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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
in research findings such as perception and coordination. This will serve as an instrument for us
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to develop an effective and efficient health care provider representing our quality of care to the
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.

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
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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

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
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.

Biographical Data

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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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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
Cerebrovascular accident (CVA). Ma’am LSP’s condition was managed by giving her
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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


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
children and let them learned from her values she used to instill to her children before. As of

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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
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
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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)

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
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just within her residence. Furthermore, she can move easily and comfortably in her own
house because she is oriented to where things are.

Date: January 26, 2011

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
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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 Actual Normal Remarks
Signs VS Ranges
Temperatu 36.2 ºC 35.6-36.7 ºC Afebrile
Pulse Rate 90 bpm 80-90 bpm Tachycardia
Respirator 21 cpm 16-20 cpm Tachypnea
y rate
Cardiac 92 bpm 80-90 bpm Tachycardia
Blood 140/80 110/70-130/90 Hypertension
Pressure mmHg mmHg


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.


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.

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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 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.


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.

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
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.

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.
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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


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 5th intercostal space,
slightly below the breast. Jugular veins are not distended and visible.


The client refused to be assessed on these parts.

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.

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.


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
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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
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 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- The client was able hear normal voice
VESTIBULOCOCHL tone and even whisper.

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9- Client is able to move her tongue from
GLOSSOPHARYNG side to side and up and down and was
EAL 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


Pupil Size 2 mm 2 mm
Pupil Reaction Sluggish Sluggish
Hand Grip Strong Weak
Leg Movement Strong Weak

Glasgow Actual Score

Coma Scale
Eye Opening 4 Eyes open
Motor spontaneously
Response 6 Obeys commands
Verbal 5 Oriented
GC Total 15
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Reaction Level Actual Score
Alert, Fully 1

Therefore, the client has a RLS/GCS of 1/15.


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.


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

Complete definition
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

of diagnosis 17| P a g e
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

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.


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.

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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 classification
The 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.

Functional classification
The 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
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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 Function

The nervous tissue is made up of two principal types of cells, the supporting cells and
the neurons.

Supporting cells
Supporting 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
delicate neurons. Each different types of neuroglia is simply
called glia or glial cells, has special functions. The CNS glia
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
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.

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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, 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
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
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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.

Functional 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.

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The spinal cord
The 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
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.
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• 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
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.


Cerebral Hemispheres
The 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
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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.
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.

The 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

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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
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

The 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.


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The 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 fluid
Cerebrospinal 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
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
Cranial nerve New research indicates CN0 may play a
olfactory trigone, medial
zero(CN0 is not role in the detection of pheromones [2]
0 olfactory gyrus, [3]
traditionally Linked to olfactory system in human
and lamina terminalis
recognized.)[1] embryos[4]
Transmits the sense of smell; Located
I Olfactory nerve Anterior olfactory nucleus in olfactory foramina in theCribriform
plate of ethmoid
Transmits visual information to the brain;
II Optic Nerve Ganglion cells of retina[5]
Located in optic canal
III Oculomotor nerve Oculomotor Innervates levator palpebrae

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superioris, superior rectus, medial
rectus, inferior rectus, and inferior
nucleus,Edinger-Westphal oblique, which collectively perform most
nucleus eye movements; Also innervates m.
sphincter pupillae. Located in superior
orbital fissure
Innervates the superior oblique muscle,
which depresses, rotates laterally (around
IV Trochlear nerve Trochlear nucleus
the optic axis), and intorts the eyeball;
Located insuperior orbital fissure
Principal sensory Receives sensation from the face and
trigeminal nucleus, Spinal innervates the muscles of mastication;
trigeminal Located in superior orbital
V Trigeminal nerve nucleus,Mesencephalic fissure (ophthalmic nerve - V1), foramen
trigeminal rotundum (maxillary nerve - V2),
nucleus,Trigeminal motor and foramen ovale(mandibular nerve -
nucleus V3)
Innervates the lateral rectus, which
VI Abducens nerve Abducens nucleus abducts the eye; Located insuperior
orbital fissure
Provides motor innervation to
the muscles of facial expression,
posterior belly of the digastric muscle,
and stapedius muscle, receives the
Facial nucleus,Solitary special sense of taste from the anterior
VII Facial nerve nucleus,Superior salivary 2/3 of the tongue, and
nucleus 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 Vestibular nuclei,Cochlear Senses sound, rotation and gravity
nerve (or auditory- nuclei (essential for balance & movement).
vestibular More specifically. the vestibular branch

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carries impulses for equilibrium and the
nerveor statoacoustic cochlear branch carries impulses for
nerve) hearing.; Located in internal acoustic
Receives taste from the posterior 1/3 of
the tongue, provides secretomotor
innervation to the parotid gland, and
Nucleus ambiguus,Inferior provides motor innervation to
IX salivary nucleus,Solitary the stylopharyngeus. Some sensation is
nucleus also relayed to the brain from the palatine
tonsils. Sensation is relayed to opposite
thalamus and some hypothalamic nuclei.
Located injugular foramen
Supplies branchiomotor innervation to
most laryngeal and all pharyngeal
muscles (except the stylopharyngeus,
which is innervated by the
provides parasympatheticfibers to nearly
Nucleus ambiguus,Dorsal all thoracic and abdominal viscera down
X Vagus nerve motor vagal to thesplenic flexure; and receives the
nucleus,Solitary nucleus 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
Controls sternocleidomastoid and
trapezius muscles, overlaps with
nerve(or cranial
Nucleus ambiguus,Spinal functions of the vagus. Examples of
XI accessory
accessory nucleus symptoms of damage: inability to shrug,
nerveor spinal
weak head movement; Located in jugular
accessory nerve)
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Provides motor innervation to the
muscles of the tongue (except for
the palatoglossus, which is innervated by
XII Hypoglossal nerve Hypoglossal nucleus the vagus) and other glossal muscles.
Important for swallowing (bolus
formation) and speech articulation.
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.

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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
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
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.

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Venous return of deoxygenated blood from the brain
Veins 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.
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 System
Composition 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, 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, 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

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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
increases, blood viscosity increases. The more hemoglobin molecules the RBCs contain, the
more oxygen they will be able to carry.

Leukocytes 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
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 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.

Normally 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

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
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is cardiac muscle tissue, makes up the bulk of the heart and is responsible for is pumping action
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
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.

When 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.

The 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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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 A transient ischemic attack (TIA) is like a
(Transient Ischemic stroke, producing similar symptoms, but
Attack) 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.

Factors Present Rationale
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

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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
High Cholesterol Cholesterol is a waxy substance that
Levels 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
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
clotting or formation of thrombus thus
increasing the risk for stroke.

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
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requires attention to diet, regular urine
tests or blood tests and probably some


Excessive use of Alcohol in excess (more than 2 drinks a day)

alcohol 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
disease, stroke, chronic obstructive
pulmonary disease, peripheral vascular
disease, peptic ulcer disease, and many
types of cancer.
Cocaine and illicit Years of research now show that drugs are
drug use 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
39| P a g e
and heart disease.

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
Dehydration Poor oral intake of fluids can lead to
increased blood viscosity, flow stagnation and
decreased brain perfusion.


Atrial fibrillation Atrial fibrillation causes cardioembolic strokes

-- 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 Carotid artery disease occurs when the
Disease 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

40| P a g e
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

Symptoms Present Rationale
Broca’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
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

41| P a g e
have great difficulty understanding speech,
and they are often unaware of their
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
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

42| P a g e
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

Short term memory Loss of short term memory is common with

loss 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
daily task or who you saw an hour ago.

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
Inability to turn eyes Due to the loss of control on the ocular
toward affected side muscles.

Hemiattention (denial Due to impaired sensory and motor activities

of paralyzed limb) in the affected area.

Dysphagia Due to the alterations of physiologic


Spasticity Spasticity involves an increase in the tone of

affected muscles and usually an element of
weakness. The flexor muscles usually more

43| P a g e
strongly affected in the upper extremities and the
extensor muscles more strongly affected in the
lower extremities.

44| P a g e
Precipitating Factor:
Predisposing Factors:
Sex Hypertension
Family history Diabetes Mellitus II
Prior Stroke (Transient Cigarette smoking
Ischemic Attack) Sedentary lifestyle
Poor diet


Atheromatous Plaques

Emboli travel throughout the body to the narrow arteries and


Occlusion in the narrow arteries and Hypertenti
blood vessels in the brain on

45| P a g e
If not managed:
If managed:

Dx: PET scan, MRI, CT scan, cerebral

angiography, lumbar puncture, ECG, Thrombus will travel into the vessels
skull x-ray, carotid ultrasound causing thickening and fragility
Tx: aspirin, thrombolytics, carotid
stenting, anti coagulants,
Increase intracranial

Sx: Cerebral Hypoperfusion / Rapture of the blood
dizziness, decreased oxygen supply vessels in the brain BT
headache Sx:
Cerebral hemorrhage sudden
Impaired distribution of severe
oxygen and glucose headache
Formation of small and unconsci
large clots ousness,
Tissue hypoxia and cellular
starvation vomiting,
Lodges unto other ces
Cerebral ischemia arteries

Initiation of ischemic

46| P a g e
Production of O2 free radicals and other
reactive O2 species

Sx: unilateral
Diagnostic exams:
vision loss in Transient Ischemic Attack (TIA) * CT or MRI scans, angiogram.
one eye, ECG, Carotid duplex (
aphasia, ultrasound), Blood clotting
dysarthria Structural integrity loss of brain tissue and tests Blood chemistry,
blood vessel Complete blood count (CBC),
C-reaction protein, ESR
(Sedimentation rate) ,
Serum lipids.
Vascular congestion

Compression of tissue Surgery (

carotid endarterectomy),
aspirin, low-fat and low-salt
Increased intracranial pressure

If managed:

Palliative care Impaired perfusion and

Frequent VS and NVS taking function
Mechanical ventilation
Osmotic diuretics
ICP monitoring If not managed:

47| P a g e
Continued insufficiency
of blood flow

Further compression of Sx:

tissues Unresponsivenes
s Absence of
Dx: Blood tests, cerebral and brain
electrocardiogram stem function
and CT scan of the Coma (Pupillary
head responses,
corneal and gag
Cerebral death reflex are absent)

Cessation of physiologic

Cardiovascular Pulmonary
system system

Loss of cardiac Relaxation of venous

muscle functions valves

48| P a g e
Failure of accessory Loss of lung
Sx: muscle for breathing movement
cardiac Hypotension


Cardiopulmonary arrest

Systemic failure


49| P a g e
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

50| 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.

51| P a g e
1. Diagnostic Exams
1.1. Actual
Laboratory Tests
Date Test Definition and Result Interpretation/ Nursing
Normal Range Significance Responsibilities
January 24, 2011 Cranial Computed Computed Multiple plain axial Abnormal findings Pretest
Tomography (CT) tomography CT images of the in: ➧ Inform the patient
Scan (CT) of the brain is head were obtained. • Abscess that the procedure
a noninvasive Minute CSF • Aneurysm assesses the brain.
procedure used to isodense change is • AVMs ➧ Note any recent
assist in diagnosing noted in the left • Cerebral atrophy procedures that can
abnormalities of the periventricular area. • Cerebral edema interfere with test
head, brain tissue, No other abnormal • Cerebral infarction results, including
cerebrospinal fluid, density changes • Congenital examinations using
and blood seen in the rest of abnormalities barium or iodine-
circulation. It the brain and • based contrast
becomes invasive if brainstem Craniopharyngioma medium.
contrast medium is parenchyma. • Cysts Ensure that barium
used. Extra- axial spaces • Hematomas (e.g., studies were
Slices or thin are wide and deep. epidural, performed more
sections of certain No evident subdural, than 4 days before
anatomic views of intracranial bleed. intracerebral) the CT scan.
the brain and Midline structures • Hemorrhage ➧ Obtain a list of
associated vascular are not displaced. • Hydrocephaly the patient’s current
system are The ventricles are • Increased medications
52| P a g e
viewed to allow not dilated. intracranial including
differentiations Sella, orbits, pressure or anticoagulants,
of solid, cystic, petromastoids and trauma aspirin and other
inflammatory, visualized paranasal • Infection salicylates, herbs,
or vascular lesions, sinuses are • Sclerotic plaques nutritional
as well as unremarkable. suggesting supplements, and
identification of Calvarium and multiple sclerosis nutraceuticals. Note
suspected visualized facial • Tumor the last time and
hematomas or bones are intact. • Ventricular or dose of medication
aneurysms. Impression: OLD tissue displacement taken.
LACUNAR or enlargement ➧ Review the
Normal Findings: INFARCT, LEFT procedure with the
Normal size, PERIVENTRICULAR In the case of our patient. Address
position, and shape AREA. AGE- patient, she has concerns about
of intracranial RELATED abnormalities in her pain and explain
structures and CEREBRAL CT scan result: that there may be
vascular system ATROPHY cerebral atrophy moments of
and cerebral discomfort and
infarction. some pain
experienced during
the test.
Inform the patient
the procedure is
usually performed

53| P a g e
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
injection of contrast

54| P a g e
➧ Instruct the
patient to remove
dentures and
jewelry and other
metallic objects
from the area to be

Intra test
➧ Ensure the
patient has
complied with
restrictions and pre
➧ Ensure the
patient has
removed dentures
and all external
metallic objects
from the area to be
examined prior to

55| P a g e
the procedure.
➧ Instruct the
patient to cooperate
fully and to follow
directions. Instruct
the patient to
remain still
the procedure
because movement
produces unreliable
➧ Administer an
antianxiety agent,
as ordered, if the
patient has
Administer a
to a child or to an
adult, as ordered.
➧ Place the patient
in the supine

56| P a g e
position on an exam
➧ 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
➧ Monitor the
patient for
related to the
procedure (e.g.,
if contrast is used.

57| P a g e
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
➧ If contrast was
used, observe for
delayed allergic
reactions, such as
rash, urticaria,

58| P a g e
nausea, or
➧ If contrast was
used, advise the
to immediately
report symptoms
such as fast heart
rate, difficulty
breathing, skin
rash, itching, or
decreased urinary
➧ Instruct the
patient to increase
intake to help
eliminate the
contrast medium, if
➧ Inform the patient
that diarrhea may
occur after

59| P a g e
ingestion of oral
contrast medium.

Date Test Definition and Result Interpretation/ Nursing

Normal Range Significance Responsibilities
January 24, 2011 Chest Radiology Chest X-rays are Study taken in AP Chest X-ray 1.) Remove from
taken when a projection. examination is the chest area all
patient is Lung fields are clear. done to identify the jewelry, clothing
suspected of The heart is presence of with snaps,
having problems magnified with left pulmonary infiltrate, electrocardiographic
with the lungs, ventricular which is fluid patches (if not
heart, or other prominence. leakage into the contraindicated),
chest structures. Aortic knob is alveoli from and other metal
Another way of calcified. inflammation. objects that may
looking for other Mediastinum and It is also use to interfere with the
complications in the hemidiaphragm are evaluate respiratory interpretation of the
60| P a g e
lungs and heart. unremarkable. status and heart results.
X-ray examination Visualized osseous size. 2.) It is important to
of the chest is done structures are porotic. Abnormalities found breathe in deeply,
to diagnose The rest of the in the lungs hold your breath,
disease and to included structures sometimes and remain
assess the are unremarkable. indicates motionless while the
progress of a pneumonia, radiograph is taken.
disease. Impression: emphysema, 4.) A radiograph
SUGGESTIVE LEFT chronic obstructive takes approximately
Normal Values: VENTRICULAR pulmonary disease, 15 minutes to
Normal anatomy CARDIOMEGALY. bronchiectasis, complete and verify
and no pathologic ATHEROSCLEROTIC pulmonary edema, that the images are
changes evident or AORTA. SENILE interstitial properly exposed.
no abnormalities OSTEOPOROSIS. pneumonitis, and 5.) No restrictions
found in the lungs, others, while in the are necessary on
heart and other heart congestive food or fluid intake.
chest structures. heart failure or 6.) No sedation is
pericardial effusion. used for this
In the case of our 7.) Views are taken
client, it was found in various positions
out that there is on the table or
enlargement of the chair.
heart 8.) When taking a

61| P a g e
atherosclerotic PA view of the
plaque in aorta and chest, instruct
osteoporosis. 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
placed against the
photographic plate.
10.) Instruct patient
to take a deep

62| P a g e
breath and hold
while the picture is
being taken.
After the test, give
back clothing,
jewelries that was
removed before the

Date Test Definition and Normal Result Interpretation/ Significance Nursing

Range Responsibilties
January 25, Fasting Blood This test is taken to 7.1 mmol/ L Increased in: Pretest
2011 Sugar (FBS) measure blood glucose (HIGH) • Acromegaly, gigantism (GH 1. Inform the
level. stimulates patient that
Fasting glucose levels the release of glucagon, which the test is
are used to help in turn inceases glucose levels) used as a
diagnose diabetes • Diabetes (Glucose intolerance general
mellitus and and elevated glucose levels indicator of
hypoglycemia. A define nutritional
randomly timed test for diabetes), status,
glucose is usually • Myocardial infarction (Related hydration and
performed for routine to stress and/or pre-existing chronic
screening and diabetes) disease.
nonspecific evaluation • Strenuous exercise 2. Obtain a
of carbohydrate (Hyperglycemia history of the

63| P a g e
metabolism. is stimulated by the patient’s
release of catecholamines complaints,
Normal value: and glucagon) including a list
3.9 - 6.1 mmol/ L of known
Decreased in: allergens.
• Glucagon deficiency (Glucagon 3. Review the
controls glucose levels; procedure
hypoglycemia with the
occurs in the absence of patient. Inform
glucagon) the patient
• Hypothyroidism (Thyroid that specimen
hormones affect glucose levels; collection
decreased thyroid hormone takes
levels result in decreased approximately
glucose levels) 5 to 10
In the case of our client, her FBS Address
result was high since she had concerns
been diagnosed of Diabetes about pain
Mellitus. and explain
Blood Urea Urea is a nonprotein 6.4 mmol/ L Increased in:
that there may
Nitrogen nitrogen compound • Acute renal failure (Related to
be some
(BUN) formed in the liver from decreased renal excretion)
ammonia as an end • Chronic glomerulonephritis
during the
product of protein (Related to decreased renal
64| P a g e
metabolism. excretion) venipuncture.
Urea diffuses freely into • Congestive heart failure 4. There are no
extracellular and (Related food, fluid or
intracellular fluid and is to decreased blood flow to the medication
ultimately excreted by kidneys, decreased renal restriction
the kidneys. excretion, unless by
Blood urea nitrogen and accumulation in circulating medical
(BUN) levels reflect the blood) direction.
balance between the • Diabetes (Related to decreased
production and renal excretion) Intra test
excretion of urea. • Shock (Related to decreased 1. If the patient
blood has a history
Normal Range: 2.5- 6.4 flow to the kidneys, decreased of allergic
mmol/ L renal excretion, and accumulation reaction to
in circulating blood) latex, avoid
• Urinary tract obstruction the use of
(Related to equipment
decreased renal excretion and containing
accumulation in circulating blood) latex.
2. Instruct the
Decreased in: patient to
• Inadequate dietary protein (Urea cooperate fully
nitrogen is a by-product of protein and to follow
metabolism; less available directions.

65| P a g e
protein is reflected in decreased Direct the
BUN levels) patient to
• Low-protein/high-carbohydrate breathe
diet normally and
(Urea nitrogen is a by-product of to avoid
protein metabolism; less available unnecessary
protein is reflected in decreased movement.
BUN levels) 3. Positively
identify the
In the case of our client, her BUN patient and
result is normal. label the
Creatinine Creatinine is produced 71.2 umol/L - An increase in creatinine
in relatively constant may indicate congestive
quantities by the heart failure, dehydration,
Perform the
muscles and is renal calculi, renal failure,
excreted by the acute and chronic renal
4. Remove the
kidneys. Thus, the failure and shock.
needle and
amount of creatinine in - A decrease in creatinine
apply direct
the blood relates to may indicate
pressure with
renal excretory hyperthyroidism, liver
dry gauze to
function. disease and inadequate
stop bleeding.
protein intake.
Normal Range: 53.0-
115.0 umol/ L The creatinine level of our client is
site for
66| P a g e
Cholesterol Total cholesterol levels 4.3 mmol/ L This test is an important bleeding or
are used for screening screening test for heart disease. hematoma
for formation and
hypercholesterolemia. Increased: secure gauze
Cholesterol is a • Type II familial with adhesive
lipid needed to form cell hypercholesterolemia bandage.
membranes and a • Biliary cirrhosis 5. Promptly
component of the • Chronic renal failure transport the
materials that render • Poorly controlled diabetes specimen to
the skin waterproof. It mellitu the laboratory
also helps form bile for processing
• Diet high in cholesterol
salts, adrenal and analysis.
and fats
estrogen, and Posttest
androgens. 1. Reinforce
• Hyperthyroidism
Cholesterol is obtained information
• Malnutrition
from the given by the
• Chronic anemias
diet (exogenous patient’s
• Severe burns
cholesterol) health care
and also synthesized in provider
In the case of our client, her
the regarding
cholesterol level is normal.
body (endogenous further testing,
cholesterol). treatment, or
referral to

67| P a g e
Normal Value: another health
0.0 – 5.2 mmol/L care provider.
LDL- Up to 70% of the total 3.1 mmol/ L Increased:
2. Depending on
Cholesterol serum cholesterol is • Familial type 2 the results of
present in the LDL. The hyperlipidemia this
“bad” cholesterol. • Secondary causes can procedure,
Normal value: include: diet high in additional
0.00 – 3.4 mmol/L cholesterol and saturated testing may be
fat, nephritic syndrome, performed to
multiple myeloma, evaluate or
diabetes mellitus, chronic monitor
renal failure progression of
the disease
Decreased: process and
• Hypolipoproteinemia determine the
• Hyperthyroidism need for a
• Chronic anemias change in
In the case of our client, the result 3. Evaluate test
is normal. results in
Rev Triglycerides are a 1.04 mmol/ L This test evaluates suspected relation to the
Triglycerides combination of three atherosclerosis and measures the patient’s
(TGL) fatty acids body’s ability to metabolize fat. symptoms and
and one glycerol other tests
molecule. Increased:
68| P a g e
They are necessary to • Hyperlipoproteinemia performed.
provide • Liver disease
energy for various • Renal disease
• Hypothyroidism
• Myocardial infarction
Triglycerides are also
synthesized in the liver
from fatty acids and
• Malnutrition
from protein and
• Hyperthyroidism
glucose above the
• Brain infarction
body's current needs
and then stored in • Chronic obstructive lung

adipose tissue. They disease

may be later retrieved

and formed into In the case of our client, the result

glucose through is normal.

gluconeogenesis when
needed by the body.
Triglyceride levels are
taken into consideration
with total cholesterol,
high-density lipoprotein
cholesterol, and
chylomicron levels

69| P a g e
when categorizing a
client's serum into
lipoprotein phenotypes
that represent genetic

Normal Value:
0.0 – 1.70 mmol/ L
HDL- A class of lipoproteins 0.75 mmol/ L Increased:
Cholesterol produced by the liver (LOW) • HDL excess
(AHDL) and intestines. The • Chronic liver disease
“good” cholesterol. • Long term aerobic or
vigorous exercise
Normal Value:
0.90 – 1.55 mmol/L Decreased:
• Familial
• Poorly controlled diabetes
• Chronic heart failure

In the case of our client, the result

is low since our client had been

70| P a g e
diagnosed of having diabetes
Serum Serum electrolytes are Sodium: • Sodium
Electrolytes often routinely ordered 144.8 mmol/ - An increase in sodium
for any client admitted L may indicate burn,
to a hospital as a Potassium: dehydration, diabetes, and
screening test for 3.24 mmol/ L diarrhea, excessive intake
electrolyte and acid- (LOW) of sodium, fever and
base imbalances. Calcium: 2. vomiting.
Serum electrolytes also 19 mmol/ L - A decrease in sodium may
are routinely assessed indicate congestive heart
for clients at risk in the failure, central nervous
community, for system disease, excessive
example, client who are antidiuretic hormone
being treated with a production, excessive use
diuretic for of diuretics, hepatic failure
hypertension or heart and nephritic syndrome.
failure. The most • Potassium
commonly ordered - An increase in potassium
serum tests are for may indicate acidosis,
sodium, potassium, acute renal failure, burns,
chloride, and dehydration, insulin
bicarbonate ions. deficiency, ketoacidosis,
Normal Values:
71| P a g e
a. Sodium: 136- - A decrease in potassium
145 mmol/L may indicate alcoholism,
b. Potassium: 3.5- alkalosis, bradycardia,
5.1 mmol/L congestive heart failure,
c. Calcium: 2.12- hypertension,
2.52 mmol/L hypomagnesemia and
renal tubular acidosis.
• Calcium
- An increase in calcium
may indicate vitamin D
toxicity and
- A decrease in calcium
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

Date Test Definition and Result Interpretation/ Nursing

72| P a g e
Normal Range Significance Responsibilities
January 25, 2011 Glycosylated Glycosylated or 6.7 % (HIGH) Increased in: Pretest
Hemoglobin (HBA- glycated • Diabetes (poorly 1. Inform the
1C) hemoglobin is a controlled or patient that
term used to uncontrolled) the test is
describe the (Related to and used as a
combination of reflective of general
glucose and elevated glucose indicator of
hemoglobin into a levels) nutritional
ketamine; the rate status,
at which this occurs Decreased in: hydration and
is proportional to • Chronic blood loss chronic
glucose (Blood disease.
concentration. loss decreases 2. Obtain a
The average life concentration history of the
span of a red of RBC-bound patient’s
blood cell (RBC) is glycated complaints,
approximately hemoglobin) including a list
120 days; • Chronic renal of known
measurement of failure (Low RBC allergens.
glycated count associated 3. Review the
hemoglobin is a with this procedure
way to monitor condition reflects with the
long-term diabetic corresponding patient. Inform
management. decrease in RBC the patient
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bound that specimen
Normal Range: glycated collection
4.5%- 6.3% hemoglobin) takes
In the case of our 5 to 10
client, the result is minutes.
high since she is a Address
diabetic person. concerns
about pain
and explain
that there may
be some
during the
4. There are no
food, fluid or
unless by

Intra test

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6. If the patient
has a history
of allergic
reaction to
latex, avoid
the use of
7. Instruct the
patient to
cooperate fully
and to follow
Direct the
patient to
normally and
to avoid
8. Positively
identify the
patient and

75| P a g e
label the
Perform the
9. Remove the
needle and
apply direct
pressure with
dry gauze to
stop bleeding.
site for
bleeding or
formation and
secure gauze
with adhesive
10. Promptly
transport the
specimen to
the laboratory

76| P a g e
for processing
and analysis.

11. Reinforce
given by the
health care
further testing,
treatment, or
referral to
another health
care provider.
12. Depending on
the results of
testing may be
performed to
evaluate or

77| P a g e
progression of
the disease
process and
determine the
need for a
change in
13. Evaluate test
results in
relation to the
symptoms and
other tests

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1.2. Possible
Diagnostic Test
Test Rationale Result Interpretation Nursing Responsibilities
Positron Emission Positron emission Normal patterns Abnormal findings in: Pretest
Tomography (PET) tomography (PET) of tissue • Alzheimer’s disease ➧ Inform the patient that the
combines metabolism, • Aneurysm procedure assesses blood
the biochemical blood flow, and • Cerebral metastases flow to the brain and brain
properties of radionuclide • Cerebrovascular accident tissue metabolism.
nuclear medicine with distribution • Creutzfeldt-Jakob disease ➧ Review the procedure with
the • Dementia the patient. Address
accuracy of computed • Head trauma concerns about pain related
tomography • Huntington’s disease to the procedure and explain
(CT). PET uses positron • Migraine to the patient that some pain
emissions from specific • Parkinson’s disease may be experienced during
radionuclides (oxygen, • Schizophrenia the test, or there may be
nitrogen, carbon, and • Seizure disorders moments of discomfort.
fluorine) to produce • Tumors Reassure the patient that
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detailed functional radioactive material poses
images within the body. minimal radioactive hazard
After the radionuclide because of its short half-life
becomes concentrated and rarely produces side
in the brain, PET effects. Inform the patient
images of blood flow or that the procedure is
metabolic processes at performed in a special
the cellular level can be department, usually in a
obtained. PET identifies radiology suite and takes
the amount of tissue approximately 60 to 120 min.
damage following a ➧ Instruct the patient to
CVA. Positron emission remove jewelry and other
tomography (PET) is a metallic objects from the
test that uses a special area to be examined prior to
type of camera and a the procedure.
tracer (radioactive ➧ Instruct the patient to
chemical) to look at avoid taking anticoagulant
organs in the body. The medication or to reduce
tracer usually is a dosage as ordered prior to
substance (such as the procedure.
glucose) that can be ➧ Instruct the patient to
used (metabolized) by restrict food for 4 hr; restrict
cells in the body. alcohol, nicotine, or caffeine-
containing drinks for 24 hr;

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and withhold medications for
24 hr before the test.

Intra test
➧ Ensure that the patient
has complied with dietary,
fluid, and medication
restrictions and pre testing
➧ 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

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unreliable results.
➧ Record baseline vital
signs and assess
neurological status.
➧ The patient may be asked
to perform different cognitive
activities (e.g., reading) to
measure changes in brain
activity during reasoning or
➧ The patient may be
blindfolded or asked to use
earplugs to decrease
auditory and visual stimuli.
➧ Monitor the patient for
related to the procedure
(e.g., allergic
reaction, anaphylaxis,

➧ Instruct the patient to
resume pretest diet, fluids,

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medications, or activity.
➧ Observe for delayed
allergic reactions,
such as rash, urticaria,
hyperpnea, hypertension,
palpitations, nausea, or
➧ 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
➧ Instruct the patient to flush

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the toilet immediately after
each voiding, and
to meticulously wash hands
with soap and water for 24 hr
after the procedure.
➧ 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/ Nursing

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Significance Responsibilities
Electroencephalogram Electroencephalography • Normal occurrences Abnormal findings in: Pretest
(EEG) (EEG) is a noninvasive of alpha, beta, • Abscess ➧ Inform the patient
study that measures the theta, and delta waves • Brain death that the procedure is
brain’s electrical activity (rhythms • Cerebral infarct performed to measure
and records that activity varying depending on • Encephalitis electrical activity of the
on graph paper. These the patent’s • Glioblastoma and brain.
electrical impulses arise age) other brain ➧ Review the
from the brain cells of • Normal frequency, tumors procedure with the
the cerebral cortex. amplitude, and • Head injury patient. Address
At one end are action characteristics of brain • Hypocalcemia or concerns about pain
potentials in a single waves hypoglycemia related to the
axon or currents within a • Intracranial procedure and assure
single dendrite, and at hemorrhage the patient there is no
the other end is the • Meningitis discomfort during the
activity measured by the • Migraine headaches procedure, but that, if
scalp EEG. • Narcolepsy needle electrodes are
• Seizure disorders used, a slight pinch
Indications: (grand mal, may be felt. Explain
• Confirm suspicion of focal, temporal lobe, that electricity flows
increased myoclonic, from the patient’s body,
intracranial pressure petit mal) not into the body,
caused by • Sleep apnea during the procedure.
trauma or disease Explain that the
• Detect cerebral procedure reveals brain
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ischemia during activity only, not
endarterectomy thoughts, feelings, or
• Detect intracranial intelligence. Inform the
cerebrovascular patient the procedure is
lesions, such as performed in a
hemorrhages and neurodiagnostic
infarcts department, usually by
• Detect seizure a HCP and support
disorders and identify staff, and takes
focus of seizure and approximately 30 to 60
seizure activity, min.
as evidenced by ➧ Inform the patient
abnormal spikes that he or she may
and waves recorded on be asked to alter
the graph breathing pattern; be
• Determine the asked to follow simple
presence of tumors, commands such
abscesses, or infection as opening or closing
eyes, blinking, or
swallowing; be
stimulated with bright
light; or be given a drug
to induce sleep
during the study.

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➧ Instruct the patient to
clean the hair
and to refrain from
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

Intra test
➧ Ensure the patient
has complied with
pretesting preparations.
Ensure that
beverages were
withheld for 8 hr before
the procedure,

87| P a g e
and that a meal was
ingested before
the study.
➧ Ensure that the
patient is able to
relax; report any
extreme anxiety or
➧ Ensure that hair is
clean and free of
hair sprays, creams, or
➧ Remind the patient
to relax and not to
move any muscles or
parts of the face
or head.

➧ When the procedure
is complete,
remove electrodes from
the hair and
remove paste by

88| P a g e
cleansing with oil or
witch hazel.
➧ If a sedative was
given during the test,
allow the patient to
recover. Bedside
rails are put in the
raised position for

Test Rationale Result Interpretation/ Nursing Responsibilities

Magnetic Resonance Magnetic resonance Normal anatomic Abnormal findings in: Pretest
Imaging (MRI)- Brain imaging (MRI) uses a structures, soft • Abscess ➧ Inform the patient that
magnet tissue density, blood • Acoustic neuroma the procedure
and radio waves to flow rate, • Alzheimer’s disease assesses the brain.
produce an face, nasopharynx, • Aneurysm ➧ Review the procedure
energy field that can be neck, tongue, • Arteriovenous with the patient.

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displayed and brain malformation Address concerns about
as an image. • Benign meningioma pain related
Brain MRI can • Cerebral aneurysm to the procedure and
distinguish • Cerebral infarction explain to the patient
solid, cystic, and • Craniopharyngioma or that no pain will be
hemorrhagic meningioma experienced
components of lesions. • Granuloma during the test, but there
This procedure • Intraparenchymal may be
is done to aid in the hematoma or moments of discomfort.
diagnosis hemorrhage Reassure the
of intracranial • Lipoma patient that if contrast is
abnormalities, • Metastasis used, it poses
including tumors, • Multiple sclerosis no radioactive hazard
ischemia, infection, • Optic nerve tumor and rarely
and multiple sclerosis, • Parkinson’s disease produces side effects.
and • Pituitary Inform the
in assessment of brain microadenoma patient the procedure is
maturation • Subdural empyema performed in
in pediatric patients. • Ventriculitis an MRI department,
usually by a health
Indications: care provider (HCP)
• Detect and locate who specializes in
brain tumors this procedures, with
• Detect cause of support staff, and

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cerebrovascular takes approximately 30
accident, cerebral to 60 min.
infarct, or ➧ Inform the patient that
hemorrhage the technologist
• Detect cranial bone, will place him or her in a
face, throat, supine
and neck soft tissue position on a flat table in
lesions a large
• Evaluate the cause of cylindrical scanner.
seizures, such ➧ Tell the patient to
as intracranial infection, expect to hear loud
edema, or banging from the
increased intracranial scanner and possibly
pressure to see
• Evaluate cerebral magnetophosphenes
changes associated (flickering
with dementia lights in the visual field);
• Evaluate these will stop
demyelinating disorders when the procedure is
• Evaluate intracranial over.
infections ➧ Explain that an IV line
• Evaluate optic and may be inserted
auditory nerves to allow infusion of IV
fluids, contrast

91| P a g e
medium, or sedatives.
➧ Instruct the patient to
remove jewelry
and all other metallic
objects from the
area to be examined
prior to the
➧ There are no food,
fluid, or medication
restrictions, unless by
medical direction.

➧ 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
change into the

92| P a g e
gown, robe, and foot
➧ Instruct the patient to
fully and to follow
directions. Instruct
the patient to remain still
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
via a microphone within
the scanner.

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➧ Place the patient in
the supine position
on an exam table.
➧ If contrast is used,
imaging can begin
shortly after the
➧ 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
➧ Instruct the patient to
take slow, deep
breaths if nausea occurs
during the
➧ Monitor the patient for
related to the procedure
(e.g., allergic

94| P a g e
reaction, anaphylaxis,

➧ Observe for delayed
allergic reactions,
such as rash, urticaria,
palpitations, nausea, or
vomiting, if contrast
was used.
➧ Instruct the patient to
report symptoms such
as fast heart
rate, difficulty breathing,
skin rash,
itching, or decreased
urinary output.

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Test Rationale Result Interpretation/ Nursing Responsibilities
Carotid Using the duplex Normal blood flow Abnormal findings Pretest
Ultrasound scanning method, through the in: ➧ Review the procedure with the
carotid US carotid arteries with • Carotid artery patient.
records sound waves no evidence occlusive disease Address concerns about pain
to obtain of occlusion or (atherosclerosis) related
information about the narrowing • Plaque or stenosis to the procedure and explain that
carotid of carotid artery some pain may be experienced
arteries. The amplitude • Reduction in during
and vessel diameter of the test, and there may be
waveform of the more than 16%, moments of
carotid pulse indicating stenosis discomfort. Inform the patient that
are measured, the
resulting in a procedure is performed in a US
two-dimensional image department by a health care
of the provider
artery. Carotid arterial (HCP) who specializes in this
sites procedure,
used for the studies with support staff, and takes
include approximately 30 to 60 min.
the common carotid, ➧ Instruct the patient to remove
external jewelry
carotid, and internal and other metallic objects from the
carotid. area to be examined.
➧ There are no food, fluid, or
restrictions, unless by medical
97| P a g e
➧ Ensure that the patient has
removed all
external metallic objects from the
Test Rationale Result Interpretation/ Nursing Responsibilities
Echocardiography Echocardiography, • Normal appearance in Abnormal findings in: Pretest
a noninvasive the size, • Aneurysm ➧ Inform the patient that
ultrasound (US) position, structure, and • Aortic valve the procedure assess
procedure, uses high- movements abnormalities cardiac function.
frequency of the heart valves • Cardiac neoplasm ➧ Review the procedure
sound waves of various visualized and • Cardiomyopathy with the patient.
intensities recorded in a • Congenital heart defect Address concerns about
to assist in diagnosing combination of • Congestive heart pain related to the
cardiovascular ultrasound modes; and failure procedure and explain
disorders. The normal • Coronary artery that there should be no
procedure records the heart muscle walls of disease discomfort during the
echoes both ventricles • Endocarditis procedure. Inform the
created by the deflection and left atrium, with • Mitral valve patient the
of an adequate abnormalities procedure is performed
ultrasonic beam off the blood filling. • Myxoma in an US or
cardiac • Pericardial effusion, cardiology department,
structures and allows tamponade, and takes approximately
visualization and pericarditis 30 to
of the size, shape, • Pulmonary 60 min.
position, hypertension ➧ Instruct the patient to
thickness, and • Pulmonary valve remove jewelry, and
98| P a g e
movement of all abnormalities other metallic objects
four valves, atria, • Septal defects from the area to be
ventricular and • Ventricular hypertrophy examined.
atria septa, papillary • Ventricular or atrial ➧ There are no food or
muscles, mural thrombi fluid restrictions, unless
chordae tendineae, and by medical direction.
This study can also Intra test
determine ➧ Ensure the patient
blood-flow velocity and has removed all external
direction metallic objects from the
and the presence of area to be examined
pericardial prior to the procedure.
effusion during the ➧ Instruct the patient to
movement of cooperate fully and to
the transducer over follow directions. Instruct
areas of the the patient to remain still
chest. throughout the
procedure because
Indications: movement produces
• Detect ventricular or unreliable results.
atrial mural ➧ Place the patient in a
thrombi and evaluate supine position on a flat
cardiac wall table with foam wedges

99| P a g e
motion after myocardial to help maintain position
infarction and immobilization.
• Detect subaortic ➧ Expose the chest, and
stenosis as evidenced attach electrocardiogram
either by displacement leads for simultaneous
of tracings, if desired.
the anterior atrial leaflet ➧ Apply conductive gel
or by a to the chest.
reduction in aortic valve Place the transducer on
flow, the chest
depending on the surface along the left
obstruction sternal border,
• Evaluate ventricular the subxiphoid area,
aneurysms suprasternal notch, and
and/or thrombus supraclavicular areas to
obtain views and
tracings of the portions
of the heart. Scan the
by systematically
moving the probe in a
perpendicular position to
direct the ultrasound
waves to each part of

100| P a g e
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
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.

101| P a g e
Test Rationale Result Interpretation/ Nursing Responsibilities
Electrocardiogram The electrocardiogram • Normal heart rate • Arrhythmias. Pretest
(ECG), a noninvasive according to age: • Atrial or ventricular ➧ Review the procedure
study, measures the range of 60 to 100 hypertrophy. with the patient.
electrical currents or beats/min in • Bundle branch block. Address concerns about
impulses that the heart adults • Electrolyte imbalances. pain related to the
generates during a • Normal, regular rhythm • MI or ischemia. procedure and explain
cardiac cycle. The ECG and wave • Pericarditis. that there should be no
is a graphic display of deflections with normal • Pulmonary infarction. discomfort related to the
the electrical activity of measurement • P wave: An enlarged P procedure. Inform the
102| P a g e
the heart, which is of ranges of cycle wave patient that the
analyzed by time components deflection could indicate procedure is performed
intervals and segments. and height, depth, and atrial by a health
Continuous tracing of duration of complexes enlargement. An absent care provider (HCP) and
the cardiac cycle as follows: or altered takes approximately 15
activities is captured as P wave: 0.12 sec or 3 P wave could suggest min.
heart cells are small blocks with that the electrical ➧ Review the procedure
electrically stimulated, amplitude of 2.5 mm impulse did not come with the patient.
causing depolarization Q wave: less than 0.04 from the SA node. Address concerns about
and movement of the mm • P-R interval: An pain related to
activity through the cells R wave: 5 to 27 mm increased interval the procedure and
of the myocardium. amplitude, could imply a conduction explain that there should
depending on lead delay in be no discomfort related
Indications: T wave: 1 to 13 mm the AV node. to the procedure. Inform
• Assess the extent of amplitude, • QRS complex: An the patient that the
myocardial infarction depending on lead enlarged Q wave procedure takes
(MI) or ischemia, as QRS complex: 0.12 sec may indicate an old approximately
indicated by abnormal or 3 small blocks infarction; an 15 min.
ST segment, interval ST segment: 1 mm enlarged deflection ➧ Instruct the patient to
times, and amplitudes could indicate remove jewelry
• Assess the function of ventricular hypertrophy. and other metallic
heart valves Increased objects from the area to
• Monitor rhythm time duration may be examined.
changes during indicate a bundle ➧ No food, fluid, or

103| P a g e
the recovery phase after branch block. medication restrictions
an MI. • ST segment: A exist, unless by medical
depressed ST direction.
segment indicates
myocardial Intra test
ischemia. An elevated ➧ Ensure the patient
ST segment has complied with
may indicate an acute pretesting preparations.
MI or pericarditis. ➧ Ensure the patient
A prolonged ST has removed all
segment external metallic objects
may indicate from the area
hypocalcemia or to be examined prior to
hypokalemia (short the procedure.
segment). ➧ Instruct the patient to
• T wave: A flat or void prior to the
inverted T wave procedure and to
may indicate myocardial change into the gown,
ischemia, robe, and foot coverings
infarction, or provided.
hypokalemia. A tall ➧ Instruct the patient to
T wave may indicate cooperate
hyperkalemia. fully and to follow
directions. Instruct

104| P a g e
the patient to remain still
the procedure because
produces unreliable
➧ Record baseline
➧ Place patient in a
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
➧ Apply the electrodes
in the proper position.

Post test
➧ When the procedure

105| P a g e
is complete,
remove the electrodes
and clean the
skin where the electrode
pads were
➧ Monitor vital signs
and compare with
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
106| P a g e
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.
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
11:35 am- Low Salt, Low Fat, Diabetic Diet This was ordered to control the total
1000kcal, Carbohydrates- 200g, Protein- caloric intake to attain or maintain a
80g, Fat- 53g reasonable body weight, control of blood
glucose level, and normalization of lipids
and blood pressure to prevent heart
2:35pm- HGT every 6 hours with sliding It is done to monitor blood glucose level.
scale SQ RI Indicated for diabetes mellitus and to
<140 md/dl: none evaluate the effectiveness of insulin
141- 160 mg/dl: 2 “U” administration.
161- 200 mg/dl: 4 “U”
201- 300 mg/dl: 6 “U”
107| P a g e
301- 400 mg/dl: 8 “U”
>400 mg/dl: refer
January 25, 2011 8: 25 am- May go to bathroom with To promote good circulation of blood in the
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 It is done to monitor blood glucose level.
2.Decrease HGT every 12 hours Indicated for diabetes mellitus and to
evaluate the effectiveness of insulin
Rehabilitation Program To develop, maintain and restore
- For PT session this afternoon then maximum movement and functional ability.
BID To treat musculoskeletal problems.
- Kindly secure 5 PT sessions
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 This to ensure continuity of care and for
- With home medications: better outcome in the treatment
• Minidiab 9mg 1 tab OD pre- To comply on treatment regimen and
breakfast maintenance medications and to prevent
• Neuroaide 4 tabs 3x a day reoccurrence of the disease.

• Aspiring 80mg/ tab 1 tab

• Lipitor 40mg 1 tab OD

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3. Drug Studies
Generic : 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
• Instruct to ask for generic for cost saving purposes.

110| P a g e
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
Contraindications : Hypersensitivity to salicylates
: Clients who have asthma , Hay fever, Nasal polyps
Side Effects :G.I.: Dyspepsia, nausea, epigastric discomfort, heartburn,
: 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

111| P a g e
• 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 Calcium

112| 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
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®

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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
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)]
: (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
• 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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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
: 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)

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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

• Advice patient to take medications at ® Alterations in doses or timing may alter the
home on time and as prescribed by the effect of the drug. Strict compliance to
physician. medication facilitates relief of any signs and
symptoms or even faster recovery from the
illness or disease.

• Instruct patient and watcher not to ® Crush tablets have a strong, persistent bitter
crush tablets and not to skip taste. Skipping medications can alter the effect
medications. of the drug and may build up to the
vulnerability of the microorganisms to the

• Discuss with the patient and watcher ® This gives patient enough knowledge about

the name of the drug, its side effects, the drugs and to know what to expect and to

its use and guidelines on when to encourage compliance to it.

contact physician.

® Some drugs may have synergistic or

• Instruct patient not to take any additive effect to certain drugs.

medicines that are contraindicated to

the prescribed drugs.
® They must also be well educated about the

• Warn not to change brands of a drug proper time to take the medications since each

without consulting the doctor first. 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.
• Instruct patient not to stop taking the
prescribed drugs without notifying their
health care provider.
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• Instruct patient to have an adequate ® This lessens the strain to the body and to
rest and sleep. allow relaxation.

• Instruct patient to do range of motion if ® This helps loosen the joint structures,
tolerated such as stretching of promote wellness and improve
extremities. circulation. It would prevent aggravation and
exhaustion of the
muscles and joints.

• Advise patient to consult a physical ® To involve re-learning functions as

therapist to determined appropriate transferring, walking and other gross motor

exercise plan. functions.

• Advise patient to join occupational ® Focuses on exercises and training to help

therapy. relearn everyday activities known as the

Activities of daily living (ADLs) such as eating,
drinking, dressing, bathing, cooking, reading
and writing, and toileting.
• Stress the importance of follow-up ® Allows adjustments of therapies or
examinations and treatment because of medications appropriate for the current health
changing physical status. status of the client to minimize fatal side
effects of the medications, in cases there
• Stress also the importance of stroke
rehabilitation ® 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.

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• Instruct patient to take a bath daily. ® This is one way to help in maintaining skin

• Avoid using any product that has an ® This is to prevent dry skin that may cause
alcohol. impairment of the skin integrity

• Encourage patient to do activities of ® To promote good health. It also increases

daily living the sense of wellness, which is very much

needed in the therapeutic process.

Out patient
• Advise patient that to consult her ® Immediate action helps in the client’s
health care providers immediately if improvement.
there are any complications arising.

• Advise patient to have a regular check ®This will help in the prevention of recurrence
up with their health care provider. and it allows monitoring of the client’s health
® To evaluate worsening condition of the client

• Advise patient and significant others to that needs medical attention.

carry out follow up diagnostic regimen

• Encourage patient to eat low salt and ® This may contribute to increasing risk of
low fat foods having stroke and hypertension

• Instructed patient to avoid sweet foods ®This may contribute to the viscosity of the
blood that may cause complications.

• Encourage patient to eat nutritious

foods such as fruits and green leafy ® This is to maintain a balance diet and to

vegetables prevent complications that may occur.

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
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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
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

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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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