, orbits,
petromastoids and
visualized paranasal
sinuses are
unremarkable.
Calvarium and
visualized facial
bones are intact.
Impression: OLD
LACUNAR
INFARCT, LEFT
PERIVENTRICULAR
AREA. AGE-
RELATED
CEREBRAL
ATROPHY
• Hydrocephaly
• Increased
intracranial
pressure or
trauma
• Infection
• Sclerotic plaques
suggesting
multiple sclerosis
• Tumor
• Ventricular or
tissue displacement
or enlargement
In the case of our
patient, she has
abnormalities in her
CT scan result:
cerebral atrophy
and cerebral
infarction.
medications
including
anticoagulants,
aspirin and other
salicylates, herbs,
nutritional
supplements, and
nutraceuticals. Note
the last time and
dose of medication
taken.
➧ Review the
procedure with the
patient. Address
concerns about
pain and explain
that there may be
moments of
discomfort and
some pain
experienced during
the test.
Inform the patient
the procedure is 54| P a g e
usually performed
in a radiology suite
by a physician
specializing in this
procedure, with
support staff, and
takes approximately
15 to 30 min.
➧ Explain that an
IV line may be
inserted to allow
infusion of IV fluids,
contrast medium,
dye, or sedatives.
Usually contrast
medium and normal
saline are infused.
➧ Inform the patient
that he or she may
experience nausea,
a feeling of warmth,
a salty or metallic
taste, or a transient
headache after 55| P a g e
injection of contrast
medium.
➧ Instruct the
patient to remove
dentures and
jewelry and other
metallic objects
from the area to be
examined.
Intra test
➧ Ensure the
patient has
complied with
medication
restrictions and pre
testing
preparations.
➧ Ensure the
patient has
removed dentures
and all external
metallic objects
from the area to be 56| P a g e
examined prior to
the procedure.
➧ Instruct the
patient to cooperate
fully and to follow
directions. Instruct
the patient to
remain still
throughout
the procedure
because movement
produces unreliable
results.
➧ Administer an
antianxiety agent,
as ordered, if the
patient has
claustrophobia.
Administer a
sedative
to a child or to an
uncooperative
adult, as ordered.
➧ Place the patient 57| P a g e
in the supine
position on an
exam table.
➧ If contrast media
is used, a rapid
series of images is
taken during and
after injection.
➧ Instruct the
patient to take slow,
deep breaths if
nausea occurs
during the
procedure.
➧ Monitor the
patient for
complications
related to the
procedure (e.g.,
allergic
reaction,
anaphylaxis,
bronchospasm)
58| P a g e
if contrast is used.
Post test
➧ Monitor vital
signs and
neurologic status
every 15 min for 1
hr, then every 2 hr
for 4 hr, and then
as ordered by the
physician. Monitor
temperature every
4 hr for 24 hr.
Compare with
baseline values.
Notify the physician
if temperature is
elevated.
➧ If contrast was
used, observe for
delayed allergic
reactions, such as
rash, urticaria,
tachycardia, 59| P a g e
hyperpnea,
hypertension,
palpitations,
nausea, or
vomiting.
➧ If contrast was
used, advise the
patient
to immediately
report symptoms
such as fast heart
rate, difficulty
breathing, skin
rash, itching, or
decreased urinary
output.
➧ Instruct the
patient to increase
fluid
intake to help
eliminate the
contrast medium, if
used.
60| P a g e
➧ Inform the patient
that diarrhea may
occur after
ingestion of oral
contrast medium.
Date Test Definition and
Normal Range
Result Interpretation/
Significance
Nursing
Responsibilities
January 24, 2011 Chest Radiology Chest X-rays are
taken when a
patient is
suspected of
having problems
with the lungs,
heart, or other
Study taken in AP
projection.
Lung fields are clear.
The heart is
magnified with left
ventricular
Chest X-ray
examination is
done to identify the
presence of
pulmonary infiltrate,
which is fluid
leakage into the
1.) Remove from
the chest area all
jewelry, clothing
with snaps,
electrocardiographic
patches (if not
contraindicated), 61| P a g e
chest structures.
Another way of
looking for other
complications in the
lungs and heart.
X-ray examination
of the chest is done
to diagnose
disease and to
assess the
progress of a
disease.
Normal Values:
Normal anatomy
and no pathologic
changes evident or
no abnormalities
found in the lungs,
heart and other
chest structures.
prominence.
Aortic knob is
calcified.
Mediastinum and
hemidiaphragm are
unremarkable.
Visualized osseous
structures are porotic.
The rest of the
included structures
are unremarkable.
Impression:
SUGGESTIVE LEFT
VENTRICULAR
CARDIOMEGALY.
ATHEROSCLEROTIC
AORTA. SENILE
OSTEOPOROSIS.
alveoli from
inflammation.
It is also use to
evaluate respiratory
status and heart
size.
Abnormalities found
in the lungs
sometimes
indicates
pneumonia,
emphysema,
chronic obstructive
pulmonary disease,
bronchiectasis,
pulmonary edema,
interstitial
pneumonitis, and
others, while in the
heart congestive
heart failure or
pericardial effusion.
In the case of our
and other metal
objects that may
interfere with the
interpretation of the
results.
2.) It is important to
breathe in deeply,
hold your breath,
and remain
motionless while the
radiograph is taken.
4.) A radiograph
takes approximately
15 minutes to
complete and verify
that the images are
properly exposed.
5.) No restrictions
are necessary on
food or fluid intake.
6.) No sedation is
used for this
procedure.
7.) Views are taken 62| P a g e
client, it was found
out that there is
enlargement of the
heart
atherosclerotic
plaque in aorta and
osteoporosis.
in various positions
on the table or
chair.
8.) When taking a
PA view of the
chest, instruct
patient to place
his/her chest
against the
photographic plate
while standing, chin
raised, with both
hands on the hips,
palms out, and the
elbows and
shoulders in a
forward position.
9.) When taking a
lateral view of the
chest, instruct
patient to raise both
hands while
standing and the left
shoulder is lightly 63| P a g e
placed against the
photographic plate.
10.) Instruct patient
to take a deep
breath and hold
while the picture is
being taken.
After the test, give
back clothing,
jewelries that was
removed before the
procedure.
Date Test Definition and Normal
Range
Result Interpretation/ Significance Nursing
Responsibilties
January 25,
2011
Fasting Blood
Sugar (FBS)
This test is taken to
measure blood glucose
level.
Fasting glucose levels
are used to help
diagnose diabetes
mellitus and
hypoglycemia. A
randomly timed test for
7.1 mmol/ L
(HIGH)
Increased in:• Acromegaly, gigantism (GH
stimulates
the release of glucagon, which
in turn inceases glucose levels)
• Diabetes (Glucose intolerance
and elevated glucose levels
define
Pretest
1. Inform the
patient that
the test is
used as a
general
indicator of
nutritional
status, 64| P a g e
glucose is usually
performed for routine
screening and
nonspecific evaluation
of carbohydrate
metabolism.
Normal value:
3.9 - 6.1 mmol/ L
diabetes),
• Myocardial infarction (Related
to stress and/or pre-existing
diabetes)
• Strenuous exercise
(Hyperglycemia
is stimulated by the
release of catecholamines
and glucagon)
Decreased in:• Glucagon deficiency (Glucagon
controls glucose levels;
hypoglycemia
occurs in the absence of
glucagon)
• Hypothyroidism (Thyroid
hormones affect glucose levels;
decreased thyroid hormone
levels result in decreased
glucose levels)
In the case of our client, her FBS
result was high since she had
hydration and
chronic
disease.
2. Obtain a
history of the
patient’s
complaints,
including a list
of known
allergens.
3. Review the
procedure
with the
patient. Inform
the patient
that specimen
collection
takes
approximately
5 to 10
minutes.
Address
concerns
about pain 65| P a g e
been diagnosed of Diabetes
Mellitus.
and explain
that there may
be some
discomfort
during the
venipuncture.
4. There are no
food, fluid or
medication
restriction
unless by
medical
direction.
Intra test
1. If the patient
has a history
of allergic
reaction to
latex, avoid
the use of
equipment
containing
Blood Urea
Nitrogen
(BUN)
Urea is a nonprotein
nitrogen compound
formed in the liver from
ammonia as an end
product of protein
metabolism.
Urea diffuses freely into
extracellular and
intracellular fluid and is
ultimately excreted by
the kidneys.
Blood urea nitrogen
(BUN) levels reflect the
balance between the
production and
excretion of urea.
Normal Range: 2.5- 6.4
mmol/ L
6.4 mmol/ L Increased in:• Acute renal failure (Related to
decreased renal excretion)
• Chronic glomerulonephritis
(Related to decreased renal
excretion)
• Congestive heart failure
(Related
to decreased blood flow to the
kidneys, decreased renal
excretion,
and accumulation in circulating
blood)
• Diabetes (Related to decreased
renal excretion)
• Shock (Related to decreased
blood
flow to the kidneys, decreased
renal excretion, and accumulation
in circulating blood)
• Urinary tract obstruction
66| P a g e
(Related to
decreased renal excretion and
accumulation in circulating blood)
Decreased in:• Inadequate dietary protein (Urea
nitrogen is a by-product of protein
metabolism; less available
protein is reflected in decreased
BUN levels)
• Low-protein/high-carbohydrate
diet
(Urea nitrogen is a by-product of
protein metabolism; less available
protein is reflected in decreased
BUN levels)
In the case of our client, her BUN
result is normal.
latex.
2. Instruct the
patient to
cooperate
fully and to
follow
directions.
Direct the
patient to
breathe
normally and
to avoid
unnecessary
movement.
3. Positively
identify the
patient and
label the
appropriate
container.
Perform the
venipuncture.
4. Remove the
needle and
Creatinine Creatinine is produced
in relatively constant
quantities by the
muscles and is
excreted by the
71.2 umol/L - An increase in creatinine
may indicate congestive
heart failure, dehydration,
renal calculi, renal failure,
acute and chronic renal 67| P a g e
kidneys. Thus, the
amount of creatinine in
the blood relates to
renal excretory
function.
Normal Range: 53.0-
115.0 umol/ L
failure and shock.
- A decrease in creatinine
may indicate
hyperthyroidism, liver
disease and inadequate
protein intake.
The creatinine level of our client is
normal.
apply direct
pressure with
dry gauze to
stop bleeding.
Observe
venipuncture
site for
bleeding or
hematoma
formation and
secure gauze
with adhesive
bandage.
5. Promptly
transport the
specimen to
the laboratory
for processing
and analysis.
Posttest
1. Reinforce
information
given by the
Cholesterol Total cholesterol levels
are used for screening
for
hypercholesterolemia.
Cholesterol is a
lipid needed to form cell
membranes and a
component of the
materials that render
the skin waterproof. It
also helps form bile
salts, adrenal
corticosteroids,
estrogen, and
androgens.
4.3 mmol/ L This test is an important
screening test for heart disease.
Increased: Type II familial
hypercholesterolemia
Biliary cirrhosis
Chronic renal failure
Poorly controlled diabetes
mellitu
Diet high in cholesterol
and fats
Decreased:
68| P a g e
Cholesterol is obtained
from the
diet (exogenous
cholesterol)
and also synthesized in
the
body (endogenous
cholesterol).
Normal Value:
0.0 – 5.2 mmol/L
Hyperthyroidism
Malnutrition
Chronic anemias
Severe burns
In the case of our client, her
cholesterol level is normal.
patient’s
health care
provider
regarding
further testing,
treatment, or
referral to
another health
care provider.
2. Depending on
the results of
this
procedure,
additional
testing may
be performed
to evaluate or
monitor
progression of
the disease
process and
determine the
need for a
LDL-
Cholesterol
Up to 70% of the total
serum cholesterol is
present in the LDL. The
“bad” cholesterol.
Normal value:
0.00 – 3.4 mmol/L
3.1 mmol/ L Increased: Familial type 2
hyperlipidemia
Secondary causes can
include: diet high in
cholesterol and saturated
fat, nephritic syndrome,
multiple myeloma,
diabetes mellitus, chronic
renal failure
Decreased:
69| P a g e
Hypolipoproteinemia
Hyperthyroidism
Chronic anemias
In the case of our client, the result
is normal.
change in
therapy.
3. Evaluate test
results in
relation to the
patient’s
symptoms
and other
tests
performed.
Rev
Triglycerides
(TGL)
Triglycerides are a
combination of three
fatty acids
and one glycerol
molecule.
They are necessary to
provide
energy for various
metabolic
processes.
Triglycerides are also
synthesized in the liver
from fatty acids and
from protein and
glucose above the
body's current needs
and then stored in
adipose tissue. They
1.04 mmol/ L This test evaluates suspected
atherosclerosis and measures the
body’s ability to metabolize fat.
Increased: Hyperlipoproteinemia
Liver disease
Renal disease
Hypothyroidism
Myocardial infarction
Decreased: Malnutrition
Hyperthyroidism
Brain infarction
Chronic obstructive lung
disease
70| P a g e
may be later retrieved
and formed into
glucose through
gluconeogenesis when
needed by the body.
Triglyceride levels are
taken into consideration
with total cholesterol,
high-density lipoprotein
cholesterol, and
chylomicron levels
when categorizing a
client's serum into
lipoprotein phenotypes
that represent genetic
lipoprotein
abnormalities.
Normal Value:
0.0 – 1.70 mmol/ L
In the case of our client, the result
is normal.
HDL-
Cholesterol
(AHDL)
A class of lipoproteins
produced by the liver
and intestines. The
0.75 mmol/ L
(LOW)
Increased: HDL excess
Chronic liver disease
Long term aerobic or 71| P a g e
“good” cholesterol.
Normal Value:
0.90 – 1.55 mmol/L
vigorous exercise
Decreased: Familial
hypolipoproteinemia
Poorly controlled diabetes
mellitus
Chronic heart failure
In the case of our client, the result
is low since our client had been
diagnosed of having diabetes
mellitus.
Serum
Electrolytes
Serum electrolytes are
often routinely ordered
for any client admitted
to a hospital as a
screening test for
electrolyte and acid-
base imbalances.
Serum electrolytes also
are routinely assessed
for clients at risk in the
community, for
Sodium:
144.8 mmol/
L
Potassium:
3.24 mmol/ L
(LOW)
Calcium: 2.
19 mmol/ L
Sodium
- An increase in sodium
may indicate burn,
dehydration, diabetes, and
diarrhea, excessive intake
of sodium, fever and
vomiting.
- A decrease in sodium may
indicate congestive heart
failure, central nervous
system disease, excessive 72| P a g e
example, client who are
being treated with a
diuretic for
hypertension or heart
failure. The most
commonly ordered
serum tests are for
sodium, potassium,
chloride, and
bicarbonate ions.
Normal Values:
a. Sodium: 136-
145 mmol/L
b. Potassium: 3.5-
5.1 mmol/L
c. Calcium: 2.12-
2.52 mmol/L
antidiuretic hormone
production, excessive use
of diuretics, hepatic failure
and nephritic syndrome.
Potassium
- An increase in potassium
may indicate acidosis,
acute renal failure, burns,
dehydration, insulin
deficiency, ketoacidosis,
leukocytosis.
- A decrease in potassium
may indicate alcoholism,
alkalosis, bradycardia,
congestive heart failure,
hypertension,
hypomagnesemia and
renal tubular acidosis.
Calcium
- An increase in calcium
may indicate vitamin D
toxicity and
hyperthyroidism.
- A decrease in calcium 73| P a g e
may indicate burns,
magnesium deficiency,
multiple organ failure and
vitamin D deficiency.
In the case of our client, her
potassium is low since she is
hypertensive.
Date Test Definition and
Normal Range
Result Interpretation/
Significance
Nursing
Responsibilities
January 25, 2011 Glycosylated
Hemoglobin (HBA-
1C)
Glycosylated or
glycated
hemoglobin is a
term used to
describe the
combination of
glucose and
hemoglobin into a
ketamine; the rate
at which this occurs
is proportional to
6.7 % (HIGH) Increased in:• Diabetes (poorly
controlled or
uncontrolled)
(Related to and
reflective of
elevated glucose
levels)
Decreased in:• Chronic blood loss
Pretest
1. Inform the
patient that
the test is
used as a
general
indicator of
nutritional
status,
hydration and
chronic 74| P a g e
glucose
concentration.
The average life
span of a red
blood cell (RBC) is
approximately
120 days;
measurement of
glycated
hemoglobin is a
way to monitor
long-term diabetic
management.
Normal Range:
4.5%- 6.3%
(Blood
loss decreases
concentration
of RBC-bound
glycated
hemoglobin)
• Chronic renal
failure (Low RBC
count associated
with this
condition reflects
corresponding
decrease in RBC
bound
glycated
hemoglobin)
In the case of our
client, the result is
high since she is a
diabetic person.
disease.
2. Obtain a
history of the
patient’s
complaints,
including a list
of known
allergens.
3. Review the
procedure
with the
patient. Inform
the patient
that specimen
collection
takes
approximately
5 to 10
minutes.
Address
concerns
about pain
and explain
that there may 75| P a g e
be some
discomfort
during the
venipuncture.
4. There are no
food, fluid or
medication
restriction
unless by
medical
direction.
Intra test
6. If the patient
has a history
of allergic
reaction to
latex, avoid
the use of
equipment
containing
latex.
7. Instruct the
patient to 76| P a g e
cooperate
fully and to
follow
directions.
Direct the
patient to
breathe
normally and
to avoid
unnecessary
movement.
8. Positively
identify the
patient and
label the
appropriate
container.
Perform the
venipuncture.
9. Remove the
needle and
apply direct
pressure with
dry gauze to 77| P a g e
stop bleeding.
Observe
venipuncture
site for
bleeding or
hematoma
formation and
secure gauze
with adhesive
bandage.
10. Promptly
transport the
specimen to
the laboratory
for processing
and analysis.
Posttest
11. Reinforce
information
given by the
patient’s
health care
provider 78| P a g e
regarding
further testing,
treatment, or
referral to
another health
care provider.
12. Depending on
the results of
this
procedure,
additional
testing may
be performed
to evaluate or
monitor
progression of
the disease
process and
determine the
need for a
change in
therapy.
13. Evaluate test
results in 79| P a g e
relation to the
patient’s
symptoms
and other
tests
performed.
80| P a g e
1.2. Possible
Diagnostic Test
Test Rationale Result Interpretation Nursing Responsibilities
Positron Emission
Tomography (PET)
Positron emission
tomography (PET)
combines
the biochemical
properties of
nuclear medicine with
the
accuracy of computed
tomography
(CT). PET uses positron
emissions from specific
radionuclides (oxygen,
nitrogen, carbon, and
fluorine) to produce
detailed functional
images within the body.
After the radionuclide
becomes concentrated
in the brain, PET
images of blood flow or
metabolic processes at
Normal patterns
of tissue
metabolism,
blood flow, and
radionuclide
distribution
Abnormal findings in:• Alzheimer’s disease
• Aneurysm
• Cerebral metastases
• Cerebrovascular accident
• Creutzfeldt-Jakob disease
• Dementia
• Head trauma
• Huntington’s disease
• Migraine
• Parkinson’s disease
• Schizophrenia
• Seizure disorders
• Tumors
Pretest
➧ Inform the patient that the
procedure assesses blood
flow to the brain and brain
tissue metabolism.
➧ Review the procedure with
the patient. Address
concerns about pain related
to the procedure and explain
to the patient that some pain
may be experienced during
the test, or there may be
moments of discomfort.
Reassure the patient that
radioactive material poses
minimal radioactive hazard
because of its short half-life
and rarely produces side
effects. Inform the patient
that the procedure is
performed in a special 81| P a g e
the cellular level can be
obtained. PET identifies
the amount of tissue
damage following a
CVA. Positron emission
tomography (PET) is a
test that uses a special
type of camera and a
tracer (radioactive
chemical) to look at
organs in the body. The
tracer usually is a
substance (such as
glucose) that can be
used (metabolized) by
cells in the body.
department, usually in a
radiology suite and takes
approximately 60 to 120 min.
➧ Instruct the patient to
remove jewelry and other
metallic objects from the
area to be examined prior to
the procedure.
➧ Instruct the patient to
avoid taking anticoagulant
medication or to reduce
dosage as ordered prior to
the procedure.
➧ Instruct the patient to
restrict food for 4 hr; restrict
alcohol, nicotine, or caffeine-
containing drinks for 24 hr;
and withhold medications for
24 hr before the test.
Intra test
➧ Ensure that the patient
has complied with dietary,
fluid, and medication 82| P a g e
restrictions and pre testing
preparations.
➧ Ensure the patient has
removed all jewelry and
external metallic objects
from the area to be
examined prior to the
procedure.
➧ Instruct the patient to void
prior to the procedure and to
change into the gown, robe,
and foot coverings provided.
➧ Instruct the patient to
cooperate fully and to follow
directions. Ask the patient to
remain still throughout the
procedure because
movement produces
unreliable results.
➧ Record baseline vital
signs and assess
neurological status.
➧ The patient may be asked
to perform different cognitive 83| P a g e
activities (e.g., reading) to
measure changes in brain
activity during reasoning or
remembering.
➧ The patient may be
blindfolded or asked to use
earplugs to decrease
auditory and visual stimuli.
➧ Monitor the patient for
complications
related to the procedure
(e.g., allergic
reaction, anaphylaxis,
bronchospasm).
Posttest
➧ Instruct the patient to
resume pretest diet, fluids,
medications, or activity.
➧ Observe for delayed
allergic reactions,
such as rash, urticaria,
tachycardia,
hyperpnea, hypertension, 84| P a g e
palpitations, nausea, or
vomiting.
➧ Instruct the patient to
immediately report
symptoms such as fast heart
rate, difficulty breathing, skin
rash, itching, or decreased
urinary output.
➧ Instruct the patient to drink
increased amounts of fluids
for 24 to 48 hr to eliminate
the radionuclide from the
body, unless
contraindicated. Educate the
patient that radionuclide is
eliminated from the body
within 6 to 24 hr.
➧ Instruct the patient to flush
the toilet immediately after
each voiding, and
to meticulously wash hands
with soap and water for 24 hr
after the procedure.
85| P a g e
➧ Instruct all caregivers to
wear gloves when discarding
urine for 24 hr after the
procedure. Wash gloved
hands with soap and water
before removing gloves.
Then wash hands after the
gloves are removed.
Test Rationale Result Interpretation/
Significance
Nursing
Responsibilities
Electroencephalogram
(EEG)
Electroencephalography
(EEG) is a noninvasive
study that measures the
• Normal occurrences
of alpha, beta,
theta, and delta waves
Abnormal findings in:• Abscess
Pretest
➧ Inform the patient
that the procedure is 86| P a g e
brain’s electrical activity
and records that activity
on graph paper. These
electrical impulses arise
from the brain cells of
the cerebral cortex.
At one end are action
potentials in a single
axon or currents within a
single dendrite, and at
the other end is the
activity measured by the
scalp EEG.
Indications:
• Confirm suspicion of
increased
intracranial pressure
caused by
trauma or disease
• Detect cerebral
ischemia during
endarterectomy
• Detect intracranial
(rhythms
varying depending on
the patent’s
age)
• Normal frequency,
amplitude, and
characteristics of brain
waves
• Brain death
• Cerebral infarct
• Encephalitis
• Glioblastoma and
other brain
tumors
• Head injury
• Hypocalcemia or
hypoglycemia
• Intracranial
hemorrhage
• Meningitis
• Migraine headaches
• Narcolepsy
• Seizure disorders
(grand mal,
focal, temporal lobe,
myoclonic,
petit mal)
• Sleep apnea
performed to measure
electrical activity of the
brain.
➧ Review the
procedure with the
patient. Address
concerns about pain
related to the
procedure and assure
the patient there is no
discomfort during the
procedure, but that, if
needle electrodes are
used, a slight pinch
may be felt. Explain
that electricity flows
from the patient’s body,
not into the body,
during the procedure.
Explain that the
procedure reveals brain
activity only, not
thoughts, feelings, or
intelligence. Inform the 87| P a g e
cerebrovascular
lesions, such as
hemorrhages and
infarcts
• Detect seizure
disorders and identify
focus of seizure and
seizure activity,
as evidenced by
abnormal spikes
and waves recorded on
the graph
• Determine the
presence of tumors,
abscesses, or infection
patient the procedure is
performed in a
neurodiagnostic
department, usually by
a HCP and support
staff, and takes
approximately 30 to 60
min.
➧ Inform the patient
that he or she may
be asked to alter
breathing pattern; be
asked to follow simple
commands such
as opening or closing
eyes, blinking, or
swallowing; be
stimulated with bright
light; or be given a drug
to induce sleep
during the study.
➧ Instruct the patient to
clean the hair
and to refrain from 88| P a g e
using hair sprays,
creams, or solutions
before the test.
➧ Instruct the patient to
eat a meal
before the study and to
avoid stimulants
such as caffeine and
nicotine for
8 hr prior to the
procedure.
Intra test
➧ Ensure the patient
has complied with
pretesting preparations.
Ensure that
caffeine-containing
beverages were
withheld for 8 hr before
the procedure,
and that a meal was
ingested before
89| P a g e
the study.
➧ Ensure that the
patient is able to
relax; report any
extreme anxiety or
restlessness.
➧ Ensure that hair is
clean and free of
hair sprays, creams, or
solutions.
➧ Remind the patient
to relax and not to
move any muscles or
parts of the face
or head.
Posttest
➧ When the procedure
is complete,
remove electrodes from
the hair and
remove paste by
cleansing with oil or
90| P a g e
witch hazel.
➧ If a sedative was
given during the test,
allow the patient to
recover. Bedside
rails are put in the
raised position for
safety.
Test Rationale Result Interpretation/
Significance
Nursing Responsibilities
Magnetic Resonance
Imaging (MRI)- Brain
Magnetic resonance
imaging (MRI) uses a
magnet
and radio waves to
produce an
energy field that can be
Normal anatomic
structures, soft
tissue density, blood
flow rate,
face, nasopharynx,
Abnormal findings in:• Abscess
• Acoustic neuroma
• Alzheimer’s disease
• Aneurysm
• Arteriovenous
Pretest
➧ Inform the patient that
the procedure
assesses the brain.
➧ Review the procedure
91| P a g e
displayed
as an image.
Brain MRI can
distinguish
solid, cystic, and
hemorrhagic
components of lesions.
This procedure
is done to aid in the
diagnosis
of intracranial
abnormalities,
including tumors,
ischemia, infection,
and multiple sclerosis,
and
in assessment of brain
maturation
in pediatric patients.
Indications:
• Detect and locate
brain tumors
• Detect cause of
neck, tongue,
and brain
malformation
• Benign meningioma
• Cerebral aneurysm
• Cerebral infarction
• Craniopharyngioma or
meningioma
• Granuloma
• Intraparenchymal
hematoma or
hemorrhage
• Lipoma
• Metastasis
• Multiple sclerosis
• Optic nerve tumor
• Parkinson’s disease
• Pituitary
microadenoma
• Subdural empyema
• Ventriculitis
with the patient.
Address concerns about
pain related
to the procedure and
explain to the patient
that no pain will be
experienced
during the test, but there
may be
moments of discomfort.
Reassure the
patient that if contrast is
used, it poses
no radioactive hazard
and rarely
produces side effects.
Inform the
patient the procedure is
performed in
an MRI department,
usually by a health
care provider (HCP)
who specializes in
this procedures, with 92| P a g e
cerebrovascular
accident, cerebral
infarct, or
hemorrhage
• Detect cranial bone,
face, throat,
and neck soft tissue
lesions
• Evaluate the cause of
seizures, such
as intracranial infection,
edema, or
increased intracranial
pressure
• Evaluate cerebral
changes associated
with dementia
• Evaluate
demyelinating disorders
• Evaluate intracranial
infections
• Evaluate optic and
auditory nerves
support staff, and
takes approximately 30
to 60 min.
➧ Inform the patient that
the technologist
will place him or her in a
supine
position on a flat table in
a large
cylindrical scanner.
➧ Tell the patient to
expect to hear loud
banging from the
scanner and possibly
to see
magnetophosphenes
(flickering
lights in the visual field);
these will stop
when the procedure is
over.
➧ Explain that an IV line
may be inserted
to allow infusion of IV 93| P a g e
fluids, contrast
medium, or sedatives.
➧ Instruct the patient to
remove jewelry
and all other metallic
objects from the
area to be examined
prior to the
procedure.
➧ There are no food,
fluid, or medication
restrictions, unless by
medical direction.
Intratest
➧ Ensure that the
patient has removed all
external metallic objects
from the area
to be examined prior to
the procedure.
➧ Instruct the patient to
void prior to the
procedure and to 94| P a g e
change into the
gown, robe, and foot
coverings
provided.
➧ Instruct the patient to
cooperate
fully and to follow
directions. Instruct
the patient to remain still
throughout
the procedure because
movement produces
unreliable results.
➧ Supply earplugs to
the patient to block
out the loud, banging
sounds that
occur during the test.
Instruct the
patient to communicate
with the
technologist during the
examination
via a microphone within 95| P a g e
the scanner.
➧ Place the patient in
the supine position
on an exam table.
➧ If contrast is used,
imaging can begin
shortly after the
injection.
➧ Ask the patient to
inhale deeply and
hold his or her breathe
while the
images are taken, and
then to exhale
after the images are
taken.
➧ Instruct the patient to
take slow, deep
breaths if nausea
occurs during the
procedure.
➧ Monitor the patient for
complications
related to the procedure 96| P a g e
(e.g., allergic
reaction, anaphylaxis,
bronchospasm)
Posttest
➧ Observe for delayed
allergic reactions,
such as rash, urticaria,
tachycardia,
hyperpnea,
hypertension,
palpitations, nausea, or
vomiting, if contrast
medium
was used.
➧ Instruct the patient to
immediately
report symptoms such
as fast heart
rate, difficulty breathing,
skin rash,
itching, or decreased
urinary output.
97| P a g e
Test Rationale Result Interpretation/
Significance
Nursing Responsibilities
Carotid
Ultrasound
Using the duplex
scanning method,
carotid US
records sound waves
to obtain
information about the
carotid
arteries. The amplitude
and
waveform of the
carotid pulse
are measured,
Normal blood flow
through the
carotid arteries with
no evidence
of occlusion or
narrowing
Abnormal findings in:• Carotid artery
occlusive disease
(atherosclerosis)
• Plaque or stenosis
of carotid artery
• Reduction in
vessel diameter of
more than 16%,
indicating stenosis
Pretest
➧ Review the procedure with the
patient.
Address concerns about pain
related
to the procedure and explain that
some pain may be experienced
during
the test, and there may be
moments of
discomfort. Inform the patient that
98| P a g e
resulting in a
two-dimensional image
of the
artery. Carotid arterial
sites
used for the studies
include
the common carotid,
external
carotid, and internal
carotid.
the
procedure is performed in a US
department by a health care
provider
(HCP) who specializes in this
procedure,
with support staff, and takes
approximately 30 to 60 min.
➧ Instruct the patient to remove
jewelry
and other metallic objects from the
area to be examined.
➧ There are no food, fluid, or
medication
restrictions, unless by medical
direction.
Intratest
➧ Ensure that the patient has
removed all
external metallic objects from the
area
to be examined prior to the
procedure.
➧ Instruct the patient to void and 99| P a g e
change
into the gown, robe, and foot
coverings
provided.
➧ Instruct the patient to cooperate
fully
and to follow directions. Ask the
patient to remain still throughout
the procedure because movement
produces unreliable results.
➧ Place the patient in the supine
position
on an exam table; other positions
may
be used during the examination.
➧ Expose the neck and drape the
patient.
➧ Conductive gel is applied to the
skin
and a Doppler transducer is
moved
over the skin to obtain images of
the
100| P a g e
area of interest.
➧ Ask the patient to breathe
normally
during the examination. If
necessary
for better organ visualization, ask
the
patient to inhale deeply and hold
his
or her breath.
Post test
➧ When the study is completed,
remove
the gel from the skin.
➧ Instruct the patient to continue
with
diet, fluids, and medications, as
directed by the HCP.
➧ Instruct the patient in the use of
any
ordered medications. Explain the
importance of adhering to the
therapy
regimen. As appropriate, instruct 101| P a g e
the
patient in significant side effects
and
systemic reactions associated with
the
prescribed medication. Encourage
him or her to review
corresponding
literature provided by a
pharmacist.
Test Rationale Result Interpretation/
Significance
Nursing Responsibilities
Echocardiography Echocardiography,
a noninvasive
ultrasound (US)
procedure, uses high-
frequency
sound waves of various
intensities
to assist in diagnosing
cardiovascular
• Normal appearance in
the size,
position, structure, and
movements
of the heart valves
visualized and
recorded in a
combination of
ultrasound modes; and
Abnormal findings in:• Aneurysm
• Aortic valve
abnormalities
• Cardiac neoplasm
• Cardiomyopathy
• Congenital heart defect
• Congestive heart
Pretest
➧ Inform the patient that
the procedure assess
cardiac function.
➧ Review the procedure
with the patient.
Address concerns about
pain related to the
procedure and explain 102| P a g e
disorders. The
procedure records the
echoes
created by the deflection
of an
ultrasonic beam off the
cardiac
structures and allows
visualization
of the size, shape,
position,
thickness, and
movement of all
four valves, atria,
ventricular and
atria septa, papillary
muscles,
chordae tendineae, and
ventricles.
This study can also
determine
blood-flow velocity and
direction
and the presence of
normal
heart muscle walls of
both ventricles
and left atrium, with
adequate
blood filling.
failure
• Coronary artery
disease
• Endocarditis
• Mitral valve
abnormalities
• Myxoma
• Pericardial effusion,
tamponade,
and pericarditis
• Pulmonary
hypertension
• Pulmonary valve
abnormalities
• Septal defects
• Ventricular hypertrophy
• Ventricular or atrial
mural thrombi
that there should be no
discomfort during the
procedure. Inform the
patient the
procedure is performed
in an US or
cardiology department,
and takes approximately
30 to
60 min.
➧ Instruct the patient to
remove jewelry, and
other metallic objects
from the area to be
examined.
➧ There are no food or
fluid restrictions, unless
by medical direction.
Intra test
➧ Ensure the patient
has removed all external
metallic objects from the
area to be examined 103| P a g e
pericardial
effusion during the
movement of
the transducer over
areas of the
chest.
Indications:
• Detect ventricular or
atrial mural
thrombi and evaluate
cardiac wall
motion after myocardial
infarction
• Detect subaortic
stenosis as evidenced
either by displacement
of
the anterior atrial leaflet
or by a
reduction in aortic valve
flow,
depending on the
obstruction
prior to the procedure.
➧ Instruct the patient to
cooperate fully and to
follow directions. Instruct
the patient to remain still
throughout the
procedure because
movement produces
unreliable results.
➧ Place the patient in a
supine position on a flat
table with foam wedges
to help maintain position
and immobilization.
➧ Expose the chest,
and attach
electrocardiogram leads
for simultaneous
tracings, if desired.
➧ Apply conductive gel
to the chest.
Place the transducer on
the chest
surface along the left 104| P a g e
• Evaluate ventricular
aneurysms
and/or thrombus
sternal border,
the subxiphoid area,
suprasternal notch, and
supraclavicular areas to
obtain views and
tracings of the portions
of the heart. Scan the
areas
by systematically
moving the probe in a
perpendicular position to
direct the ultrasound
waves to each part of
the heart.
➧ To obtain different
views or information
about heart function,
position the
patient on the left side
and/or sitting up, or
request that the patient
breathe slowly or hold
the breathe during the
procedure. To evaluate 105| P a g e
heart function changes,
the patient may be
asked to inhale amyl
nitrate (vasodilator).
➧ Administer contrast
medium, if ordered. A
second series of images
is obtained.
Post test
➧ When the study is
completed, remove the
gel from the skin.
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Test Rationale Result Interpretation/
Significance
Nursing Responsibilities
Electrocardiogram The electrocardiogram
(ECG), a noninvasive
study, measures the
electrical currents or
impulses that the heart
generates during a
cardiac cycle. The ECG
is a graphic display of
the electrical activity of
the heart, which is
analyzed by time
intervals and segments.
Continuous tracing of
the cardiac cycle
activities is captured as
heart cells are
electrically stimulated,
causing depolarization
• Normal heart rate
according to age:
range of 60 to 100
beats/min in
adults
• Normal, regular rhythm
and wave
deflections with normal
measurement
of ranges of cycle
components
and height, depth, and
duration of complexes
as follows:
P wave: 0.12 sec or 3
small blocks with
amplitude of 2.5 mm
Q wave: less than 0.04
• Arrhythmias.
• Atrial or ventricular
hypertrophy.
• Bundle branch block.
• Electrolyte imbalances.
• MI or ischemia.
• Pericarditis.
• Pulmonary infarction.
• P wave: An enlarged P
wave
deflection could indicate
atrial
enlargement. An absent
or altered
P wave could suggest
that the electrical
impulse did not come
Pretest
➧ Review the procedure
with the patient.
Address concerns about
pain related to the
procedure and explain
that there should be no
discomfort related to the
procedure. Inform the
patient that the
procedure is performed
by a health
care provider (HCP) and
takes approximately 15
min.
➧ Review the procedure
with the patient.
Address concerns about 107| P a g e
and movement of the
activity through the cells
of the myocardium.
Indications:
• Assess the extent of
myocardial infarction
(MI) or ischemia, as
indicated by abnormal
ST segment, interval
times, and amplitudes
• Assess the function of
heart valves
• Monitor rhythm
changes during
the recovery phase after
an MI.
mm
R wave: 5 to 27 mm
amplitude,
depending on lead
T wave: 1 to 13 mm
amplitude,
depending on lead
QRS complex: 0.12 sec
or 3 small blocks
ST segment: 1 mm
from the SA node.
• P-R interval: An
increased interval
could imply a conduction
delay in
the AV node.
• QRS complex: An
enlarged Q wave
may indicate an old
infarction; an
enlarged deflection
could indicate
ventricular hypertrophy.
Increased
time duration may
indicate a bundle
branch block.
• ST segment: A
depressed ST
segment indicates
myocardial
ischemia. An elevated
ST segment
may indicate an acute
pain related to
the procedure and
explain that there should
be no discomfort related
to the procedure. Inform
the patient that the
procedure takes
approximately
15 min.
➧ Instruct the patient to
remove jewelry
and other metallic
objects from the area to
be examined.
➧ No food, fluid, or
medication restrictions
exist, unless by medical
direction.
Intra test
➧ Ensure the patient
has complied with
pretesting preparations.
➧ Ensure the patient 108| P a g e
MI or pericarditis.
A prolonged ST
segment
may indicate
hypocalcemia or
hypokalemia (short
segment).
• T wave: A flat or
inverted T wave
may indicate myocardial
ischemia,
infarction, or
hypokalemia. A tall
T wave may indicate
hyperkalemia.
has removed all
external metallic objects
from the area
to be examined prior to
the procedure.
➧ Instruct the patient to
void prior to the
procedure and to
change into the gown,
robe, and foot coverings
provided.
➧ Instruct the patient to
cooperate
fully and to follow
directions. Instruct
the patient to remain still
throughout
the procedure because
movement
produces unreliable
results.
➧ Record baseline
values.
➧ Place patient in a 109| P a g e
supine position.
Expose and
appropriately drape the
chest, arms, and legs.
➧ Prepare the skin
surface with alcohol
and remove excess hair.
Shaving may
be necessary. Dry skin
sites.
➧ Apply the electrodes
in the proper position.
Post test
➧ When the procedure
is complete,
remove the electrodes
and clean the
skin where the electrode
pads were
applied.
➧ Monitor vital signs
and compare with
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baseline values.
2. Therapeutics
Date Order Rationale
January 24, 2011 Diet as tolerated Diet as tolerated is ordered when the
client’s appetite, ability to eat, and
tolerance for certain foods may change.
PNSSτL @ 80cc/ hour; regulated Intravenous fluid therapy is essential when
client is unable to take foods and fluids
orally prior to a procedure or surgery. This
was ordered to maintain fluids and
electrolytes in the body and base on the
body weight of the patient. Isotonic
Solutions initially remain in the vascular
compartment, expanding vascular volume.
11:10 am- HGT monitoring every 6 hours It is done to monitor blood glucose level.
Monitor VS every 4 hours and record This was ordered to check and monitor the
functions of the body. These signs reflect
changes in function that otherwise might
not be observed.
Monitor NVS every 4 hours This was ordered to know the mental
status, level of consciousness, motor
function and sensory function of the client.
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Deterioration in a client’s level of
consciousness may indicate that
intracranial pressure is increasing. This is
a life threatening condition that requires
immediate intervention because it
depresses respiration.
Monitor Intake and Output every shift This was ordered to provide important
data about the client’s fluid and electrolyte
balance.
11:35 am- Low Salt, Low Fat, Diabetic Diet
1000kcal, Carbohydrates- 200g, Protein-
80g, Fat- 53g
This was ordered to control the total
caloric intake to attain or maintain a
reasonable body weight, control of blood
glucose level, and normalization of lipids
and blood pressure to prevent heart
disease.
2:35pm- HGT every 6 hours with sliding
scale SQ RI
<140 md/dl: none
141- 160 mg/dl: 2 “U”
161- 200 mg/dl: 4 “U”
201- 300 mg/dl: 6 “U”
301- 400 mg/dl: 8 “U”
>400 mg/dl: refer
It is done to monitor blood glucose level.
Indicated for diabetes mellitus and to
evaluate the effectiveness of insulin
administration.
January 25, 2011 8: 25 am- May go to bathroom with To promote good circulation of blood in the 112| P a g e
assistance body, maintain good body alignment and
to prevent further problems such as
weakness and difficulty of walking.
11:00 am- Plan: 1. D/C Sliding scale
2.Decrease HGT every 12 hours
It is done to monitor blood glucose level.
Indicated for diabetes mellitus and to
evaluate the effectiveness of insulin
administration.
Rehabilitation Program
- For PT session this afternoon then
BID
- Kindly secure 5 PT sessions
To develop, maintain and restore
maximum movement and functional ability.
To treat musculoskeletal problems.
January 26, 2011 May have fresh fruits on diet Fruits provide the body with so many
nutrients. These include numerous forms
of vitamins and energy.
1: 40pm- MGH after PT session
- With home medications:
Minidiab 9mg 1 tab OD pre-
breakfast
Neuroaide 4 tabs 3x a day
Aspiring 80mg/ tab 1 tab
OD
Lipitor 40mg 1 tab OD
This to ensure continuity of care and for
better outcome in the treatment
To comply on treatment regimen and
maintenance medications and to prevent
reoccurrence of the disease.
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3. Drug StudiesGeneric : Amlodipine
Brand : Amvaz® , Norvasc®
Classification : Calcium Channel Blocker
Date Ordered : 1/24/11
Ordered Dose : 10mg/1tab (1 tab, once a day)
Suggested Dose : 2.5mg, 5.0mg, 10mg
Action : Inhibits influx of calcium through the cell membrane, resulting in a
depression of automaticity and conduction velocity in cardiac muscle.
Decreases SA and AV conduction and prolongs AV nod effective and
functional refractory periods.
Indications : Hypertension and Chronic angina
Contraindications : Clients with impaired hepatic function
: Clients with CHF
Side Effects : Edema, palpitations, dizziness, headache, fatigue, muscle
cramps, nasal or Chest congestion, polyuria, dysuria
Drug Interactions :Diltiazem (increase plasma levels of Amlodipine and further decrease
Blood Pressure)
: Grapefruit juice (increase plasma levels of Amlodipine)
Nursing Responsibilities:
Instruct that taking with or without food does not affect the bioavailability of amlodipine.
Patients with hepatic insufficiency may be started on 2.5mg/day.
Can safely be taken with beta-blockers, nitrates, nitroglycerin (sublingual).
Take as directed, once daily.
Report unusualities felt such as (dizziness, chest pain, swelling of extremities, irregular
pulse).
Instruct to ask for generic for cost saving purposes.
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Generic : aspirin (Acetylsalicylic acid)
Brand : Bayer®
Classification : NSAIDS, antipyretic and analgesic
Date Ordered : 1/24/11
Ordered Dose : 80mg/tab (1 tab, once a day)
Suggested Dose : tablets (325mg), enteric-coated (80mg, 165mg, 325mg, 500mg)
Action : Exhibits antipyretic, anti-inflammatory, and analgesic effects.
: The antipyretic effect is due to an action on the hypothalamus, resulting
in heat loss by vasodilation of peripheral blood vessels.
: The anti-inflammatory effects are probably mediated through inhibition of
cyclo-oxygenase, which results in a decrease in prostaglandin (implicated
in the inflammatory response).
Indications : Analgesic ( pain from integumentary, myalgia, neuralgia,
arthralgia, headache, dysmenorrhea, pain secondary to trauma)
: Reduces risk of death, nonfatal stroke, and recurrent myocardial
infarction.
Contraindications : Hypersensitivity to salicylates
: Clients who have asthma , Hay fever, Nasal polyps
Side Effects :G.I.: Dyspepsia, nausea, epigastric discomfort, heartburn,
anorexia
: Hematologic: Prolongation if bleeding time, thrombocytopenia,
leukopenia, shortened erythrocyte survival time
Drug Interactions : ACE inhibitors (decreases effect of ACE inhibitors)
: Acetazolamide (increases CNS toxicity of salicylates and increases
secretion of salicylic acid in alkaline urine)
: Ethyl Alcohol (increases chance of GI bleeding caused by salicylates)
: Antacids (decreases salicylate levels in plasma due to increased rate of
renal excretion)
: Ammonium Chloride (increases effect of salicylates by increased renal
tubular reabsorption)
Nursing Responsibilities:
Take as directed. To reduce gastric irritation administer with meals and a full glass of
water.
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Instruct to avoid taking antacids within 1 to 2 hours after ingestion of enteric-coated
tablets this is because Sodium Bicarbonate may decrease serum level of aspirin thus
reducing its effectiveness.
Instruct to note expiration date and color of product before taking.
Report toxic effects immediately such as: (hearing, dizziness or unusual increase in
sweating and severe abdominal pain)
Avoid high alcohol ingestion; may cause GI bleeding.
Generic : Atorvastatin Calcium116| P a g e
Brand : Lipitor®
Classification : Antihyperlipidemic
Date Ordered : 1/24/11
Ordered Dose : 40mg/tab (1 tab at hour of sleep)
Suggested Dose : 10mg, 20mg, 40mg, 80mg
Action : Competitively inhibits HMG-CoA reductase; this enzyme catalyzes
the early rate-limiting step in the synthesis of cholesterol. Thus,
cholesterol synthesis is inhibited/decreased. Decreases cholesterol,
triglycerides, LDL, and increases HDL.
Indications : Hypercholesterolemia, Dyslipidemia, Adjunct to diet to decrease
elevated total LDL cholesterol.
Contraindications : Active liver disease, Pregnancy, Lactation
Side Effects : Headache, asthenia, abdominal pain, cramps
Drug Interactions : Antacids (decrease atorvastatin levels)
: Clarithromycin (increase atorvastatin plasma levels)
: Colestipol (decreases atorvastatin levels)
: Digoxin (increases digoxin levels)
: Erythromycin (increases atorvastatin levels)
Nursing Responsibilities:
Instruct to take as single dose at any time of the day, with or without food.
Determine lipid levels within 2-4 weeks; adjust dosage accordingly
Instruct to continue dietary restrictions of saturated fat and cholesterol.
Encourage to have regular exercise and weight loss in the overall goal of lowering
cholesterol levels.
Report unexplained muscle pain, weakness, or tenderness, especially if accompanied by
fever or malaise.
Generic : citicoline
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Brand : Zynpase®
Classification : Psychostimulant
Date Ordered : 1/24/11
Ordered Dose : 2gms IVTT q 12 hours
Suggested Dose : Zynapse 500 - 125mg/mL Injection: 1 to 2 injections daily
: Zynapse 1000 - 250mg/mL Injection: 1 Injection daily
: Dosage may be adjusted based on the seriousness of the disease. It can
be administered intravenously, (3 to 5 minute) injection and in intravenous
drop perfusion (dripping speed 40-60 drops/minute). Zynapse is
compatible with all intravenous isotonic solutions.
Action : Activates the bio-synthesis of structural phospholipids in the
neuronal membrane. Increases cerebral metabolism and the levels of
various neurotransmitters, including acetylcholine and dopamine.
Restores the activity of mitochondrial ATPase and of membranal
Na+/K+ATPase and inhibits the activation of phospholipase A2 and
accelerates the re-absorption of cerebral edema in various experimental
models.
Indications : Cerebrovascular diseases - e.g. from ischemia due to stroke
: Head Trauma of varying severity
: Cognitive disorders
: Parkinson's disease
Contraindications : Pregnancy, lactating patients, persistent Intracranial Hemorrhage
Side Effects : Hypotensive Effect, sleeplessness
Drug Interactions : L-DOPA (potentiates effects of L-DOPA)
Nursing Responsibilities:
Instruct to take drug during day time.
Monitor Pulse and Blood Pressure before and after giving citicoline.
Generic : Potassium Chloride
Brand : Kalium Durule®118| P a g e
Classification : Electrolyte
Date Ordered : 1/25/11
Ordered Dose : 750mg/1tab (3 times a day)
Suggested Dose : 750mg, 3 to 4 tablets, not exceeding 12 tablets a day.
Action : Replaces potassium loss and maintains potassium level.
Indications : To prevent hypokalemia, Prophylaxis during treatment with
diuretics.
Contraindications : Patients with oliguria, anuria, untreated Addison’s disease, acute
dehydration, heat cramps
: Use cautiously with patient with cardiac disease and renal impairment
Side Effects : Arrhythmias, Heart block, Hypotension, Cardiac arrest,
Hyperkalemia, Respiratory paralysis, Nausea, Vomiting, Abdominal pain
Drug Interactions : Angiotensin converting enzyme (ACE) inhibitors [enalapril (Vasotec)]
: Angiotensin receptor blockers (ARB) drugs [valsartan(Diovan)]
: Spironolactone (Aldactone)
: Triamterene(Dyrenium)]
: NSAIDS
: (Concurrent use with potassium supplements may increase serum
potassium concentrations, which may cause severe hyperkalemia and
lead to cardiac arrest, especially in renal insufficiency).
: (NSAIDs in combination with potassium supplements may increase the
risk of gastrointestinal side effects)
Nursing Responsibilities:
Monitor potassium levels
Instruct to take with food to avoid GI irritation.
Instruct to report any unusualities felt such as difficulty of breathing, abdominal pain and
dizziness.
Check blood pressure before and after giving of potassium chloride.
Instruct to increase oral fluid intake.
Monitor pulse, blood pressure and ECG periodically during IV therapy.
Monitor serum potassium levels before and after therapy.
Generic : Glipizide
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Brand : MINIDIAB®
Classification : Sulfonylurea hypoglycaemic agent
Date Ordered : 1/25/11
Ordered Dose : 5mg/1tab (once a day, before meals)
Suggested Dose : starting dose (5mg), for geriatric patients with live disease (2.5mg)
Action : Lowers down blood glucose acutely by stimulating the release of
insulin from the pancreas, an effect dependent upon functioning beta cells
in the pancreatic islets.
Indications : For control of hyperglycaemia and treatment for non-insulin
dependent diabetes
Contraindications : Hypersensitivity to MINIDIAB or other sulphonylurea derivatives
: Patients with diabetic ketoacidosis, with or without coma (this condition
must be treated with insulin)
: Severe renal and hepatic insufficiency
: Pregnancy
Side Effects : Hypoglycaemia, Nausea, Abdominal Pain, Allergic reaction (skin
rash), Dizziness, Drowsiness, Blurred Vision
Drug Interactions : Fluconazole (increase chance of hypoglycaemia and increase half-life of
glipizide)
: Alcohol (increases hypoglycaemic effect of MINIDIAB which can lead to
hypoglycaemic coma)
: ACE inhibitors ( may lead to increased hypoglycaemic effect in diabetic
patients treated with MINIDIAB)
: H2 Receptor Antagonists(i.e. cimetidine) (may potentiate
hypoglycaemic effects of sulphonylureas including MINIDIAB
Nursing Responsibilities:
Instruct to take blood glucose level before and after giving of hypoglycaemic drug.
Enquire for any history of hypersensitivity to sulphonylurea derivative drugs.
Instruct to take during meal time.
Intruct to take drug as ordered specifically the dosage prescribed and the frequency.
Watch out for unusualities such as allergic reaction and signs of hypoglycaemia
such as (drowsiness, blurred vision and weakness)
120| P a g e
Generic : MLC 601
Brand : NeuroAid
Classification : Neuroprotective Agent
Ordered Dose : 3 capsules (3 times a day)
Suggested Dose : 3 capsules daily for 3 months.
Action : Potential role in neuroplasticity and neurogenesis. Stimulates the
secretion of BDNF and makes cells more resistant against glutamate
aggression. Increases neurite outgrowth and connectivity as well as
reduces the infarct volume which results in better neurological function.
Indications : Cerebral Stroke
: Heart Stroke
: Neurodegenerative diseases
: Brain Trauma
: Nervous System trauma
: Stroke disabilities such as: hemi paralysis or aphasia
Contraindications : No known contraindications
Side Effects : Nausea, Vomiting, Mild Headache, Thirst
Drug Interactions : No known drug interactions
Nursing Responsibilities:
Instruct to increase oral fluid intake.
Instruct to take analgesics as ordered to relieve headache.
Provide snacks of preferred bland food when available.
Encourage slow deep breathing to promote relaxation to avoid nausea.
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2. Discharge Plan
RATIONALE
MEDICATIONS
Advice patient to take medications at
home on time and as prescribed by the
physician.
Instruct patient and watcher not to
crush tablets and not to skip
medications.
Discuss with the patient and watcher
the name of the drug, its side effects,
its use and guidelines on when to
contact physician.
Instruct patient not to take any
medicines that are contraindicated to
the prescribed drugs.
Warn not to change brands of a drug
without consulting the doctor first.
Instruct patient not to stop taking the
prescribed drugs without notifying their
® Alterations in doses or timing may alter the
effect of the drug. Strict compliance to
medication facilitates relief of any signs and
symptoms or even faster recovery from the
illness or disease.
® Crush tablets have a strong, persistent bitter
taste. Skipping medications can alter the effect
of the drug and may build up to the
vulnerability of the microorganisms to the
drugs.
® This gives patient enough knowledge about
the drugs and to know what to expect and to
encourage compliance to it.
® Some drugs may have synergistic or
additive effect to certain drugs.
® They must also be well educated about the
proper time to take the medications since each
medication has prescribed time depending on
its possible side effects and pharmacokinetics.
® The amount of medicine that a person takes
depends on the strength of the medicine.
144| P a g e
health care provider.
Exercise
Instruct patient to have an adequate
rest and sleep.
Instruct patient to do range of motion if
tolerated such as stretching of
extremities.
Advise patient to consult a physical
therapist to determined appropriate
exercise plan.
Advise patient to join occupational
therapy.
® This lessens the strain to the body and to
allow relaxation.
® This helps loosen the joint structures,
promote wellness and improve
circulation. It would prevent aggravation and
exhaustion of the
muscles and joints.
® To involve re-learning functions as
transferring, walking and other gross motor
functions.
® Focuses on exercises and training to help
relearn everyday activities known as the
Activities of daily living (ADLs) such as eating,
drinking, dressing, bathing, cooking, reading
and writing, and toileting.
Treatment
Stress the importance of follow-up
examinations and treatment because of
changing physical status.
Stress also the importance of stroke
rehabilitation
® Allows adjustments of therapies or
medications appropriate for the current health
status of the client to minimize fatal side
effects of the medications, in cases there
maybe.
® To help them return to normal life as much
as possible by regaining and relearning the
skills of everyday living. It also aims to help
the survivor understand and adapt to
difficulties, prevent secondary complications
and educate family members to play a
supporting role.
145| P a g e
Hygiene
Instruct patient to take a bath daily.
Avoid using any product that has an
alcohol.
Encourage patient to do activities of
daily living
® This is one way to help in maintaining skin
care.
® This is to prevent dry skin that may cause
impairment of the skin integrity
® To promote good health. It also increases
the sense of wellness, which is very much
needed in the therapeutic process.
Out patient
Advise patient that to consult her
health care providers immediately if
there are any complications arising.
Advise patient to have a regular check
up with their health care provider.
Advise patient and significant others to
carry out follow up diagnostic regimen
® Immediate action helps in the client’s
improvement.
®This will help in the prevention of recurrence
and it allows monitoring of the client’s health
status.
® To evaluate worsening condition of the
client that needs medical attention.
Diet
Encourage patient to eat low salt and
low fat foods
Instructed patient to avoid sweet foods
Encourage patient to eat nutritious
foods such as fruits and green leafy
vegetables
® This may contribute to increasing risk of
having stroke and hypertension
®This may contribute to the viscosity of the
blood that may cause complications.
® This is to maintain a balance diet and to
prevent complications that may occur.
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The prognosis following a stroke is related to the severity of the stroke and how much of
the brain has been damaged. Some patients return to a near-normal condition with minimal
awkwardness or speech defects. Many stroke patients are left with permanent problems such
as hemiplegia (weakness on one side of the body), aphasia (difficulty or the inability to speak),
or incontinence of the bowel and/or bladder. A significant number of persons become
unconscious and die following a major stroke.
Disability affects 75% of stroke survivors enough to decrease their employability. Stroke
can affect patients physically, mentally, emotionally, or a combination of the three. The results of
stroke vary widely depending on size and location of the lesion. Dysfunctions correspond to
areas in the brain that have been damaged.
30 to 50% of stroke survivors suffer post stroke depression, which is characterized by
lethargy, irritability, sleep disturbances, lowered self esteem, and withdrawal. Depression can
reduce motivation and worsen outcome, but can be treated with antidepressants.
Emotional lability, another consequence of stroke, causes the patient to switch quickly
between emotional highs and lows and to express emotions inappropriately, for instance with an
excess of laughing or crying with little or no provocation. While these expressions of emotion
usually correspond to the patient's actual emotions, a more severe form of emotional lability
causes patients to laugh and cry pathologically, without regard to context or emotion. Some
patients show the opposite of what they feel, for example crying when they are happy.
Emotional lability occurs in about 20% of stroke patients.
Cognitive deficits resulting from stroke include perceptual disorders, speech problems,
dementia, and problems with attention and memory. A stroke sufferer may be unaware of his or
her own disabilities, a condition called anosognosia. In a condition called hemispatial neglect, a
patient is unable to attend to anything on the side of space opposite to the damaged
hemisphere. Up to 10% of all stroke patients develop seizures, most commonly in the week
subsequent to the event; the severity of the stroke increases the likelihood of a seizure.
So as to our patient’s condition, she was last admitted at the hospital due to right sided
weakness, couldn’t talk clearly and her face was quite deformed where it was then the start of
her Cerebrovascular accident. She underwent some treatments but unfortunately due to some
147| P a g e
reasons it happened that she had an attacked again. That is why she was prompted again to
seek medical treatment at the hospital because of her condition that it happened to become
severe and as of now she’s undergoing treatment to at least lessen or minimize attacks of her
situation. Overall, our patient’s condition is poor since it will be a lifetime state of her and
because of the severity of her condition. She has now complications that arise where the only
treatment is to maintain a good health of her to continue living life normally.
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