I. INTRODUCTION Cerebrovascular Disease It is a group of brain dysfunctions related to disease of the blood vessels supplying the brain.

It occurs when impaired Circulation in the brain disrupts the supply of oxygen. It is a condition that affects the blood vessels in the brain. Cerebral refers to the brain and vascular refers to vessels. Strokes can result from blood vessel conditions such as aneurysms (blood vessel weakness which can result in a rupture) and thrombosis (blood vessel blockage). Atherosclerosis is a common cerebrovascular condition where fatty deposits are laid down inside arteries causing them to become increasingly narrowed. Alternate Names: Cerebral Infarction, Stroke. CAUSE: HYPERTENSION- is the most important cause. It damages the blood vessel lining, endothelium, exposing the underlying collagen where platelets aggregate to initiate a repairing process which is not always complete and perfect. Hypertension permanently changes the architecture of the blood vessels making them narrow, stiff, deformed, uneven and more vulnerable to fluctuations in blood pressure.

Major modifiable risk factors: hypertension, smoking, obesity, and diabetes. RISK FACTORS: 1. Atherosclerosis - is a condition in which an artery wall thickens as a result of the accumulation of fatty materials such as cholesterol. 2. Hypertension. 3. Anticoagulation therapy- is a course of drug therapy in which anticoagulant medications are administered to a patient to slow the rate at which the patient's blood clots. 4. Cardiac Vascular Disease. 5. Atrial Arrythmias 6. Diabetes. SIGNS & SYMPTOMS 1. 2. 3. 4. 5. 6. Persistent headache Dizziness or slight headache Altered LOC Blurring of vision one or both eye Stumbling of speech Bladder or bowel incontinence.

MEDICAL TREATMENT: Steroids/ Corticosteroids given in full stomach with antacid. Vitamin B complex- promotes restitution of functions of neurons which have reversible damage. Cerebral Activator/Stimulants- Stimulate CNS: Nootrophil,encephabol,hydergine. Drugs if it is due to thrombus, give Anti-Coagulant. Drugs if it is due to hemorrhage with large hematoma patient may need removal of blood clot or craniotomy. Blood Test

DIAGNOSTIC TEST: EKG - to measure heart rhythm & check for an irregular heartbeat. Ultrasound MRI Scan to make pictures of structures inside the head. CT Scan type of x-ray that uses a computer to make pictures of structure inside the head. Magnetic Resonance Angiography Arteriogram Echocardiogram EEG detect seizures by measuring sound waves.

Medical Management
Pre hospital Assessment Immediate General Assessment Immediate Neurologic Assessment General Measures. Admit 24-48 hours, V/S, Cardiac Monitoring, Keep NPO. Observe for threat Complication. Seizures, delirium, bed sores. Adjunctive Therapy. Early Rehabilitation. (Speech Therapy, Physical Therapy) Prognosis. (Hyperglycemia, fever, hypertension) AGE 2/3 of stroke occurs in people over the age of 65. Strokes affect men more often than women although woman is more likely to die from stroke. The incidence of stroke among people ages 30-60 is less than 10 % triples the age of 80.

II. NURSING HISTORY PATIENT: X ADDRESS: Purok 6, Patul, Santiago City SEX: Female AGE: 83 CIVIL STATUS: Widowed OCCUPATION: Stays at home RELIGION: Roman Catholic DOCTOR/ATTENDING PHYSICIAN: Dra. Yambot reffered to Dr. Gener Maylem ADMITTING DIAGNOSIS: Body malaise and Aphasia

HISTORY OF PRESENT ILLNESS According to the patients son, they were shocked about what happen to patient X because she was very energetic and lively before she was admitted to the hospital. The son also added that she leaved patient X for awhile while she was washing their dishes. When the son came back, he saw his mother lying on the floor unconscious. Patient X is hospitalized at Southern Isabela General Hospital- Santiago City having the diagnosis of body malaise and aphasia. Patient X had undergone different diagnostic exams such as cbc, cxr, cranial CT scan. Etc... The result of the CT scan revealed that patient X had Intracerebral Hemorrhage. When patient X was endorsed to us, she was inserted of NGT and IFC. We also noticed the weak and lethargic appearance of the patient. Patient X used to hold the tubing that was attached to her body which shows indicates irritability. Based on Patient Xs Glasgow Coma Scale, she used to open her eyes only when she heard a voice, her verbal response is through incomprehensible sounds and motor response is through obeying commands which contributed to the score of 11pts. Patient x also experienced hemiplagia or paralysis of the half body.

PAST HEALTH HISTORY Patient X is very active at home as stated by her son and other relative during our interview. She does a lot of chores such washing the dishes, clothes, and cleaning the house. The family thought that she was healthy except that she had hypertension and doesnt take any medication to treat her hypertension. The relatives also added that patient X is not open to them when it comes to health. Patient Xs was only monitored when she is being called at the barangay for senior citizen.

FAMILY HISTORY Patient Xs husband and 3rd son died due to hypertension and her only daughter died due to severe anemia as stated by the SO we interviewed. There are no other known family health problems aside from hypertension and anemia.

MEDICAL HISTORY It is the first time of patient X to be hospitalized.

III. PHYSICAL EXAMINATION NAME: PATIENT X DATE OF ASSESSMENT: JANUARY 14, 2012 VITAL SIGNS BP: 160/100mmhg TEMPERATURE: 36.2OC PULSE RATE: 80bpm RESPIRATION RATE: 20cpm

GLASGOW COMA SCALE

FACULTY MEASURE Eye opening

RESPONSE spontaneous To verbal command To pain No response

SCORE 4 3 2 1

Motor response

to verbal command To localized pain Flexes and withdraws Flexes abnormally Extends abnormally No response 4

6 5

3 2 1

Verbal response

oriented, converses Disoriented, oriented Uses inappropriate words Makes incomprehensible sound No response

5 4 3 2 1

______________ 11 Legend: score of patient

ASSESSMENT SKIN Skin color and its uniformity. Assess edema if present Describing skin lesions Skin moisture Skin temperature

METHOD

DEVIATION FROM NORMAL

INTERPRETATION

INSPECTION

PALPATION

PALPATION PALPATION

Note skin turgor (fullness or elasticity)

PALPATION

HAIR The evenness of growth over the skull Hair thickness or thinness. Hair texture and oiliness. INSPECTION

INSPECTION

INSPECTION

Presence of infections or infestation Amount of body hair NAILS

INSPECTION

INSPECTION INSPECTION INSPECTION Excessive thickness, beaus lines Due to severe illness or injury Early clubbing Due to long term lack of oxygenation

Fingernails plate shape, determine its curvature and angle Fingernail and toenail texture Fingernail and toenail bed color Tissues surrounding nails Perform blanch test

INSPECTION

SKULL AND FACE Skull for size, shape and symmetry Skull for nodules or masses and depressions Facial features Eyes for edema and hollowness Note symmetry for facial movements

INSPECTION

PALPATION INSPECTION INSPECTION

N/A. The patient is half paralysis

EYE STRUCTURE AND VISUAL ACUITY EXTERNAL EYE STRUCTURES: Eyebrows for hair distribution and alignment and skin quality movement Eyelashes for evenness and distribution and direction of curl INSPECTION

PALPATION

INSPECTION Eyelids for surface characteristics position in relation to the cornea, ability to blink, and frequency of blinking. Bulbar and palpebral conjunctiva for color, texture and the presence of lesions Lacrimal gland Lacrimal sac and nasolacrimal duct Cornea for clarity Perform the corneal sensitivity(reflex) to determine the function of the fifth (trigeminal) cranial nerve Pupil for color, shape, and symmetry of size Assess each pupil's direct consensual reaction to light to INSPECTION N/A. The patient is not awake

INSPECTION

PALPATION PALPATION

INSPECTION

INSPECTION

determine the function of the third (oculomotor) and fourth (trochlear) cranial nerves. Assess each pupils reaction to accommodation

INSPECTION The patient is sleeping we omitted the corneal sensitivity test

VISUAL FIELDS: Assess visual fields to determine function of the retina and neuronal visual pathways to the brain and second (optic) cranial nerve.

N/A. The patient is not awake.

EXTRAOCULAR MUSCLE TEST: Assess six ocular movements to determine eye alignment and coordination. Assess for location of light reflex by shining penlight on pupil in

INSPECTION

INSPECTION

corneal surface. VISUAL ACUITY: Assess near vision by providing adequate lighting and asking the client to read from a magazine at a distance of 36 cm (14 in). EARS AND HEARING AURICLES: For color, symmetry of size, and position. Texture, elasticity and areas of tenderness. N/A. The patient is half paralysis, unable to sit.

INSPECTION

INSPECTION

EXTERNAL EAR CANAL AND TYMPANIC MEMBRANE: The external ear canal for cerumen, skin lesions, pus and blood

INSPECTION

GROSS HEARING ACUITY TEST: Assess clients response

to normal voice tones. NOSE AND SINUSES The external nose for any deviations in shape, size, or color and flaring or discharge from the nares. The external nose to determine any areas of tenderness, masses and displacements of bone and cartilage. Determine patency of both nasal cavities. Observe for the presence of redness, swelling, growths, and discharge. The nasal septum between the nasal chambers FACIAL SINUSES: The maxillary and frontal sinuses for INSPECTION Presence of NGT at the left nasal

The patient responses when she addressed lola

INSPECTION

PALPATION

tenderness. PALPATION MOUTH AND OROPHARYNX The outer lips for symmetry of contour, color, and texture. The inner lips and buccal mucosa for color, moisture, texture, and the presence of lesions. TEETH AND GUMS The teeth and gums while examining the inner lips and buccal mucosa. INSPECTION Missing teeth, brown discoloration of the enamel. Due to of old age and the presence of dental caries INSPECTION

INSPECTION AND PALPATION

Excessive dryness

Due to using of mouth in breathing

TONGUE/FLOOR OF THE MOUTH The surface of the tongue for position, color, and texture. The tongue movement.

The base of the tongue.

N/A. The patient is not awake.

The tongue and floor of the mouth for any nodules, lumps, or excoriated areas. SALIVARY GLAND The salivary duct openings for any swelling or redness.

INSPECTION INSPECTION PALPATION N/A. The patient is not awake. N/A. The patient is not awake. N/A. The patient is not awake.

PALATES AND UVULA The hard and soft palate for color, shape, texture, and the presence of bony prominences. The uvula for position and mobility while examining the palates OROPHARYNX AND TONSILS The oropharynx for color and texture. The tonsils.

INSPECTION N/A. The patient is not awake.

INSPECTION N/A. The patient is not awake.

INSPECTION N/A. The patient is not awake.

Elicit the gag reflex. INSPECTION NECK

Inspect the neck muscles (sternocleidomastoid and trapezius) for abnormal swellings or masses.

INSPECTION

Absent of gag reflex

Observe head movement Assess muscle strength

Due the problem of the ninth nerve (hypoglossal) or tenth nerve (vagus

INSPECTION

LYMP NODES The entire neck for enlarged lymph nodes. TRACHEA Trachea for lateral

N/A. The patient is half paralysis

The patient is sleeping.

deviation. THYROID GLAND The thyroid gland The spinal alignment for deformities. Posterior thorax The shape and symmetry of the thorax from posterior and lateral views. The posterior thorax. INSPECTION The posterior chest for respiratory excursion. The chest for vocal (tactile) fremitus, INSPECTION INSPECTION INSPECTION N/A. The patient is in side lying position and unable to stand N/A. The patient is in side lying position and unable to stand PALPATION N/A. The patient is in side lying position and unable to stand PALPATION N/A. The patient is in side lying position and unable to stand

N/A. The patient is in side lying position and unable to stand

PALPATION The thorax PALPATION The chest PERCUSSION

Diaphragmatic excursion.

N/A. The patient is in side lying position and unable to stand N/A. The patient is in side lying position and unable to stand N/A. The patient is in side lying position and unable to stand

ANTERIOR THORAX Breathing patterns . The costal angle by the intersection and the angle at which the ribs enter the spine. The anterior chest.

PERCUSSION

AUSCULTATION

INSPECTION

INSPECTION The anterior chest for respiratory excursion.

N/A. The patient is in side lying position and unable to stand N/A. The patient is in side lying position and unable to stand

PALPATION

ABDOMEN

The abdomen for skin integrity. PALPATION

N/A. The patient is in side lying position and unable to stand N/A. The patient is in side lying position and unable to stand

The abdomen for contour and symmetry INSPECTION

The abdomen INSPECTION

The abdomen for bowel sounds, vascular sounds, and peritoneal friction rubs. For bowel sounds

AUSCULTATION

The abdomen

AUSCULTATION

Several areas in each of the four quadrants The abdomen

AUSCULTATION

N/A. The patient is sleeping.

PERCUSSION

The liver PERCUSSION

The bladder MUSCULOSKELETAL

PALPATION

The patient is comatose

PALPATION The muscle size The muscles and tendons for contractures The muscles for tremors PALPATION

INSPECTION

Muscles at rest Test muscle strength

INSPECTION

INSPECTION BONES The skeleton PALPATION The bones

JOINTS INSPECTION The joint for swelling

PALPATION Range of motion

NEUROLOGIC SYSTEM 1. LANGUAGE 2. ORIENTATION INSPECTION 3. MEMORY 4. ATTENTION SPAN AND CALCULATION CRANIAL NERVES 5. REFLEXES MOTOR FUNCTION: 1. FINGER-TO-NOSE TEST 2. WALKING GAIT 3. ROMBERG TEST

4. STANDING ON ONE FOOT WITH EYES CLOSED 5. HEEL-TOE WALKING

6. TOE OR HEEL WALKING 7. FINGER TO NOSE TEST 8. ALTERNATING SUPINATION AND PRONATION OF HANDS ON KNEES 9. FINGER TO NOSE AND TO THE NURSES FINGER 10. FINGERS TO FINGERS 11. FINGERS TO THUMB 12. HEEL DOWN OPPOSITE SHIN 13. TOE OR BALL OF FOOT TO THE NURSES FINGER 14. LIGHT-TOUCH

SENSATION: 15. PAIN SENSATION: 16. TEMPERATURE SENSATION: 17. POSITION OR KINESTHETIC SENSATION 18. TACTILE DISCRIMINATION 19. ONE AND TWOPOINT DISCRIMINATION 20. STEREOGNOSIS (ABILITY TO RECOGNIZE OBJECTS BY TOUCHING THEM)

21. EXTINCTION PHENOMENON

Failure to perceive touch on one side of the body specially in right part of the body