This document provides a case study of a 64-year-old male patient who presented with stiffening of the extremities. The patient has a history of hypertension, diabetes, and thyroid cancer. Physical assessment revealed weakness on the right side of the body. Diagnostic tests showed signs of inflammation and slightly abnormal thyroid and kidney function. A CT scan found lesions in the brain consistent with ischemic stroke. The case study aims to educate nursing students on assessing and caring for patients with ischemic stroke through knowledge of pathophysiology, appropriate interventions, and developing rapport with patients.

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2. Ischemic
Stroke
Case Study
January 2014
1. Basis of selection of case
In the previous years, a Food and Nutrition Research Institute 1998 study, about
21 percent of adults aging from 20 years old and above have hypertension, (the single

3. most important risk factor for stroke and it causes about 50 per cent of ischemic strokes
and also increases the risk of hemorrhagic stroke) while a Philippine Health Statistics
1993 figure showed 28 deaths per 100 000 population caused by stroke.
Nowadays, still, stroke makes its way on top. Worldwide, stroke is the second-
leading cause of death after heart disease and is also a big contributor to disability. Due to
the increasing number of stroke cases annually and the expanding cases in the younger
generation, the government of the Philippines should emphasize primary and secondary
prevention strategies.
As we talk about prevention strategies, there is a great role for nurses/student
nurses, as well as for the rest of the medical team, comes in. Reading a case study and
coming up with a diagnosis is a good way for nursing students to test the knowledge
they've acquired in the classroom in a more realistic, clinical way. Writing case studies is
also a useful learning tool; it forces students to reflect on the entire course of treatment
for a patient, ranging from obtaining important information to diagnosis to treating the
medical condition. Increasing the knowledge regarding the disease process of stroke, the
proper assessment of the patient, correct intervention, effective health teaching, etc will
contribute a lot in improving prevention strategies.
2. Clarity of Objectives
General Objectives

4. After 2 hours of case presentation, the students will be able to obtain the
knowledge to enhance skills and to develop the attitude towards caring of the patient with
cases regarding ischemic stroke.
Specific Objectives
Specifically, this aims to
KNOWLEDGE
1. Explain the pathophysiology of ischemic stroke.
2. Identify the main cause of the disease.
3. Name the signs and symptoms of the disease manifested by the client.
SKILLS
1. Carry out independent and dependent intervention being done to the client
appropriately and with care.
2. Perform comprehensive nursing interventions based on the client’s priority needs.
3. Demonstrate proper approach used in clients with ischemic stroke.
ATTITUDES
1. Establish rapport to the client and folks.
2. Encourage the folks to cooperate to the intervention being performed.
3. Avoid promising words that might worsen the client’s condition.
3.1 ASESSMENT
A. PATIENT’S PROFILE

5. NAME: R. C.
AGE: 64 years old
SEX: Male
DATE OF BIRTH: June 28, 1949
ADDRESS: Barotac Viejo, Iloilo
OCCUPATION: National Referee, Retired Teacher
RELIGION: Roman Catholic
NATIONALITY: Filipino
ACTIVITY: Moderate Backrest
CC: Stiffening of extremities
DATE OF ADMISSION: December 12, 2013
DIAGNOSIS: T/C Brain Mets v/s restroke prob. Bleed,
S/P CVD with no residuals (2013) HCVD R/O Metastatic cause DM 2- NIR
S/P Thyroidectomy for thyroid CA Stage 1
PHYSICIAN: Dr. A
B. NURSING HISTORY

6. I. Reason for Seeking Care
Stiffening of extremities
II. Present Health History
Patient R.C. is 64 years old, male and married. He is a retired teacher and a national
referee.
8 months prior to admission, patient experienced episode of syncope. He was then
admitted at St. Paul’s Hospital for 1 month and managed as CVP, no residual noted.
1 month prior to admission, undocumented fever was noted. He was admitted at Don
Ramon Tugbang Medical Center and diagnosed to have Urinary Tract Infection.
On the day of admission, patient experienced generalized weakness and stiffening of
extremities. A complaint of dizziness was noted. He was responsive and slurring of speech is
noted. He was brought to Don Ramon Tugbang Medical Center and then referred at Iloilo
Mission Hospital.
III. Past Health History

7. It was known that he is hypertensive and have Diabetes Mellitus. He has many previous
hospitalizations. He was diagnosed to have thyroid cancer stage 1 back in 1986. He had
undergone radiation therapy and left thyroidectomy in the same year at Philippine General
Hospital. No known allergies.
Last December 2012, He underwent Cranial CT scan and CT scan with contrast. January 7,
2014, he again underwent cranial CT scan.
IV. Current Medication
For now, he has current medication such as Amlodopine 10mg/tab OD, Simvastatin 40 mg/tab
OD, Losartan 50 mg/tab 1 tab OD for his hypertension and Metformin 500 mg 1 tab OD for his
Diabetes Mellitus.
V. Lifestyle
He is non-smoker and non-alcoholic drinker. He is also an athletic person. As verbalized
by the wife, most of the time he ate carrots instead of rice.
VI. Family History
As verbalized by the wife, he has familial history of Hypertension and Diabetes Mellitus.
C. PHYSICAL ASESSMENT

8. VITAL SIGNS
R.C.’s temperature is 36.5 °C, pulse rate is 88 beats per minute, respiratory rate is 20
breaths per minute, and blood pressure is 180/100 mmHg.
GENERAL APPEARANCE
R.C. is a 64 year old male, a national referee and a retired teacher. Bedridden since the
day of admission. Ectomorph, well developed and appears to be at stated age. Well cleaned and
wears appropriate clothes. Difficulty or discomfort making laryngeal speech sounds or varying
volume, quality, or pitch of speech. Comprehends directions. Appears to be in distress.
SKIN
Brown in color, dry, and wrinkled due to old age.Peeling, scaly and flaky skin on heels of the
feet. Skin color differences among body areas and between sun-exposed and non-sun-exposed
areas. Darker skin around elbows and knees. Warm in temperature. Turgor resilience. Bilateral
symmetry. Hair present on scalp, lower face, nares, chest, legs, and pubic areas.
NAILS
Nails beds pink with varying opacity. Short, squoval, smooth, flat, with edges smooth and round,
Longitudinal ridging and beading. Hard and firm with uniform thickness. Well-groomed and
uniform without deformities. Good capillary refill.
HEAD AND FACE

9. Hair is short, black with minimal gray hairs, and distributed evenly. Hair strands are thin,
fine and silky. Head is midline. Skull normocephalic, symmetric and without deformities. Scalp
is intact and without lesions or mass noted. Temporal pulses palpable. No bruits. Presence of
beard on upper lip and chin. Presence of black heads on the nose. Presence of dimple at the right
side of the face.
EYES
Eyebrows are smooth, black in color and distributed evenly and in line with each other.
With mole noted on the left inner end of the brow.Superior eyelid covering a portion of iris when
open. Eyelashes are black, evenly distributed, present on both lids and turned outward.
Conjunctivae pink, sclera anecteric. Irides black. Pupils equal, round, and reactive to light and
accommodation.
EARS
Auricles in alignment, same color as facial skin.Firm and mobile, readily coiling from
position; non-tender.Absence of discharges.
NOSE
Nose in midline, no discharges or polyps, mucosa pink and moist, septum midline, patent
bilaterally. Conforms to face to color.Nares oval and symmetrically positioned. No sinus
tenderness to palpation. With O2 at 2Lpm via nasal cannula.
MOUTH AND OROPHARYNX

10. Lips symmetric vertically and horizontally at rest and moving.Dry, bluish purple, distinct
border between lips and facial skin. Teeth are stained yellow and absence of left lateral incisor.
Gingiva pink and moist. Tongue is midline, dull red in color and moist. No tremors and
fasciculation. Hard palate and soft palate are pinkish in color. Pharynx clear without erythema.
Uvula rises evenly.
NECK
Neck is straight and symmetrical. Trachea midline. Jugular vein distention noted. Carotid
pulse palpable.Cricoid cartilages smooth and moves during swallowing. Left thyroid palpable,
firm, and smooth; presence of slightly hypoechoic nodule.Absence of right thyroid lobe.
THORAX AND CHEST
Minimal increase in the anteroposterior diameter of chest.Thoracic expansion symmetric.
No adventitious breath sounds. Regular respiratory rate. Chest retraction noted. Apical pulse on
5th intercostals space. The areola and nipples are dark brown in color and no discharges noted.
ABDOMEN
Soft, flat and symmetrical. Uniform in color, no pigmentation and rashes noted. No
abdominal scars and masses. Active bowel sounds audible in four quadrants.
UPPER EXTREMITIES

11. Arms fair in color and symmetrical. No tenderness upon palpation of muscle and joints.
Unable to passively perform full range of motion at right affected hand; stiffness noted. Palms
are pale and warm. Radial and brachial pulses palpable.With PNSS 1L x 80cc/H infusing well at
left cephalic vein.
LOWER EXTREMITIES
Legs are fair in color and symmetrical. Muscles are firm and skin is slightly dry. Soles
are pale and warm to touch. Unable to passively perform full range of motion at right affected
leg. Popliteal and dorsalis pedis pulses palpable.
GENITO-ANAL AND GENITO-URINARY
Pubic hairs are present. No skin lesions, penile discharges and swelling noted. Urinated to
a moderate amount of yellowish colored urine.Defecated to a soft brown stool.
D. DIAGNOSTIC TEST

12. LABORATORY TEST RESULT NORMAL VALUES SIGNIFICANCE
URINALYSIS
 Color Pale straw
 Transparency Slightly Hazy
 Reaction 7.0
 Specific Gravity 1.015 1.010 – 1.025 NORMAL
 Sugar 1+
 Albumin Neg ( - )
 Pus cells 3.6 hpf
 Red Bloodcells 0.3 hpf
 Amorphous urates FEW
 Squamous Cells FEW
 Bacteria Occasional
 Mucus Threads FEW
 Yeast Cells NONE
HEMATOLOGY
 Hemoglobin 103 g/L 140 – 180 Anemia, bleeding, blood
dyscrasia
 Hematocrit 0.31 vol.fr. 0.42- 0.52 Anemia
 Red bloodcell count 3.77 x 10^ 12/L 4.7 – 6.1 Anemia, bleeding, bone marrow
failure, malnutrition
 White bloodcell count 14.98 x 10 ^9/ L 5.2 -12.4 Infection, Anemia, adrenal or
thyroid gland issues, immune
system disorder, inflammation,
tissue
damage, severe stress
 Segmenter 90% 50 – 70 infection, inflammation
 Stab 0 2-5
 Juvenile 0 0 - 1 Normal

13.  Basinophil 0 0.0 – 1.5 Normal
 Eosinophil 0 0 – 7 Normal
 Lymphocyte 9% 19 – 48 not significant
 Monocyte 1% 3.4 – 9 not significant
 Platelet Count 341 x 10^9/ L 130 – 400 Normal
 MCV 83 fl 80 – 94 Normal
 MCH 27 pq 27 – 31 Normal
 MCHC 33g/dL 33 – 37 Normal
 RDW 11.7% 11.5 – 14.5 Normal
 ESR 37 mm/ Hr 0 – 10 inflammation
IMMUNOLOGY
 CRP 48 mg/L <6- inflammation
 T3 95nmol/L 0.95 – 250 Normal
 T4 91.43 nmol/L 60 – 120 Normal
 TSH 0.88 u/ v/mL 0.25 – 5.0 Normal
Euthyroid: 0.25 – 5.0u/V/ml
Hypothyroid : greater than
7.0u/V/ml
Hyperthyroid: less than
0.15u/V/ml
 APTT 24.4 sec 24.0 – 35.0 Normal
 % Activity 99% 70-100 Normal
 Patient 13.1 sec 11.6- 16.0 Normal
 INR 1.00 -
CHEMISTRY
 Fastingbloodsugar 9.58 mmol/L 4.10 – 5.90 heart attack, stroke
 Cholesterol 3.44 mmol/L 1.30 – 5.2 Normal
 Triglycerides .94 mmol/L 0.17 – 1.70 Normal

14.  HDL 0.84 mmol/L .90 – 1.55 atherosclerosis, CVD
 LDL 2.17 mmol/L 0.0 – 3.9 Normal
 Uric Acid 178 mmol/L 160-430 Normal
 Calcium 2.05 mmol/L 2.12- 2.25 Hypocalcemia
ULTRASOUND
Thyroid Ultrasound:
 The right thyroidlobe is surgically absent. Theleft thyroidmeasures 3.73x 1.63 x 1.29cm ( LxWxAP ). The
isthmus is not thickenedandmeasures 0.21mmin thickness. Thereis a slightly hyporechoic nodule notedin the
inferior aspect of the left thyroid lobe measuring0.81x 0.71 x 0.53cm ( LxWxAP ). There is a cystic focus
notedat the junctionof the isthmus andleft thyroidlobe measuring0.46 x 0.46x 0.26cm ( LxWxAP ). A cystic
focus is also notedin the midportion ofthe thyroidlobe measuring0.24x 0.11cm ( WxAP ).
The surroundingsoft tissues andvascular structures are unremarkable.
No mass/enlargedcervical lymphnodes appreciated.
Remarks:
 Left thyroidnodule andcyst.
 S/P Right thyroidectomy.
CHESTX-RAY
ChestPA:
 Clear lungfield with no grossly evident active koch’s infiltrates
 Tracheamidline
 Intact costophrenicsinuses
 Smooth diaghragmatic leaves
 Cardiac silhouettenorenlargedtransversely
 Curvilinear calcific densitynotedat the aortic knob
 Rest of the visualizedsoft andosseous tissues appear
 Unremarkable
Impression:
 Atherosclerosis: Aorta
CTSCAN

15.  Plain andcontrast enhancedaxial tomographicsections of the headreveal inhomogeneously enhancinghypodensitywith gyral
enhancement at theright frontoparietal areas. Also note of enhancingisodense nodules lesions withsurroundingedema in the right
inferior frontal andright frontal periventricular areas.
There are small hypodensities onboth capsuloganghenic andbifrontoparietal periventricularareas.
The ventricles areenlarged.
The midline structures are displacedto theleft.
The cerebral sulci are effaced.
No abnormal extra-axial fluidcollectiondemonstrated.
No posterior fossa , brain stemandsellar region do not appear unusual.
The petromastoids, includedorbits andparancoal sinuses andthe bony calvarium are unremarkable.
Remarks:
 Right frontoparietalhypodensity withgyral enhancement.
 Right inferiorfrontal andright frontal periventricular enhancinglesions withsurroundingedema.
 Lacunar infarcts, bilateral capsuloganglionicbifrontoparietal periventricular areas.
 Leftwardsubfalcine herniation.
 Obstructive hydrocephalus.
Drug Therapy
Generic name:Valporic Acid
Classification: Anti Convulsant
Dosage:( Adult and children > 10 y.o )
= 10- 15 mg/kg/day PO Route: Oral
Therapeutic Actions:
 Mechanism of action not understood; Anti epileptic activity may be related to the
metabolism of inhibitory neurotransmitter, GABA.
Indications:
 Solo and adjunctive therapy in simple ( petit mal ) and complex absence seizure
 Acute treatment of manic episode associated with bipolar disorder
 Prophylaxis of migraine headache
Contraindication and Cautions:
 Contraindicated with hypersensitivity to valporic acid, hepatic disease or significant
hepatic impairment
 Use cautiously with children younger than 18 months; children younger than 2 y.o
Adverse Effects:

16.  CNS: Sedation, emotional upset, depression, psychosis, aggression, behavioral
deterioration, suicibility.
 SKIN: Hair loss, rash
 GI: Nausea, vomiting, indigestion, diarrhea, abdominal cramps, constipation.
 GU: Irregular menses, amenorrhea
 HEMATOLOGIC: Altered bleeding, bruising.
Nursing considerations:
 Products containing alcohol should be avoided.
 Give drug with food if GI upset occurs.
 Be aware that the patient maybe increased risk for suicidal ideation monitor accordingly.
Patient Teaching:
 Take this drug exactly as prescribed.
 Do not chew tablet or capsule before swallowing them.
 Do not discontinue this drug abruptly or change dosage.
 Avoid alcohol and sleep inducing drugs.
Generic name:Losartan Potassium
Classification:Angioten II Antagonist
Dosage:( Adult and children 6 yrs and older )
= Starting dose of 50 mg PO daily Route: Oral
Therapeutic Actions:
 Selectively blocks the binding of angiotensin II to specific tissue receptors found in the
vascular smooth muscle and adrenal gland.
Indications:
 Treatment of hypertension, done or combination with other hypertensive.
 Treatment of diabetic nephropathy.
 Reduction of risk of CVA in patients.
Contraindications and Cautions:
 Contraindicated in previous hypersensitivity.
 Pregnancy or lactation
 Reduce dosage with hepatic or renal impairment.
Adverse Effects:
 CNS: Headache, dizziness and insomnia

17.  CV: Hypertension
 SKIN: Rash and dry skin
 GI: Diarrhea, abdominal pain and nausea
 RESPIRATORY: Cough
 OTHER: Back pain, fever and gout
Nursing Considerations:
Assessment
 Hypersensitivity to Losartan
 Pregnant
 Lactation
Patient Teaching:
 Take drug without regard to meals
 May experience these side effects:
- Dizziness
- Headache
- Nausea and vomiting
 Report fever, chills and pregnant
Generic name:Metformin
Classification:Antidiabetic Agents
Drugs:( Adult and pediatric 10 – 16 y.o )
= 500 mg bid/ 250 mg bid Route: Oral
Therapeutic Reaction:
 Increase peripheral utilization of glucose and decrease hepatic glucose production.
Indications:
 Adjunct to diet to lower blood glucose with type 2 DM
Contraindication and Cautions:
 With allergy to metformin, heart failure, diabetes complicated by fever, severe trauma
and severe infection.
 Use cautiously with the elderly
Adverse Effects:
 ENDOCRINE: Hypoglycemia
 GI: Anorexia, nausea and vomiting
 HYPERSENSITIVITY: Allergic skin reaction
Nursing Considerations:
 Allergy to metformin
 Pregnancy
 Lactation

18. Patient Teaching:
 Monitor blood for glucose and ketones as prescribed.
 Do not use this drug during preganancy.
 Avoid using alcohol while taking this drug.
 Report fever, sore throat, unusual bleeading and bruising.
Other anti-diabetic drugs: Gliclazide, Sitagliptin
Generic name: Baclofen
Classification: Muscle relaxant
Dosage: 5 mg PO tid for 3 days Route: Oral
Therapeutic Actions:
 Inhibits both monosynaptic and polysynaptic spinal reflexes; CNS depressant
Indications:
 Alleviation of signs and symptoms of spasticity resulting from MS
 Spinal cord injuries and other spinal cord diseases
Contraindications and Cautions:
 Contraindicated in previous hyper sensitivity.
 With skeletal muscle spasm
 Use cautiously with strokes, cerebral palst, parkinson’s disease
 Lactation and pregnancy
Adverse Effects:
 CNS: Transient drowsiness, weakness, fatigue
 CV: Hypotension
 GI: Nausea, Constipation
 GU: Urinary frequency, dysuria
 OTHER: Rash, pruritus, ankle edema
Nursing Considerations:
 Discontinue drug if hypersensitivity reaction occur
 Lactation
 Evaluate therapeutic response
Patient Teachings:
 Take this drug exactly as prescribed
 Avoid alcohol
 Do not take this during pregnancy

19. Generic Name: Amlodipine
Classification:Antianginal; Antihypertensive; Calcium channel blocker
Dosage: Adult and Pediatric 6-17 y.o.
2.5-5 mg daily
Route: Oral
Therapeutic actions:
 Inhibits the movement of calcium ions across the membranes of cardiac cells; inhibits
transmembrane calcium flow, w/c result in depression of impulse formation in
specialized cardiac pacemaker cells, slowing velocity of conduction of the cardiac
impulse.
Indications:
 Angina pectoris due to coronary artery spasm(Prinzmetal’s
Variant angina)
 Essential hypertension
Contraindications and cautions:
 Contraindicated w/ allergy to amlodipine
 Use cautiously w/ heart failure
 Pregnancy
Adverse effects:
 CNS: Dizziness, headache, and fatigue
 CV: Peripheral edema

20.  Skin; Flushing, rash
 GI: Nausea, abdominal discomfort
Nursing Consideration:
 Administer drug w/out regards to meals
 Monitor BP carefully
Patient teachings:
 Take w/ meals if upset stomach occurs
 Report irregular heartbeat, shortness of breath, and constipation
Generic name: Diazepam 5 mg IV
Classification: Antiepileptic; Anxiolytic
Dosage: Usual dosage is 2-20 mg IM/IV
Route: IM/IV
Therapeutic actions:
 Acts mainly as the limbic system and reticular formation; may act in spinal cord and at
supraspinal sites to produce skeletal muscle relaxation
Indications:
 Management of anxiety d/o
 Acute alcohol withdrawal
 Muscle relaxant
Contraindications and cautions:
 Contraindicated w/ hypersensitivity to benzodiazepines
 Use cautiously w/ elderly, impaired renal function
Adverse effects:
 CNS: Sedation, depression, fatigue, and restlessness
 CV: Bradycardia, CV collapse, and hypertension
 Skin: Rash and dermatitis
 GI: Constipation and diarrhea
 GU: Urinary retention
 Hematologic: Decreased Hct
 Other: Phlebitis and thrombosis in IV site, fever, diaphoresis, and muscular disturbances

21. Nursing considerations:
 Hypersensitivity to benzodiazepines
 Pregnancy and lactation
 Carefully monitor P, BP, respiration, during IV administration
Patient teachings:
 Take this drug exactly as prescribed
 Tell patient to report drowsiness, and weakness
Generic name: Mannitol
Classification: Osmotic; Urinary irrigant
Dosage: 50-200g/day
Route: IV
Therapeutic actions:
 Elevates the osmolarity of the glomerular filtrate, thereby hindering the reabsortion of
water leading to a loss of water, sodium, chloride: creates an osmotic gradient in the eye
between plasma and ocular fluids thereby reducing IOP.
Indications:
 Prevention and treatment of oliguric phase of renal failure
 Promotion of urinary excretion of toxic substances
 Irrigant in transurethral prostatic resection
Contraindications and cautions:
 Contraindicated w/ anuria due to severe renal disease
 Use cautiously w/ pulmonary congestion, dehydration, heart failure
 Lactation
 Pregnancy
Adverse effects:
 CNS: Dizziness, headache , blurred vision, SEIZURES
 CV: Hypertension, edema, thrombophlebitis and chest pain
 Skin: Skin necrosis w/ infiltration
 GI: Nausea, dry mouth
 GU: Diuresis, urine retention
 Hematologic: Fluid and electrolyte imbalance
 Respiratory: Pulmonary congestion

22. Nursing Considerations:
 Do not expose solution to low temp crystallization may occur
 Make sure infusion set contains a filter if giving concentrated mannitol
 Monitor serum electrolytes periodically w/ prolonged therapy
Patient teachings:
 Patient may experience these side effects: Increased urination, GI upset, dry mouth,
headache, blurred vision- ask for assistance
 Report difficulty of breathing, pain at the IV site and chest pain
Generic name: Simvastatin
Classification:Antihyperlipidemic
Dosage: 20-40 up to 80 mg PO daily in the evening
Route: Oral
Therapeutic actions:
 Inhibits HMG-CoA reductase, the enzyme that catalyze the first step in the cholesterol
synthesis pathway
Indications:
 To reduce the risk of coronary disease
 Treatment of patients w/ isolated hyper triglyceridemia
 Treatment of type III hyperlipoproteinemia
Contraindications and cautions:
 Contraindicated w/ allergy to simvastatin
 Use cautiously w/ impaired hepatic and renal function
 Cataracts
Adverse effects:
 CNS: Headache, sleep disturbances
 GI: Flatulence, diarrhea, abdominal cramps, constipation, nausea, heartburn, LIVER
FAILURE
 Respiratory: Sinusitis
 Other: ACUTE RENAL FAILURE, myalgia
Nursing considerations:
 Allergy to simvastasin
 Give in evening; highest rate of cholesterol synthesis are bet midnight and 5 am

23.  Advise patient that this drug cannot be taken during pregnancy
Patient teachings:
 Take drug in the evening
 Patient may experience these side effects: Nausea, headache, muscle and joint pains,
sensitivity to light
 Report severe GI upset, changes in vision, unusual bleeding/bruising, dark urine or light
colored stool, fever, muscle pain or soreness
E. Pathophysiology
Stroke or cerebrovascular accident also known as the brain attack is a vascular disorder
that injures the brain function. Stroke remains one of the leading causes of mortality and
morbidity. The term brain attack has become a popular substitute for stroke, with the intent of
equating stroke with a heart attack in terms of the timetable associated with the development of
neurologic deficits and the need for prompt emergency treatment.
A brain attack is a sudden impairment of cerebral circulation in one or more blood
vessels. It occurs when a blood clot blocks the blood flow in a vessel or artery or when a blood
vessel breaks, interrupting blood flow to an area of the brain. Regardless of the cause, the
underlying event is deprivation of oxygen and nutrients. Normally, if the arteries become
blocked, autoregulatory mechanisms help maintain cerebral circulation until collateral circulation
develops to deliver blood to the affected area. If the compensatory mechanism becomes
overworked, or if cerebral blood flow remains impaired for more than a few minutes, oxygen
deprivation leads to infarction of brain tissue. Stroke interrupts or diminishes oxygen supply and

24. commonly causes serious damage or necrosis in the brain tissues. When either of these things
happens, brain cells begin to die.
When brain cells die during a stroke, abilities controlled by that area of the brain are lost.
These include functions such as speech, movement, and memory. The specific abilities lost or
affected depend on the location of the stroke and its severity.
There are two types of “brain attacks” – ischemic and hemorrhagic. With ischemic
strokes, a blood clot blocks or plugs a blood vessel in the brain. With hemorrhagic strokes, a
blood vessel in the brain breaks or ruptures.
An ischemic stroke can occur in several ways – embolic, thrombotic, Transient ischemic
attack, and lacunar infarcts. Embolic stroke occurs when a blood clots forms in the body (usually
the heart) and travels through the blood stream to the brain. Once in the brain, the clot eventually
travels to a blood vessel small enough to blocks its passage. The clot lodges there, blocking the
blood vessel causing a stroke. In the thrombotic stroke, blood flow is impaired because of the
blockage to one or more arteries supplying blood in the brain. Blood-clot strokes can also happen
as the result of unhealthy blood vessels clogged with the build up with fatty acids and
cholesterol. So your body reacts in these injuries just as it would if you were bleeding from a
wound- it responds by forming clots. Transient ischemic attacks, or TIAs, are brief episodes of
stroke symptoms resulting from temporary interruptions of blood flow to the brain. It can last
anywhere from a few seconds up to 24 hours. Lacunar infarcts are small (1.5 to 2.0 cm) to very
small (3 to 4 mm) infarcts located in the deeper noncortical parts of the brain or in the brain
stem. They are found in the territory of single deep penetrating arteries supplying the internal
capsule, basal ganglia, or brain stem. They result from occlusion of the smaller branches of large

25. cerebral arteries, commonly the middle cerebral and posterior cerebral arteries and less
commonly the anterior cerebral, vertebral, or basilar arteries. In the process of healing, lacunar
infarcts leave behind small cavities, or lacuna. Six basic causes of lacunar infarcts have been
proposed: embolism, hypertension, small-vessel occlusive disease, hematologic abnormalities,
small intracranial haemorrhages, and vasospasm. Because of their size and location, lacunar
infarcts do not usually cause profound deficits such as aphasia or apracticagnosia of the minor
hemisphere. Instead, they often produce syndromes such as pure motor hemiplegia, pure sensory
hemiplegia, and dysarthria with the clumsy hand syndrome.
Overview
The Neurological System is divided into two major parts: the Central Nervous System
(CNS) and the Peripheral Nervous System (PNS).
The Central Nervous System is the body’s information headquarters, ultimately
regulating nearly all body functions. It CNS includes the brain and spinal cord.
The brain processes incoming information from within the body, and outside the body by
way of the sensory nerves of sight, touch, smell, sound, and taste. In other words, the brain is
where all thinking and decision-making takes place.
The spinal cord is the main pathway for information connecting the brain and peripheral
nervous system. Electrical impulses travel through the nerves and allow the brain to
communicate with the rest of the body.

26. The Peripheral Nervous System is responsible for the remainder of the body. It includes
cranial nerves (nerves emerging from the brain), spinal nerves (nerves emerging from the spinal
cord) and all the major sense organs.
The PNS is divided into the somatic (SNS) and autonomic nervous system (ANS).
The Somatic Nervous System (SNS) is responsible for all muscular activities that we
consider voluntary or that are within our conscious control.
The Autonomic Nervous System (ANS) is responsible for all activities that occur
automatically and involuntarily, such as breathing, muscle contractions within the digestive
system, and heartbeat.
The ANS is further divided into two- the sympathetic and parasympathetic system.
The Sympathetic System stimulates cell and organ function. It is activated by a perceived
danger or threat: by very strong emotions such as fear, anger or excitement; by intense exercise;
or when under large amounts of stress.
The Parasympathetic System inhibits cell and organ function. It slows down heart rate,
resumes digestion, and increases relaxation throughout the body.
The brain is the center of our body functioning. Once it is injured the total functioning of our
body will be affected. Physical activities are hampered and other vital organs will also be
affected as well. Once vital organs are not in their optimum functioning, it will aggravate the
seriousness of the condition of the patient.

27. Space – occupying blood
clots put more pressure in
the brain tissues
The ruptured cerebral
The regulatorymechanisms
of the brain attempt to
maintain equilibrium by
increasing BP and ICP.
Due to thrombosis, or
embolism, someneuronsdie
because of lack of oxygen
and nutrients
Hemorrhagic
Infarction of the Cerebral Vessels known as
Stroke
Tissue injury triggers an
inflammatory response
whichincreasesintracranial
pressure.
The injury disrupts
metabolism leading to
changes in ionic transport,
localized acidosis, and free
radical formation
Calcium,Sodium,water
accumulate inthe injured

28. F. Prioritizing Nursing Diagnosis
1. Ineffective Cerebral Tissue Perfusion related to cerebral edema as evidenced by altered
level of consciousness, stiffening of extremities, slurred speech
2. Impaired Physical Mobility r/t neuromuscular/musculoskeletal impairment
3. Self-Care Deficit r/t impaired mobility status
4. Disturbed Sensory Perception r/t altered sensory perception
5. Impaired Verbal Communication r/t decreased circulation to the brain

30. Cues Nursing Diagnosis Outcome Criteria Nursing Intervention Rationale Evaluation Discharge Planning
Subjective:
“ Budlayan siya
maghulag kag
maluya na ang
tuo nga parti
sang iya lawas.
Nabudlayan sya
maghambal daw
indi
maintindihan.”
as verbalized by
the folk.
Objective:
 T–36.5
 P - 88
 R - 22
 BP – 180/100
 GCS – 11
 Stiffening of
extremities
 Slurred
speech
 Ineffective
Cerebral
Tissue
Perfusion
related to
cerebral
edema as
evidenced by
altered level of
consciousness,
stiffening of
extremities,
slurred speech
Short Term:
After 8 hours of
effective nursing
intervention the
patient will be able
to:
1. Demonstrate
stable vital
signs.
2. Prevent /
minimize
complications.
3. Daily needs are
met either by
himself or
others.
4. Be free from
injury and fall
Long Term:
After 2 weeks of
effective nursing
intervention the
patient will be able
to:
1. Maintain
Independent:
1. Determine factors
related to individual
situation /decreased
cerebral perfusion.
2. Monitor/document
neurological status
frequently and
compare with
baseline.
3. Monitor vital signs.
4. Provide safety
measures
5. Evaluate pupils,
noting size, shape,
equality, light
 Influences choice of
interventions.
 Assesses trends in level
of consciousness
(LOC) and useful in
determining location,
extent, and
progression/resolution
of CNS damage. May
also reveal presence of
TIA, which may warn
of impending
thrombotic CVA.
 Monitor Alterations
 Prevent falls and injury
 Pupil reactions are
regulated by the
oculomotor (III) cranial
PARTIALLY
MET
Short Term:
After 8 hours of
effective nursing
intervention the
patient was
partially able to:
1. Demonstrate
stable vital
signs.
2. Prevent /
minimize
complications.
3. Daily needs are
met either by
himself or
others.
4. Free from
injury and fall
Long Term:
After 2 weeks of
effective nursing
intervention the
M – Instruct the
folks and the
patient to take
drugs as ordered.
Emphasize the
importance of
taking the drugs
at the right timing
of intake and
right dosage.
Explain to
patient/folks the
adverse effects of
the drugs.
E –
Provide/maintain
stress free
environment for
the client to
lessen discomfort.
T – Instruct
patient to perform
exercise treatment
given by physical

31. usual/improved
level of
consciousness,
cognition, and
motor/sensory
function.
2. Increased
cerebral
function and
decrease
neurological
deficits.
reactivity.
6. Assess higher
functions, including
speech, if patient is
alert.
7. Position with head
slightly elevated
and in neutral
position.
nerve and are useful in
determining whether
the brainstem is intact.
Pupil size/equality is
determined by balance
between
parasympathetic and
sympathetic enervation.
Response to light
reflects combined
function of the optic
(II) and oculomotor
(III) cranial nerves
 Changes in cognition
and speech content are
an indicator of
location/degree of
cerebral involvement
and may indicate
deterioration/increased
ICP.
 Reduces arterial
pressure by promoting
venous drainage and
may improve cerebral
patient was
partially able to:
1. Maintain
usual/improved
level of
consciousness,
cognition, and
motor/sensory
function.
2.Increased
cerebral
function and
decrease
neurological
deficits.
therapist. Advice
folks to assist
patient.
H – Instruct folks
to place patient
on moderate
backrest.
Encourage active
ROM for
unaffected
extremities and
perform passive
ROM for affected
extremities.
O – Explain to the
patient and folks
the importance of
keeping follow-
up appointments
with health care
providers and to
report any
untoward signs
and symptoms.

32. 8. Maintain bedrest;
provide quiet
environment;
restrict
visitors/activities as
indicated. Provide
rest periods
between care
activities, limit
duration of
procedures.
Dependent:
1. Administer oxygen
at 2 Lpm as
ordered.
2. Administer the
following as
ordered:
-Baclofen1tab BID
and ValproicAcid
-Mannitol
circulation/perfusion
 Continual
stimulation/activity can
increase ICP. Absolute
rest and quiet may be
needed to prevent
rebleeding in the case
of hemorrhage.
 Reduces hypoxemia,
which can cause
cerebral vasodilation
and increase
pressure/edema
formation.
 For skeletal muscle
spasticity of spinal
&cerebral origin
D – Instruct the
patient/folks to
follow the diet
intended for the
patient. Healthy
and rich in
vitamins and
minerals.
Collaborate with
the dietician.
S – Encourage
folks to provide
physical,
emotional,
financial, and
spiritual support
to the patient.

33. 25cc IV q8H
-Levetriacetam
500mg 1tab OD
-Losartan
50mg/tab 1tab OD
-Citicoline 500mg
1tab BID
-Amlodipine 20mg
1tab OD
-Simvastatin
40mg/tab 1tab OD
 To increase urine flow
in patients w/ acute
renal failure, reduce
raised intracranial
pressure & treat
cerebral edema.
 Adjunctive therapy in
the treatment of partial
seizures w/ or w/o
secondary
generalization.
 To manage HTN
 To treat
cerebrovascular
disorders including
ischemic stroke,
Parkinsonism & head
injury.
 To manage HTN &
angina pectoris.
 To treatment
hyperlipidemia;
prophylaxis in
hypercholesterolemic
patients w/ ischemic
heart disease.