CEREBROVASCULAR ACCIDENT

(CVA)
By:
Ramirez, Maureen Louise L
Macundo, Joan Mariel S.
Maraganas, Novieme D.
Henry, Nicole Cris
ACKNOWLEDGEMENT
First and foremost, we would like to thank our beloved
Heavenly Father for helping us, we could never done it
without Him for He has given us the strength and faith
to finish this case study. We thank Him for giving us the
inspiration to overcome this challenge as part of our
journey for success
We would like to express our gratitude to the
family of Mr. & Mrs. Prodente who are residing at Purok
Mangga Cebu for corresponding properly to our
questions and making us feel comfortable during our
interactions. We are very thankful for their honesty and
patience with us because we were able to finish and
conduct our community based case study. We are so
fortunate that we were given a chance to sit down with
them and conduct a study about Mr. Prodentes
condition because it is such a pleasure that they
allowed us to get into their lives to find out the factors
that have triggered or have caused the health condition
of Mr. Prodente. Also to the Purok President of Purok
Mangga Cebu Mr.Salazar for allowing us to choose a
family in their community for our case study and to her
loving wife Mrs. Salazar for accompanying us to
houses where we conducted our interviews.

We would like to thank our clinical
instructors Ms. Ma. Cristina T. Mamugay,RN
and Mrs. Viola T. Singanon,RN, MAN, for
explaining to us how a Community based case
study would be like, for giving us more ideas
and for pushing us harder to strive for success.
To our Dean of Nursing Ms. Gay R.
Sandiqu,RN, MN and Clinical Instructor
Ms.Ritchel P. Boloron, RN for their patience on
helping us finish this study.

To our beloved families for their
encouragement and never-ending support. We
really learned a lot from this activity for it has
given us the courage to even look more forward
to our future and to be able to encourage more
families to live life in a healthy way.



Introduction
Cerebrovascular accident (CVA) is the
medical term for Stroke. It is the term used
to describe any functional or structural
abnormality of the brain caused by a
pathological condition of the cerebral
vessels of the entire cerebrovascular
system. The pathology either causes
hemorrhage from a tear in the vessel wall
or impairs the cerebral circulation by a
partial or complete occlusion of the vessel
lumen with transient or permanent effects. If
blood is disrupted at any point between the
heart and the brain, portions of the brain
relying on blood from the obstructed blood
vessels becomes deprived of oxygen, thus
making it starve to death.
The most common symptom of a stroke is
sudden weakness or numbness of the face,
arm or legs, most often on one side of the
body. Other symptoms include: confusion,
difficulty speaking or understanding speech;
difficulty seeing with one or both eyes;
difficulty walking, dizziness, loss of balance
or coordination; severe headache with no
known cause; fainting or unconsciousness.
The effects of a stroke depend on which part
of the brain is injured and how severely it is
affected. A very severe stroke can cause
sudden death. The two major types of stroke
are ischemic and hemorrhagic. Ischemic
stroke is caused by a thrombotic or embolic
blockage of blood flow to the brain. Bleeding
into the brain tissue or the subarachnoid
space causes a hemorrhagic stroke.
Ischemic strokes account for about 83% of
all strokes. The remaining 17% of strokes
are hemorrhagic. (Black&Hawks,2004)
Stroke is the third most common cause of death
in developed countries. The incidence of stroke
increases exponentially from 30yrs of age and
etiology varies by age. However, stroke can
occur at any age including childhood. Family
members may have genetic tendency for stroke
or share a lifestyle that contributes to stroke.
Stroke affects around 1.2% of Australian
patients at some time in their lives, which
corresponds to 216,500 Australians affected.
With the growing incidence of obesity in
Australia (which contributes to stroke through
hypertension and atherosclerosis-fatty plaques
in blood vessels) the incidence of strokes is
expected to sky-rocket by 2050. . Men are at
greater risk of stroke than woman up until the
age of 55 yrs. old, after which both sexes have
similar risks. Stroke is a major cause of
morbidity and mortality in the elderly. While
stroke is considered a disease more commonly
affecting men, women are actually twice as
likely to die from stroke as men.
In the United States, Cerebrovascular
disorders are the third leading cause of
death and account for about 164,000
mortalities annually. An estimated 550,000
people experience a stroke each year. When
second strokes are considered in the
estimates, the incidence increases 700,000
per year in the United States alone. Stroke is
a leading cause of adult disability and a
leading primary diagnosis for a long-term
care. More than four million stroke survivors
are living with varying degrees of disability in
the United States. Along with a high
mortality rate, strokes produce significant
morbidity in people who survive them. Of
stroke survivors, 31% require assistance
with self-care, 20% require assistance with
ambulation, 71% have some impairment in
vocational ability up to 7 years following the
stroke, and 16% are institutionalized.
(Black&Hawks,2004)

Stroke is also the second leading cause of
death in the Philippines with a total of 51,680
according to DOH. Along with this are 37,092
who survived with it. According from the Manila
Bulletin September 13, 2008, stroke remains to
be the leading cause of disability, affecting
400,000 Filipinos yearly, making it one of the
leading causes of death together with vascular
diseases. The former Health Secretary Alberto
G. Romualdez said in a press release the cost
of treating uncomplicated stroke for 5-7days
ranges from Php 15,000-20,00 making it not
only a burden emotionally but also economically
to the family and community. There are millions
of stroke survivors living with varying degree of
disability in the world. Along with high mortality
rate, strokes produce significant morbidity in
people who survive them. There is a growing
concern because of lifestyle and diet of Asians,
particularly Filipinos, Cholesterol levels are
rising, resulting in an increased risk for stroke
(DOH)

Medical management of Cerebrovascular
accident commonly includes physical
rehabilitation, dietary and drug regimens to
help decrease risk factors, possibly surgery,
and care measures to help the patient adapt
to specific deficits, such as speech
impairment and paralysis. New therapies
can now prevent or limit the extent of
damage to brain tissue caused by acute
ischemic stroke. Thrombolytic therapy must
be administered as soon as possible after
onset of the stroke; a treatment window 3
hours from the onset of manifestations has
been established. To convey this sense of
urgency regarding the evaluation and
treatment of stroke, health care
professionals now refer to stroke as brain
attack. (Black&Hawks,2004)



OBJECTIVES

Client and Significant Other Centered
Performance Objective

This study attempts to assist the client and family
in determining the clients health status and
improving the clients capabilities for self-care at
Purok Mangga, Poblacion Kidapawan City, 2014.

Specific Objectives:
Establish rapport and gain the trust and
cooperation of the patient and immediate family
members.
Identify measures that could minimize the risk
of occurrence of the disease.
Identify possible risk factors that may have
contributed to the development of
Cerebrovascular accident.
Increase awareness on the risk factors of
Cerebrovascular accident.
Develop the familys support
system and distinguish their
respective roles in improving
patient health status

Involve the family in promoting
the health care of the patient.


B. Nursing Students- Centered Performance
Objective
This study attempts to assess the health status
and the nursing care management of a client who
had Cerebrovascular Accident.

Specific Objectives:

Describe the Cerebrovascular Accident
To gather personal data to obtain baseline
information
Perform and obtain thorough and complete
physical assessment using the assessment
techniques; obtain complete medical, socio-
cultural, and family history related to the
patients current health condition
To discuss the anatomy and physiology of the
Nervous System.
To trace the pathophysiology of
Cerebrovascular Accident.
To identify Nursing problems.

To formulate appropriate nursing diagnosis
to client who had Cerebrovascular accident.

To develop nursing care plan for client
based on the identified nursing problem
and eliminate the problems

Impart useful health teachings to the patient
and immediate family members to prevent
further development of the patients
condition and other related complications,
and for the patient to be able to adjust well
and continue with her normal life

To enumerate the different sources
including books and websites which served
as references for the scientific and medical
facts cited in this case study.


THEORY BASED

Self-Care Deficit Theory
Dorothea Orem
Dorothea E. Orem identified three
theories of self-care, self-care deficit, and
nursing systems. The ability of the person to
meet daily requirements is known as selfcare,
and carrying out those activities is self-care
agency. Parents serve as dependent care
agents for their children. The ability to
provide self-care is influenced by basic
conditioning factors including but not limited to
age, gender, and developmental state. Self-
care needs are partially determined by the
self-care requisites, which are categorized as
universal (air, water, food, elimination,
activity and rest, solitude and social
interaction, hazard prevention, function with
social groups), developmental, and health
deviation (needs arising from injury or illness
and from efforts to treat the injury or illness).

The total demands created by the
self-care requisites are identified as
therapeutic self-care demand. When the
therapeutic self-care demand exceeds
self-care agency, a self-care deficit
exists and nursing is needed. Based
on the needs, the nurse designs
nursing systems that are wholly
compensatory (the nurse provides all
needed care), partly compensatory (the
nurse and the patient provide care
together), or supportive educative (the
nurse provides needed support and
education for the patient to exercise self-
care).
SIGNIFICANCE OF THE
STUDY

The case study regarding patient who had
Cerebrovascular Accident provides awareness
and knowledge regarding the disease and its
warning signs that can be used as a tool for
further management of the disease and its
prevention.

The study will benefit the following:

Client
This case will inform the client of what his
condition is all about. It will also lessen the
burden of the client increasing his awareness
about the whole course of treatments. And also,
the client will be able to familiarize himself
about the importance taking of his own self
through the use of medical regimens and
preventions.


Nursing Student
The student will gain more information and
knowledge about the disease and will lead to
a certain new facts about the said condition,
such as course of disease, pathophysiology,
and manifestations related factors as well as
the proper nursing care management and
medical regimens to be rendered. Through
this research, it promotes the image of the
nurses in the community and among the people
that nursing actions are evidenced based
therefore, more prcised.

College of Nursing
This study could be a used as a guide for the
students and and a source of the facts and
information to students of different colleges;
especially to the students of college of nursing.

SCOPE AND DELIMITATION


The study is limited to the methodology
used wherein the researchers only
describes the conditions of the client who
had Cerebrovascular Accident. It is also
limited only to the respondent, Mr. Cezar
Prodente and his health status. Necessary
information needed for the completion of the
study was gathered from the assessment
done, interaction with the patient and from
the patients wife who gave us the
informations needed for this study. This
study was conducted only for 6 days at the
respondents house at Purok Mangga Cebu,
Kidapawan City.

DEFINITION OF TERMS

Arachnoid layer- is a thin membrane that covers the
entire brain and is positioned between the dura mater
and the pia mater, and for the most part does not
follow the folds of the brain.

Apraxia- a condition in which a client can move the
affected part but cannot use it for
purposeful actions

Basal Ganglia: The basal ganglia are clusters of
nerve cells around the thalamus which are heavily
connected to the cells of the cerebral cortex. The
basal ganglia are associated with a variety of
functions, including voluntary movement, procedural
learning, eye movements, and cognitive/emotional
functions. The various components of the basal
ganglia include caudate nucleus, putamen, globus
pallidus, substantia nigra, and subthalamic nucleus.
Diseases affecting these parts can cause a number of
neurological conditions, including Parkinson's disease
and Huntington's disease.

Brain Cells: The brain is made up of two types of
cells: neurons and glial cells. Neurons are
responsible for all of the functions that are
attributed to the brain while the glial cells are non-
neuronal cells that provide support for neurons.
In an adult brain, the predominant cell type is
glial cells, which outnumber neurons by about
50 to 1. Neurons communicate with one another
through connections called synapses.

Brainstem: The brainstem is the lower extension of
the brain which connects the brain to the spinal
cord, and acts mainly as a relay station
between the body and the brain. It also
controls various other functions, such as
wakefulness, sleep patterns, and attention; and is
the source for ten of the twelve cranial nerves. It is
made up of three structures: the midbrain, pons
and medulla oblongata. The midbrain is involved in
eye motion while the pons coordinates eye and
facial movements, facial sensation, hearing,
and balance. The medulla oblongata controls
vegetative functions such as breathing, blood
pressure, and heart rate as well as swallowing.

Cerebrospinal Fluid (CSF): CSF is a clear fluid
that surrounds the brain and spinal cord, and
helps to cushion these structures from injury.
This fluid is constantly made by structures deep
within the brain called the choroid plexus which is
housed inside spaces within the brain called
ventricles, after which it circulates through
channels around the spinal cord and brain where
is it finally reabsorbed. If the delicate balance
between production and absorption of CSF is
disrupted, then backup of this fluid within the
system of ventricles can cause hydrocephalus.

Cerebellum: The cerebellum is located at the
lower back of the brain beneath the occipital
lobes and is separated from them by the
tentorium. This part of the brain is
responsible for maintaining balance and
coordinating movements. Abnormalities in either
side of the cerebellum produce symptoms on the
same side of the body.


Cerebrum: The cerebrum forms the major
portion of the brain, and is divided into the
right and left cerebral hemispheres. These
hemispheres are separated by a groove called the
great longitudinal fissure and are joined at the
bottom of this fissure by a structure called the
corpus callosum which allows communication
between the two sides of the brain. The surface
of the cerebrum contains billions of neurons
and glia that together form the cerebral cortex
(brain surface), also known as "gray matter." The
surface of the cerebral cortex appears wrinkled with
small grooves that are called sulci and bulges
between the grooves that are called gyri. Beneath
the cerebral cortex are connecting fibers that
interconnect the neurons and form a white-
colored area called the "white matter.

Cranial Nerves: There are 12 pairs of nerves that
originate from the brain itself, as compared to
spinal nerves that initiate in the spinal cord. These
nerves are responsible for specific activities.


Dura mater -is a whitish and nonelastic membrane
which, on its outer surface, is attached to the
inside of the cranium. This layer completely covers
the brain and the spinal cord and has two major
folds in the brain, which are called the falx and the
tentorium. The falx separates the right and left
halves of the brain while the tentorium separates the
upper and lower parts of the brain.

Embolic stroke: This occurs when a blood clot or
piece of plaque (cholesterol or calcium deposits) on
the wall of an artery breaks loose and travels to the
brain. When this happens, the flow of oxygen-rich
blood to the brain is blocked and tissue is damaged
or dies.

Cerebral embolism- occurs when a blood clot from
elsewhere in the circulatory system breaks free

Cerebral thrombosis occurs when a blood clot, or
thrombus, forms within the brain itself, blocking the
flow of blood through the affected vessel. Clots most
often form due to "hardening" (atherosclerosis) of
brain arteries.

Dysarthria- imperfect articulation condition

Hemiparesis/Hemiplegia- the former means
weakness of one side of the body while
the latter means paralysis of one side of the
body .

Hemorrhagic stroke- This occurs when an
artery in the brain ruptures (bursts) and
leaks blood into the brain (cerebral
haemorrhage). This break in the blood
pipeline means parts of the brain are
deprived of blood and a stroke occurs.
Blood irritates brain tissue, causing swelling
and pressure, which cause further damage
and loss of function. Subarachnoid
haemorrhage (SAH) is when blood leaks
into thesurface of the brain. Intracranial
haemorrhage (ICH) is when there is
bleeding into the brain tissue itself.

Hypothalamus: The hypothalamus is a
structure that communicates with the
pituitary gland in order to manage
hormone secretions as well as
controlling functions such as eating,
drinking, sexual behavior, sleep,
body temperature, and emotions.

Ischaemic stroke: This is the most
common type of stroke, particularly in
older people. An ischaemic stroke
occurs when a clot blocks an artery in
the brain. The clot usually forms in a
small blood vessel inside the brain that
has become narrowed through high
blood pressure, high cholesterol,
diabetes or smoking.

Lobes: Several large grooves (fissures)
separate each side of the brain into four
distinct regions called lobes: frontal, temporal,
parietal, and occipital. Each hemisphere has one
of each of these lobes, which generally control
function on the opposite side of the body. The
different portions of each lobe and the four
different lobes communicate and function
together through very complex relationships, but
each one also has its own unique characteristics.
The frontal lobes are responsible for voluntary
movement, speech, intellectual and behavioral
functions, memory, intelligence, concentration,
temper and personality. The parietal lobe
processes signals received from other areas of
the brain (such as vision, hearing, motor, sensory
and memory) and uses it to give meaning to
objects. The occipital lobe is responsible for
processing visual information. The temporal lobe
is involved in visual memory and allows for
recognition of objects and peoples' faces, as
well as verbal memory which allows for
remembering and understanding language.

Meninges: The bony covering around the
brain is called the cranium, which combines
with the facial bones to create the skull. The
brain and spinal cord are covered by a
tissue known as the meninges, which are
made up of three layers: dura mater,
arachnoid layer, and pia mater.


Pia mater-which is attached to the surface of
the entire brain, follows the folds of the brain
and has many blood vessels that reach deep
into the brain. The space between the
arachnoid layer and the pia mater is called the
subarachnoid space and it contains the
cerebrospinal fluid.

Pineal Gland: The pineal gland is an outgrowth
from the back portion of the third ventricle, and
has some role in sexual maturation, although
the exact function of the pineal gland in humans
is unclear.


Pituitary Gland: The pituitary gland is a small
structure that is attached to the base of the
brain in an area called the sella turcica. This
gland controls the secretion of several
hormones which regulate growth and
development, function of various organs
(kidneys, brea sts, and uterus), and the
function of other glands (thyroid gland,
gonads, and the adrenal glands).

Thalamus: The thalamus is a structure that is
located above the brainstem and it serves as a
relay station for nearly all messages that travel
from the cerebral cortex to the rest of the
body/brain and vice versa. As such, problems
within the thalamus can cause significant
symptoms with regard to a variety of functions,
including movement, sensation, and
coordination. The thalamus also functions as
an important component of the pathways within
the brain that control pain sensation, attention,
and wakefulness.

Ventricles: Brain ventricles are a system of
four cavities, which are connected by a series
of tubes and holes and direct the flow of
CSF within the brain. These cavities are
the lateral ventricles (right and left), which
communicate with the third ventricle in the
center of the brain through an opening called
the interventricular foramen. This ventricle is
connected to the fourth ventricle through a
long tube called the Cerebral Aqueducts
then exits the ventricular system through
several holes in the wall of the fourth ventricle
(median and lateral apertures) after which it
flow around the brain and spinal cord.


REVIEW OF RELATED
LITERATURE

Stroke could soon be the most common cause
of death worldwide. Stroke is currently the
second leading of death in the Western world,
ranking after heart disease and before cancer,
and causes 10% of deaths worldwide.
Geographic disparities in stroke incidence have
been observed, including the existence of a
stroke belt in the southeastern United States,
but causes of these disparities have not been
explained.
The incidence of stroke increases exponentially
from 30 years of age, and etiology varies by
age. Advanced age is one of the most
significant stroke risk factors. 95%% of strokes
occur in those over the age of 65. A persons
risk of dying if he or she does have a stroke
also increases with age. However, stroke can
occur at any age, including in childhood.


Telestroke Networks Can Be Cost-Effective For
Hospitals, Good for Patients
Article Date: 22 Dec 2012

Telestroke networks that enable the remote and
rapid diagnosis and treatment of stroke can
improve the bottom line of patients and
hospitals, researchers report. A central hub
hospital delivering rapid stroke diagnosis and
treatment partnering with typically smaller
spoke hospitals in need of those services
means more patients recover better and the
network - and hospitals - make money,
according to a study in the American Heart
Association journal Circulation: Cardiovascular
Quality and Outcomes."We measure stroke
treatment in reduced disability and improved
function and we have clear evidence that
patients who get timely intervention do best,"
said Dr. Jeffrey A. Switzer, stroke specialist at
the Medical College of Georgia at Georgia
Health Sciences University.
"If you are hospital administrator, you may like
the idea conceptually but you have to be
concerned about the risks of investing up front to
do this. This is the first study to show that if it's
set up correctly, a telestroke network will more
than pay for itself."Switzer is corresponding
author on the study using five years of patient
and hospital data from telestroke networks at
GHSU and the Mayo Clinic. Researchers
plugged the data into a model designed to
compare effectiveness and hospital costs with
and without a telestroke network. The telestroke
model has one hub and seven spokes, the
average network size in the United States. They
found that annually with a network: 45 more
patients would receive the clot buster tPA, or
tissue plasminogen activator, the only Food and
Drug Administration-approved stroke drug 20
more patients would receive endovascular
therapy such as mechanically removing the clot
from a blood vessel. Six more patients would be
discharged to their home instead of a nursing
home.

The network made nearly $360,000, with each spoke
hospital making more than $100,000. Major costs of
telestroke networks include technology, technical
support, transferring patients and paying physicians
to take the extra call, said Switzer. "The question is
whether it's in the interest of hospitals to develop
networks that set up these telestroke relationships."
The study suggests it is. It supports a model
emerging across the nation, where large, hub
hospitals such as GHS Medical Center pay
equipment and other costs smaller hospitals incur
using their network. In the vast majority of cases,
patients are seen via the network by stroke
specialists in Augusta; eligible patients are given tPA
at the spoke hospital then transported to GHS Health
System for follow-up care. A new iteration in recent
years has larger, urban hospitals also utilizing the
guaranteed acute stroke care but keeping most
patients at their hospital afterward. The larger
hospitals pay for their own telestroke equipment but
also receive larger reimbursement from public and
private insurance for their service, benefiting hospitals
and patients, Switzer said. "Patients receive quality
care and can stay closer to home."
."A major driver behind these types of stroke-
care extenders is a lack of stroke specialists.
Georgia, for example, is nestled in the stroke
belt and has less than 20 fellowship-trained
stroke specialists to treat a population of 10
million. Each year only 50-60 stroke specialists
complete training at centers across the nation
such as MCG and GHS Health System.The
long-distance approach appears to work well:
MCG researchers showed in a 2003 study
published in the journal Stroke that stroke
patients in rural communities could be
assessed and treated via the wireless Internet
program just as well as they could be in person.
While tPA has been FDA-approved for 16
years, still fewer than 5 percent of patients
receive it, often because they don't get a
definitive stroke diagnosis within the three-hour
time frame the drug should be given. . Three
separate clinical trials in the United States and
Europe have shown it improves the likelihood of
patients resuming normal or near-normal lives.
Dr. David Hess, stroke specialist and Chair
of the MCG Department of Neurology,
helped developed the Augusta system a
dozen years ago, initially connecting with a
small number of rural hospitals. Today,
GHS Health System serves as the hub for
17 spokes. The biotech company, REACH
Health, Inc., emerged about six years ago
to help other hospitals and states develop
similar networks.

Gut Metagenome Changes Protect Against
Stroke
Article Date: 19 Dec 2012 - 1:00 PST

Researchers at the University of Gothenburg,
Sweden, and the Chalmers University of
Technology, Sweden, demonstrate that an
altered gut microbiota in humans is associated
with symptomatic atherosclerosis and stroke.
These findings are presented in a study
published in Nature Communications. The
human body contains ten times more bacterial
cells than human cells, most of which are found
in the gut. These bacteria contain an enormous
number of genes in addition to our host
genome, and are collectively known as the gut
metagenome. How does the metagenome
affect our health? This question is currently
being addressed by researchers in the rapidly
expanding field of metagenomic research.
Several diseases have been linked to variations
in the metagenome.
Researchers at Chalmers University of Technology and
Sahlgrenska Academy, University of Gothenburg, now
also show that changes in the gut metagenome can be
linked to atherosclerosis and stroke. The researchers
compared a group of stroke patients with a group of
healthy subjects and found major differences in their
gut microbiota. In particular, they showed that genes
required for the production of carotenoids were more
frequently found in gut microbiota from healthy
subjects. The healthy subjects also had significantly
higher levels of a certain carotenoid in the blood than
the stroke survivors. Carotenoids are a type of
antioxidant, and it has been claimed for many years
that they protect against angina and stroke. Thus, the
increased incidence of carotenoid-producing bacteria in
the gut of healthy subjects may offer clues to explain
how the gut metagenome affects disease states. .
Carotenoids are marketed today as a dietary
supplement. The market for them is huge, but clinical
studies of their efficacy in protecting against angina
and stroke have produced varying results. Jens
Nielsen, Professor of Systems Biology at Chalmers,
says that it may be preferable to take probiotics instead
- for example dietary supplements containing types of
bacteria that produce carotenoids.
"Our results indicate that long-term exposure to
carotenoids, through production by the bacteria in
the digestive system, has important health benefits.
These results should make it possible to develop
new probiotics. We think that the bacterial species
in the probiotics would establish themselves as a
permanent culture in the gut and have a long-term
effect". "By examining the patient's bacterial
microbiota, we should also be able to develop risk
prognoses for cardiovascular disease", says Fredrik
Bckhed, Professor of Molecular Medicine at the
University of Gothenburg. "It should be possible to
provide completely new disease-prevention
options". The researchers have now started a
company, Metabogen, to further develop their
discoveries relating to the metagenome. Their
success is based on close cooperation between
engineers, microbiologists and doctors. Jens
Nielsen and Fredrik Bckhed both agree that one of
the challenges in the rapidly developing area of
metagenomics is its multidisciplinary facets,
requiring novel collaborations and merging of
research fields.

Eating tomatoes is shown to slash stroke risk in
half
Wednesday, October 17, 2012 by: John Phillip

Lycopene from tomatoes and tomato-based foods
dramatically lowers stroke risk in men. After determining
the amount of lycopene consumed by the participants,
researchers found that 9.7 percent of those men with
the lowest intake of lycopene experienced a stroke. 4.2
percent of the men with the highest lycopene
consumption had a stroke over the study period. The
study team determined that people with the highest
amounts of lycopene in their blood were 55 percent less
likely to have a stroke than people with the lowest
amounts of lycopene in their blood. When the
researchers further broke down the results, they found
that those with the highest levels of lycopene were 59
percent less likely to have an ischemic stroke (caused
by a blood clot, the most common type of stroke) than
those with the lowest levels. Lead research author, Dr.
Jouni Karp pi concluded "This study adds to the
evidence that a diet high in fruits and vegetables is
associated with a lower risk of stroke.
... the results support the recommendation
that people get more than five servings of
fruits and vegetables a day, which would likely
lead to a major reduction in the number of
strokes worldwide, according to previous
research."Interestingly, the scientists reviewed
blood levels of the antioxidants alpha-
carotene, beta-carotene, alphatocopherol and
retinol, but found no association between the
blood levels and risk of stroke. This provides
further support for consumption of a varied
diet from a wide array of fruits, vegetables,
nuts and seeds supplying a rainbow of
antioxidant compounds and omega-3 fats to
prevent disease. Health-conscious individuals
will want to include one to two daily servings
of tomatoes and tomato-based foods to
dramatically lower stroke risk.


METHODOLOGY
Method:
The method used was case study wherein the
researchers interviewed and described the
condition of the client. Case study is one of the
ways of doing research whether it is social
science related or even socially related. It is an
intensive study of a single group, incident, or
community. Rather than using samples and
following a rigid protocol to examine limited
number of variables, case study methods
involve an in-depth, longitudinal examination of
a single instance or event: a case. The
researchers used this method because they
provide a systematic way of looking at events,
collecting data, analyzing information and
reporting results. Since this study focuses on a
certain participant, it can help the researchers
attain detailed information to unlock the clients
unmet needs and potential problem.

Research locale:
The study was conducted at Purok Mangga
Cebu, Kidapawan City located at approximately
one and a half kilometers away from the city
proper.

Selection of Respondents:
On the first day of exposure to the community,
the researchers were assisted by their clinical
instructor as they searched for a person with
CVA. We chose Mr. Cezar Prudente because
he had the worst symptoms than the first
respondent that we met.

Tools used:
In this case study, the researchers formulated a
series of questions for their interview to the client and
his family which outlines all the data including how
the client adapts to physiological and psychosocial
changes and how the client practice appropriate
methods in taking care of his past and present
condition.

Research Procedure:
The purok president made a courtesy call to the
3
rd
year nursing students of Notre Dame of
Kidapawan College for them to conduct a case
study of a certain client in the community. Then
in collaboration with the researchers clinical
instructors, they gave information on who were
the persons with CVA in the community. Then
the researchers went to conduct a home visit.
After the researchers selected their respondent,
they first established rapport and then
conducted an ocular survey of the clients
environment and physical assessment of the
client.
After the survey, the researchers interviewed
the respondents family about the clients
condition. When the data was gathered, the
researchers formulated nursing diagnoses and
plans for health education for the client and
then provided health teachings regarding
treatment of stroke such as appropriate care for
his self and some tips for care at home.

PRESENTATION, ANALYSIS
AND INTERPRETATION OF
DATA
Initial Data Base

Family Characteristics

Mr.& Mrs. Prudente was lived in Purok
Mangga Cebu Kidapawan City the family
compose of 4 members that include 1 daughter
and 1 son, they have also a stay in caregiver and
1 working student who lived together with them.
Their family structure may considered as
cohabiting or communal family since they have a
member which is the caregiver and the working
student who stayed in their house that is not
related to them.
According to the Mrs. Prudente in terms
of authority and decision maker her husband is
responsible but after the attack Mrs. Prudente is
the decision maker in terms of family issues.

TIME ACTIVITY
5:00 am Patient Wake- up
5:15-6:00am Patient is sitting in the wheel
chair while waiting for
breakfast
6:00-6:20am Breakfast Time
6:20-8:00 Patient is sitting in a chair
outside side the house.
8:15-9:00 Take a bath (Kada sabado
lang as verbalized)
10:30-11:00 Lunch time
12-1:00pm Take a Sleep
2:00-2:30pm Patient take a snack if it is
available usually fruits while
sitting outside the house
4:00-5:00 Dinner time
5:15-7:00pm Watch a television
7:00pm Bedtime
Activities of Daily Living

Analysis:
Family meet their own needs relative
to their own priorities(Characteristics of basic
needs: Kozier & Erb 2008); basic needs must
be met, but in the situation of our case study
respondent his needs is being altered like the
needs of being independent because of his
health condition.

Economic Factor

Mr. Cezar Prudente is formerly farmer
and his wife is an elementary teacher but
because of the stroke incidence patient work
was stop since 2007. His wife earns a month
salary of php14, 000 a month they have also
other source of income came from their farm
lot. They have also health insurance, according
to the patient wife the biggest expenditure in
their budget is the foods and the health
maintenance of the patient.


Analysis:
An individuals standard of living reflect
the occupation, income and education of an
individual because low income families often
defined health in terms of work if people can
work they are healthy(Standard of Living:
Kozier & Erb 2008).
In the case of our patient we can considered
them as middle class of family in terms of family
income even though the patient need not finish
his education but they have a farm lot that may
support their family needs aside from the salary
of his wife as a teacher.

Cultural Factors
Mr. Prudente is a Ilonggo while his wife Mrs.
Prudente is Ibuloy came from the benguit
provinces according to the wife they dont have
any health beliefs and they dont belief in any
superstitious.


Analysis:
Culture and social interaction influence
how the person perceives, experiences, and
copes with health illness (Family and
Culture Beliefs: Kozier and Erb, 2008).
In the case of our patient they use a home
remedies and other alternative medicine as
their first medication compare with the
scientific health practices.



Political
Before the stoke attack the patient is a active member
of the Purok Mangga Cebu, at present his wife and
other member of family is active, sometimes they seek
an advice from their Purok President in some issue. The
family has a good relationship with their neighbors.
Analysis:
In the case of our patient they have a close
relationship with his family and their neighborhood.

Home and Environment
The patient family is lives in the house that is owned by
his wife, the family lived together for 20-25 years. The
house is has 200meter dimension with 3 bedroom and 1
dining room, it is made of half concrete and half bamboo
(kalakat). Their dirty kitchen is located outside of their
house. They have own toilet. They have their own
electricity; they also have water come from the water
district of kidapawan. The garbage is sometimes burned
out we also observe some flowers in their house and a
big tree of Tamarin fruits.
Analysis:
In the situation of our patient we could say
that it is helpful for him because there is fresh air and it
is not too crowded area.


Social Factor
The client attains information by means of the
radio and television. The patient is High School
Graduate. His religion is Roman Catholic. The
patient cannot practice his socialization needs
because of his situation but sometimes his
neighbors, family and relatives visits him.
Analysis:
Having a support with the family, friends
or a confidant help the person confirm that illness
is exits. Support people also provide the stimulus
for an ill person to become well again ( Hurdle,
2011).
In our patient condition there has a
strong support from his family and friends,
because according the patient sometimes their
close relative and friends visit him.


Sources of Medicine

The patient is a dependent of his wife
health insurance, his wife income is
usually the first source for buying medicine
but sometimes there daughter help them to
buy maintenance medicine.
Analysis:
A sick people need to sick an
advice from health professional either on
their own initiative or at the urging of
significant care. (Illness Behavior: Kozier &
Erb, 2008).


Family Perception of the Role of the Health
Professional and Their Services

According to the patient they seek a
medical consultation when their self will not
tolerate their illnesses, client believe that
medical consultation will be the last option. But
according to Mrs. Prudente her husband did not
follow the prescribe medication because Mr.
Prudente said that if he will take a medicine his
kidney will be destroyed.
Analysis:
In the case of our patient we could say
that our patient is not so conscious of his
health, because they use remedial action they
assumed that his condition will be healed
without the consultation of medical professional


Past Experiences with Health Professional
From the onset of stroke attack last 2007 the
patient sought a medical check-up, then after 90 days the
patient confined in a hospital.
Analysis:
The action of the patient and family seeking
health assistance indicates the theory of self-care and
promotes well-being, independently or dependently by
Dorothy Orem theories.
Marital Status and Relationship
Mr. & Mrs. Prudente were married for 25 years
they have 2 children. Mr. Prudente stated that for 25
years they have harmonious relationship as husband and
wife after all those trials, it is because of their love and
respect to each they are open to all member of the family,
if there will be problem will come they discuss it and one
of them will give way. They have also good relationship
with their children in fact their daughter help them for the
financial needs.
Analysis:
Open communication is helpful to our patient
because it will help ease his depression specially his
difficulty condition. Effective family communication will
help the member to express their feelings without fear of
jeopardizing their standing in the family. (Kozier & Erb
2008)


Family Responsibility for Health Monitoring

Since the wife of the our patient is
working the primary caretaker of the patient
is his personal caregiver during the week
days the caregiver assist the patient on his
basic needs such as personal hygiene and
as much as possible they to maintain the
proper hygiene and the caregiver also the
one prepared the foods of the patient.
During the week ends the caregiver will
have a day off the wife will take care her
husband according to Mrs. Prudente she
usually prepare fruits and vegetable for his
husband diet.


Family APGAR

Adaptation
The salary of the client and his wife is budgeted fairly to
the familys daily needs. Food is the very first priority,
followed by others such as water, clothing, and so on.

Partnership
Back then, the client was an active farmer and goes
home only during weekends. His wifes a teacher and
takes care of the children while her husband was away.
Before the client had his stroke, he was usually the one
who leads and makes decisions for the family. Thats
when the wife took over the position. For now, shes
the one who makes decisions for the family.
Growth
The clients wife has spent more time with their children
since the client spends too much of his time for his
farm in order to provide his family their daily needs.
Now that he could no longer visit his farm, he spends
most of his at home.

Affective
Every time the family
experiences problems, they
always talk about it.

Resolution
In times of personal and financial
problems, the couple usually
gets over it by talking it over.
Sometimes they seek help from
the clients side of family.


Socio-Cultural Assessment

The client is currently residing at
their own house with his family. The
clients religion is Roman Catholic while
his wife is a Protestant. The client used to
go to church every Sunday at the cathedral
but now he is unable to do so.
He used to participate in whatever
activities that community had if he was not
busy. According to the daughter, he also
used to attend meetings and some
important events in the community.

Nutritional Status


Back then, he used to eat bulad,
bagoong, piniritong baboy and so on.
Anything thats salty was his favorite and
couldnt control his food intake.
Today Mr. Prudents diet has
changed. His diet mostly consists of fruits
and vegetables from their garden and his
farm. He is now prohibited from taking in
too much sweet and salty food.
When I did the physical
assessment, he had no evident signs of
malnutrition.

9 coping Areas

Physical Independence
The patient family has an open relationship the
patient itself is a dependent to his family due to
his condition he also dependent to his wife in
terms of decision making for the family concern.
They have their own electric line; radio and
television is their source of information. The
house lot is own by Mrs.Prudente they have
also a clean source of water from the water
district.

Analysis:
The client is physically dependent to
his wife and his family, he cannot make his own
decision because his centered of his attention
was his condition how to overcome the difficult
situation.


Therapeutic Competence
Patient is taking a vitamins and other
alternative herbal drug, he also take 1 one the
prescribe medicine of the physician which is the
Losartan 50mg, but upon the treatment period
of the stroke attack the patient did not follow all
the prescribe medication that is prescribe by his
attending physician because of fear that if he
will take those medicine the main organ that will
be affected is his kidney.
Analysis:
Patient has poor compliance of
medicine during the attack of stroke; he is more
confident to take an alternative medicine than
those branded medicine; this may result poor
progress of healing.



Knowledge of Health Condition
The patient knew and accepts the
reality of his condition that is difficult and it
takes a period of time to back to the normal life.
The patient knew that stroke attack can affect
your body such your speeches.

Analysis:

The patient is knowledgeable of his
CVA condition. This is because of his
consultation and confinement to the health
facilities.

Application of Principles of General Hygiene

According to the patient he only take a
bath every weekends it du to his condition that
he need an assistance in taking a bath and
sometimes he will not take a bath because he
cannot tolerate the coldness of the water.

Analysis:
The patient applies a poor hygiene
practice as verbalized and observed situation.

Health Attitudes
The practice of our patient and his
family is more on alternatives medicine, at
present our present is taking an alternative
medicine like usana, malunggay leaves capsule
etc. They also have a reflexology session in
every Saturday as way of relaxation.

Analysis
Using an alternative medicine is a way
of coping the financial constraints of the family.

Emotional Competence
The support and love of his family
made him to be a emotional
competent and the fact that they
lived together for 25 years. He
accept that in present he cannot a
decision for the family he just trust
to his wife.

Analysis
The patient is now emotionally
competent after a long period of
marriage he has an own strategies
of coping the situation.

Family Living

The family has a close relationship with the
members, the wife and his daughter speed their
time in school they are both teacher will his son
is still a student. For the past 25 years patient
and his urge usually urge because of patient
diet aside from diet patient didnt remember any
reason of their urge as husband and wife. They
dont have any conflict with their neighbors and
families.

Analysis
They have established well-founded
relationship with his family as evidence of
strong support from his wife and children.

Physical Environment
Their house is made of half concrete and half
kalakat that have an area of approximately
200 meter. Have 3 bedrooms and 1 dining
room with separated dirty kitchen and comfort
room. There are some flower located in their
surrounding and has a big tamarin tree which
provide a fresh air that is helpful to the patient
condition.

Use of Community Facilities
They dont use any health facilities in
their barangay because when they get sick they
usually use an alternative medicine then if the
illness will not cure, they immediately seek a
medical attention since they have their health
insurances.
Analysis
Patient family use their own health
insurance that to use any community health
facilities.

DEVELOPMENTAL DATA

AGE/STAGE DESCRIPTION ACCORDING TO THEORIES ANALYSIS

50 years old

Havighurst
-Later Maturity

Erikson
-Maturity

Kohlberg
-Postconventional
Havighurst Erikson Kohlberg On Havighursts theory,
the client is adjusting to
reduced income
considering his expenses
with hemodialysis. He is
also adjusting to
decreasing physical
strength and health and
the presence of the
disease, and establishing
satisfactory physical
living arrangements.
On Eriksons theory, the
client accepts his worth
and uniqueness.
On Kohlbergs theory, the
client is Social Contract
Driven and Universal
Ethical Principle Driven.
He still thinks of what
would have happened to
him without dialysis and
and what life would be
like if he wasnt suffering
from diabetic
nephropathy
Later Maturity:
1. Adjusting to
decreasing physical
strength and health.
2. Adjusting to reduced
income.
3. Adjusting to death of
spouse.
4. Establishing an
explicit affiliation with
ones age group.
5. Meeting social and
civil obligations.
6. Establishing
satisfactory physical
living arrangement.
Maturity:
Central task
- Integrity vs. Despair

Positive Resolution:
- Acceptance of worth and
uniqueness of ones own life.
- Acceptance of death.

Negative Resolution:
- Sense of loss; contempt for
others.


Postconventional:
Social Contract Driven
-The world is viewed as holding different
opinions, rights and values. Such
perspectives should be mutually
respected as unique to each person or
community. Laws are regarded as social
contracts rather than rigid edicts. Those
that do not promote the general welfare
should be changed when necessary to
meet the greatest good for the greatest
number of people. This is achieved
through majority decision, and
inevitable compromise.
Universal Ethical Principle
- This involves an individual imagining
what they would do in anothers shoes, if
they believed what that other person
imagines to be true. In this way action is
never a means but always an end in
itself; the individual acts because it is
right, and not because it is instrumental,
expected, legal, or previously agreed
upon. Although Kohlberg insisted that
stage six exists, he found it difficult to
identify individuals who consistently
operated at that level.
Physical Assessment
General Status

Glasgow Coma Scale: 9 (E4, V4, M1)
Level of consciousness: Obtunded
Monoparesis (left arm)
Paraplegia
Disoriented to time when asked
Slurred speech
Use of non-verbal cues
Use of an assistive device (wheelchair)

Motor Strength








Clients right hand was able to tightly grip
one of the researchers hand.
Left hand unable to move but there was a
little contraction of muscle.
Both feet didnt show any muscle
contraction. Completely paralyzed.


Sensory Examination:

The client was able to differentiate which
was dull and sharp.

He was able to identify the number we drew
on the palm of his right hand.

He felt the stimuli we introduced on both of
his feet but failed to show any motor
response.
Skin
Tan complexion, dry, and no presence
of lesions. Nail beds were pink, no clubbing, no
discolorations and nails well-trimmed. Good
skin turgor, skin rapidly resumed to its original
shape.
Head
Hair was black and well distributed. No
presence of lice and dandruff noted. His hair
was curly and short.

Nails
Nails were smooth with surrounding
cuticles. No abnormalities noted. Finger and toe
nails were long. Had spontaneous capillary
refill.

Head
The skull was symmetrical and
generally round. No skull deformities noted.
Eyes
Eyes were symmetrically aligned and
equal in movement, eyelashes were evenly
distributed and curled. Both pupils were equally
reactive to light on examination (using a
penlight). He could still see clearly.
Conjunctivas were pale and eyeballs were in
good position and alignment.

Ears
The client was able to locate the
direction of the sound of cars passing by. No
hearing abnormalities. His ears were
symmetrically aligned. Some discharges noted.
Nose
No asymmetry, no nasal discharges
noted and can identify odors. It was normal in
shape and size. No swelling, inflammation
Neck/throat
No neck vein engorgement. Tonsils
were in normal size, no difficulty on swallowing.
The neck could move freely without any
discomfort.

Chest and Lungs
Equal chest expansion, no retractions
noted. Clear breath sounds and with bilateral
chest movements. RR 19 cpm.
Heart and Circulation
Distinct heart sounds, regular rhythm.
BP - 140/100 mmHg. PR - 83 bpm.
Abdomen
No masses, scars and lesions noted.
Abdomen symmetrically aligned. No tenderness
noted.
Genito-Urinary
According to the client, there were no
skin lesions. He defecates once a day. He
voids 3 times a day.

Extremities
Upper Extremities
No skin lesion noted. No growth
deformities. He could not move his left hand but
his right hand could move and grip tightly. Both
were not symmetrical in size. The left one was
bigger than the right hand.

Lower Extremities
No skin lesion noted. No growth
deformities. His lower extremities were not
symmetrical in size. Both were paralyzed. The
right foot was bigger than the left foot.

ANATOMY AND PHYSIOLOGY
NERVOUS SYSTEM

The nervous system is a complex, highly
organized network of billions of neurons and
even more neuroglia. The structures that make
up the nervous system include the brain, cranial
nerves and their branches, the spinal cord,
spinal nerves and their branches, ganglia,
enteric plexuses, and sensory receptors. The
two big initial division of the nervous system are
the central nervous system (CNS) consists of
the brain and spinal cord. The peripheral
nervous system (PNS) consists of all nervous
outside the CNS. It consists of 31 spinal nerves
and 12 cranial nerves.

The nervous system helps maintain
homeostasis and integrates all body activities
by sensing changes (sensory function),
interpreting them (integrative function), and
reacting to them (motor function).

Sensory (afferent) neurons carry sensory
information from cranial and spinal nerves into
the brain and spinal cord or from a lower to a
higher level in the spinal cord and brain.
Interneurons have short axons that contact
nearby neurons in the brain, spinal cord or out
of the brain and spinal cord into cranial or
spinal nerves.

Components of PNS include the somatic
nervous system (SNS), autonomic nervous
system (ANS), and enteric nervous system
(ENS). The somatic nervous system consists of
neurons that conduct impulses from somatic
and special sense receptors to the CNS and
motor neurons from the CNS to skeletal
muscles. The autonomic nervous system
contains sensory neurons from visceral organs
and motor neurons that convey impulses from
the CNS to smooth muscle tissue, cardiac
muscle tissue, and glands. The enteric nervous
system consists of neurons in enteric plexuses
in the gastrointestinal (GI) tract that function
independently of the ANS and CNS to some
extent. The ENS monitors sensory changes in
and controls operation of the GI tract.

Nervous tissue consists of neurons (nerve cells) and
neuroglia. Neurons have the property of electrical
excitability and are responsible for most unique
functions of the nervous system: sensing, thinking,
remembering, controlling muscle activity, and
regulating glandular secretions. Neuroglia support,
nurture, and protect the neurons and maintain
homeostasis in the interstitial fluid that bathes
neurons. Most neurons have three parts. The
dendrites are the main receiving or input region.
Integration occurs in the cell body, which includes
typical cellular organelles. The output part typically is
a single axon, which propagates nerve impulses
toward another neuron, a muscle fiber, or a gland
cell. Synapses are the site of functional contact
between two excitable cells. Axon terminals contain
synaptic vesicles filled with neurotransmitter
molecules. Slow axonal transport and fast axonal
transport are systems for conveying materials to and
from the cell body and axon terminals. On the basis
of their structure, neurons are either multipolar,
bipolar, or unipolar.

Neuroglia includes astrocyte, oligodendrocytes,
microglia, ependymal cells, Schwann cells, and
satellite cells. Two types of neuroglia produce
myelin sheaths: oligodendrocytes myelinate
axons in the CNS, and Schwann cells
myelinate axons in the PNS. White matter
consists of aggregates of myelinated
processes, whereas gray matter contains cell
bodies, dendrites, and axon terminals of
neurons, unmyelinated axons, and neuroglia. In
the spinal cord, gray matter forms an H-shaped
inner core that is surrounded by white matter. In
the brain, a thin, superficial shell of gray matter
covers the cerebral and cerebellar
hemispheres.

The nervous system exhibits plasticity (the
capability to change based on experience), but
it has very limited powers of regeneration (the
capability to replicate or repair damaged
neurons). Neurogenesis, the birth of new
neurons from undifferentiated stem cells, is
normally very limited. Repair of damaged
axons, does not occur in most regions of the
CNS. Axons and dendrites that are associated
with a neurolemma in the PNS may undergo
repair if the cell body is intact, the Schwann
cells are functional, and scar tissue formation
does not occur too rapidly.

SPINAL CORD
The spinal cord is protected by the vertebral
column, the meninges, cerebrospinal fluid, and
denticulate ligaments. The three meninges are
coverings that run continuously around the
spinal cord and brain. They are dura mater,
arachnoid mater, and pia mater. The spinal
cord begins as a continuation of the medulla
oblongata and ends at about the second lumbar
vertebra in an adult. The spinal cord contains
cervical and lumbar enlargements that serve as
points of origin for nerves to the limbs.

Spinal nerves connect to each segment of the spinal
cord by two roots. The posterior or dorsal root
contains sensory axons, and the anterior or ventral
root contains motor neuron axons. The anterior
median fissure and the posterior medial sulcus
partially divide the spinal cord into right and left sides.
The gray matter in the spinal cord is divided into
horns, and the white matter into columns. In the
center of the spinal cord is the central canal, which
runs the length of the spinal fluid. Parts of the spinal
cord observed in transverse section are the gray
commissure; central canal; anterior, posterior, and
lateral gray horns; and anterior, posterior, and lateral
white columns, which contain ascending and
descending tracts. Each part has specific functions.
The spinal cord conveys sensory and motor
information by way of ascending and descending
tracts, respectively.

Spinal Nerves
The 31 pairs of spinal nerves are named and
numbered according to the region and level of the
spinal cord from which they emerge. There are 8
pairs of cervical, 12 pairs of thoracic and 5 pairs of
lumbar, 5 pairs of sacral and 1 pair of coccygeal
nerves. Spinal nerves typically are connected with the
spinal cord by a posterior root and as anterior root. All
spinal nerves contain both sensory and motor axons
(are mixed nerves). Three connective tissue
coverings associated with spinal nerves are the
endoneurium, perineurium, and epeneurium.
Branches of a spinal nerve include the posterior
ramus, meningeal branch, and rami communicantes.
Sensory neurons within spinal nerves and cranial
nerve V (trigeminal nerve) serve specific, constant
segments of the skin called dermatomes. Knowledge
of dermatomes helps a physician determine which
segment of the spinal cord or which spinal nerve is
damaged.

BRAIN
The major parts of the brain are the brain stem,
cerebellum, diencephalon, and cerebrum. Blood flow
to the brain is mainly via the internal carotid and
vertebral arteries. Any interruption of the oxygen or
glucose supply to the brain can result to weakening
of, permanent damage to, or death of brain cells. The
blood-brain barrier (BBB) causes different substances
to move between the blood and the brain tissue at
different rates and prevents the movement of some
substances from blood into the brain. Cranial bones
and cranial meninges protect the brain. The cranial
meninges are continuous with the spinal meninges.
From superficial to deep they are dura mater,
arachnoid mater, and pia mater. Cerebrospinal fluid
(CSF) provides mechanical protection, chemical
protection, and circulation of nutrients. It forms in the
choroid plexuses and circulates through the lateral
ventricles, third ventricle, fourth ventricle,
subarachnoid space, and central canal. Most of the
fluid is absorbed into the blood across the arachnoid
villi of the superior sagittal blood sinuses.

Brain stem
The medulla oblongata attaches to the spinal
cord and contains both motor and sensory
tracts. It contains nuclei that are reflex centers
for regulation of heart rate, respiratory rate
vasoconstriction, swallowing, coughing,
vomiting, and sneezing. It also contains nuclei
associated with cranial nerves VII through XII.

The pons is superior to the medulla. It connects
the spinal cord with the brain and links parts of
the brain with one another by way of tracts.
Pontine nuclei relay nerve impulses related to
voluntary skeletal movements from the cerebral
cortex to the cerebellum. The pons contains the
pneumotaxic and apneustic centers, which help
control breathing. It contains nuclei associated
with cranial nerves V-VII and the vestibular
branch of cranial nerve VIII.

The midbrain is between the pons and
diencephalon and surrounds he cerebral
aqueduct. It conveys motor impulses from the
cerebrum to the cerebellum and spinal cord,
sends sensory impulses from the spinal cord to
the thalamus, and mediates auditory and visual
reflexes. It also contains nuclei associated with
cranial nerves III and IV.

A large part of the brain stem consists of small
areas of gray matter and white matter called the
reticular formation. It helps maintain
consciousness, causes awakening from sleep,
and contributes to regulating muscle tone.

Cerebellum
The cerebellum occupies the inferior and posterior
aspects of the cranial cavity. It consists of two lateral
hemispheres and a medial, constricted vermis. It
connects to the brain stem by three pairs of
cerebellar peduncles. The cerebellum functions to
coordinate movements and to maintain normal
muscle tone, posture, and balance.

Diencephalon
The diencephalon surrounds the third ventricle and
consists of the thalamus, hypothalamus. The
thalamus is superior to the midbrain and contains
nuclei that relay sensory impulses to the cerebral
cortex. It also allows crude appreciation of painful,
thermal and pressure sensations and mediates some
motor activities. The hypothalamus is inferior to the
thalamus. It controls the autonomic nervous system,
secretes hormones, functions in rage and aggression,
governs body temperature, regulates food and fluid
intake, and establishes circadian rhythms.

Cerebrum
The cerebrum is the largest part of the brain. Its
cortex contains gyri (convolutions), fissures,
and sulci. The cerebral lobes are named the
frontal, parietal, temporal, and occipital. The
white matter is deep to the cortex and consists
of myelinated and unmyelinated axons
extending to other regions as association,
commissural, and projection tracts. The basal
ganglia are several groups of nuclei in each
cerebral hemisphere. They help control
automatic movements of skeletal muscles and
help regulate muscle tone. The limbic system
encircles the upper part of the brain stem and
the corpus callosum. It functions in emotional
aspects of behavior and memory.

Cranial Nerves
Twelve pairs of cranial nerves originate from the
nose, eyes, inner ear, brainstem, and spinal cord.
They are named primarily based on their distribution
and are numbered I-XII in order of attachment to the
brain.
12 Cranial Nerves
1. Olfactory
This is a type of sensory nerve that contributes in the
sense of smell in human being. These basically
provide the specific cells that are termed as olfactory
epithelium. It carries the information from nasal
epithelium to the olfactory center in brain.

2. Optic nerve
This again is a type of sensory nerve that transforms
information about vision to the brain. To be specific
this supplies information to the retina in the form of
ganglion cells.


3. Oculomotor nerve
This is a form of motor nerve that supplies to
different centers along midbrain. Its functions include
superiorly uplifting eyelid, superiorly rotating eyeball,
construction of pupil on the exposure to light and
operating several eye muscles.
4. Trochlear
This motor nerve also supplies to the midbrain and
performs the function of handling the eye muscles
and turning the eye.
5. Trigeminal
This is a type of largest cranial nerve in all and
performs many sensory functions related to nose,
eyes, tongue and teeth. It basically is further divided
in three branches that are ophthalmic, maxillary and
mandibular nerve. This is a type of mixed nerve that
performs sensory and motor functions in brain.

8. Abducent
This is again a type of motor nerve that supplies to
the pons and perform function of turning eye laterally.
7. Facial
This motor nerve is responsible for different types of
facial expressions. This also performs some functions
of sensory nerve by supplying information about
touch on face and senses of tongue in mouth. It is
basically present over brain stem.
8. Vestibulocochlear
This motor nerve is basically functional in providing
information related to balance of head and sense of
sound or hearing. It carries vestibular as well as
cochlear information to the brain and is placed near
inner ear.

9. Glossopharyngeal
This is a sensory nerve which carries sensory
information from pharynx (initial portion of throat) and
some portion of tongue and palate. The information
sent is about temperature, pressure and other related
facts.
It also covers some portion of taste buds and salivary
glands. The nerve also carries some motor functions
such as helping in swallowing food.
10. Vagus
is also a type of mixed nerve that carries both motor
and sensory functions. This basically deals with the
area of pharynx, larynx, esophagus, trachea, bronchi,
some portion of heart and palate. It works by
constricting muscles of the above areas. In sensory
part, it contributes in the tasting ability of the human
being.

11. Spinal accessory nerve
As the name intimates this motor
nerve supplies information about
spinal cord, trapezius and other
surrounding muscles. It also
provides muscle movement of the
shoulders and surrounding neck.
12. Hypoglossal nerve
This is a typical motor nerve that
deals with the muscles of tongue.

Etiology

Factor Actual Rationale Justification
Gender
X
Men are more common in having CVA because
of lifestyle especially alcohol intake
Patient lifestyle is more on farming, he only
take alcohol occasional.
Hereditary An individual risk may increase if a maternal
and paternal has had stroke since hypertension
is genetically transferred.
In case of our patient there was hereditary
hypertension since his parents, brother and
sister was died due to stroke attack.
Race African, American, and Asian have a much
higher risk of death from stroke. As now
hypertension is one of highest concern in the
Philippines
Patient live in the Philippines
Diet



Diet may lead to hypertension specially
frequent consumption of food that is rich
sodium and fatty; caloric content.
The case of our patient his usual diet is more
on salty and fatty foods that are high content of
sodium and cholesterol which trigger the attack
of stroke.
SYMPTOMATOLOGY
Symptoms
Actual
Rationale Justification
Hemiparesis




This deficits is usually caused by a stroke in
the anterior or middle cerebral artery leading
to infarction in the motor strip of the frontal
cortex
In our patient his life side of the body
experiences a hemiparesis.
Aphasia


X

Blood clot from the CVA can prevent oxygen
and nutrient from reaching nerve cell thus,
resulting to cell death and the affected body
ceases to function.
In our patient is well oriented and
responsive to our question even though he
has a difficulty in word pronunciation.
Dysphagia











Cranial nerve 9 and 10 located in the left
hemisphere which may result to Dysphagia/
imperfect articulation of speech due to
disturbance of muscular control resulting
from central and Peripheral nervous system
changes.
As we observe our patient is experience a
difficulty in word pronunciation maybe it due
to damage hemisphere after the stroke
attack
Hemiplegia








Due to the damage lateral gaze center. Upon performing neuro vital signs, his left
side of the body the lower and the upper
extremities cannot move.
Nursing History

1. General Appearance at first Sight
The patient is seated in the wheelchair
well groomed, wearing with blue shirt and black
short, with blanket covered in his lower part of
the body. The patient was conscious, coherent
and responsive to the researcher, difficulty of
speech noted.
2. Expectation of Cebrovascular accident
(stroke)
Family Expectation:
According to the patient wife they
expect that the patient condition would be
difficult situation, knowing that his husband was
attack for 4x since 2007, as the wife said there
was a time the she was thinking that she will
accept if her husband will be gone (die) after
those frequent episode of attack.

Client Expectation:
According to the patient he accepted his
condition, but still he is hoping that he can back to the
normal life which can perform ADL, hoping that he
can stand after the episode of therapies.
3. Heredo-familial Disease
Mr. Prudente has a familial history of
hypertension both mother and father side in fact his
father, mother, 2 brothers, and sister was died due to
cerebrovascular accident. They have also a familial
history of Diabetes Mellitus and Cardiovascular
diseases.

4. History of Past Illness
There is no history of past illnesses
mentioned by the patient aside from Cerebrovascular
accident.

5. History of Present Illness
In the year of 2007 prior to attack the
patient experience headache and pain in on his
lower portion of the head and there was a difficulty of
speech(dysarthia) and they noted that his mouth is
deform immediately they confined Mr. prudente at
Kidapawan Doctor Hospital Inc under the service of
Doctor Paul Jerry Natanagarra. The 2
nd
Stroke attack
was on Dec 18, 2010 which he experience
Hemiplegia and he was connected to NGT for 3
months as portal entre of his diet. During the 3
rd

attack the patient is confined in the other hospital for
the medical insurance concerned that was last 2011
and his 4
th
attack patient confined at Midway Hospital
Inc.
6. Risk Factors
Risk for injury due to impaired physical
Mobility
Risk for skin integrity due to Immobility


7. Activity and Rest
The patient has no difficulty in terms of
sleep pattern aside from his concerned he could back
in his normal were can performed ADL. He wake up
as early as 5 oclock in the morning and take his
breakfast at 6 am after 2 hours he will take a bath
and after than he will seat outside of their house to
inhaled fresh air and wait until the time of lunch,
sometimes at 2 oclock he eat his snack and take his
dinner at 5-6pm in the afternoon.
8. Circulation
Subjective: No Subjective reported
Objective: BP- 140/100mmHg
Respiratory rate: 19 cpm
Pulse Rate: 83 bpm
Body Temperature: 36 C

9. Ego integrity:
Subjective: No Subjective reported
Objective: Patient is coherent and
responsive during the time of home
visitation and assessment.
10. Social Interaction
Subjective: Living with family and
caregiver and working student, Has
a good and open relationship to
everyone .

11. Neurosensory:
Subjective:
Language: Patient displayed a difficulty in speech
Orientation: Patient oriented to person, time, and
placeLevel of Consciousness: Patient is coherent
and responsive
Special Senses:
Visual Acuity: Patient did not manifest any sign of
visual impairment; patient can see object far or
periphery distance
Auditory: Patient can hear in normal voice tone
Tactile: Patient feels the pain being introduce which
means patient is sensitive to stimuli.
Gustatory: Patient can distinguish the different taste.
Olfactory: Patient can distinguish different smell

12. Pain and Comfort
Subjective: Wala man sakit sa akong lawas
maam
Objective: Patient seat comfortably
13. Respiratory:
: No Subjective reported
Objective: 19 cpm
14. Integumentary System
Subjective: No Subjective reported
Objective: Body Temperature: 36 C; Dry skin
noted, Head dandruff noted.

Nursing Priorities
The patient Mr. Prudente is at risk
of injury due to impaired physical
immobility causing it a potential
problem for the client. Hemeplegia
is one post complication
Cerebrovascular accident. We
being a nursing student should
emphasize to the family and
caregiver the importance of safety
precaution such as when the
patient is seated at the wheel chair
they should make sure that is being
lack to prevent accidental
movement of the wheel chair.

Nursing Diagnosis
Risk for injury r/t body weakness
Risk for skin integrity r/t Inability to
change position as evidence by inability
to purposefully move within the physical
environment
Activity intolerance r/t Immobility
Impaired Verbal Communication r/t loss
facial or oral muscle tone control
Ineffective cerebral tissue perfusion r/t
Impaired cerebral circulation as
evidenced by altered level of
consciousness, changes in
motor/sensory responses, and motor/
sensory deficit

Chapter V
Medical and Nursing
Management

Patient Assessment Diagnosis Planning Nursing intervention Rationale Expected Outcomes
Subjectives:
Diri lang ko perme
maglingkod sa akong wheel
chair.


Objectives:
BP140/100mmHg
RR- 19 cpm
PR- 83 bpm
Risk for injury related to body
weakness

SCIENTIFIC BASIS:

Hemeplegia (weakness) it is a
paralysis of one part of the
body it is due
To brain damage caused by
stroke resulting to limitation in
independence; purposeful
physical movement of the
body or one or more
extremities.
After our 6 days of duty client
will remain free and
significant others will gain
knowledge how to prevent
injury an absence of abrasion,
burns, or fall.
-Encourage the patient and
caregiver to always check
the lock of the wheel chair.



-Encourage the significant
other to check time to time
patient position.

-Maintain body alignment as
much as possible sing pillow,
use
- Frequent checking of the
wheel lock will prevent from
accidentally movement of the
wheel chair.

Checking the skin of the
patient will help patient
condition.


Proper position of the patient
will help the patient for
comfortable position
-Goal meet patient and
significant other gain
knowledge how to prevent
protect patient from injuries.
NURSING CARE PLAN

HEALTH TEACHINGS

Most of the controllable risk factors for stroke
relate to cardiovascular fitness. Because stroke
is a form of cardiovascular disease, it makes
sense that keeping your heart and blood
vessels as healthy as possible will reduce
your risk of stroke. The following are the most
important measures you can take to control
your stroke risk.

Regular Medical Check-ups
Risk factors such as heart disease, high blood
pressure, and elevated blood cholesterol must
be monitored by the physician on a regular
basis. These risk factors can be changed or, at
minimum, controlled by proper medical
treatment and appropriate diet and lifestyle
modifications.

Control Blood Pressure
High blood pressure (hypertension) is the
single most important risk factor for stroke.
Even mild hypertension, if not adequately
treated, increases stroke risk. In general, blood
pressure should be below 120/80. Elevated
blood pressure promotes atherosclerosis and
puts abnormal pressure on blood vessel walls,
which can cause a rupture at a weak spot.
Hypertension is often called the"silent killer"
because there may be no obvious symptoms. It is
important to check your blood pressure regularly.

Remember: medication to control hypertension
is effective only if taken on a regular basis.
Treatment of hypertension in older adults is also
important. However, in elderly individuals, an
abrupt fall in blood pressure may actually cause a
stroke. Therefore, treatment of high blood
pressure in the elderly may need to start with
small doses of medication, so that blood pressure
is reduced gradually.

Improve Diet
Consumption of foods high in fat, cholesterol
and salt increases the risk for stroke. The
following recommendations are among the most
important for stroke prevention.
1) Avoid excess fat: High intakes of fat, particularly
saturated fat, and cholesterol may contribute to
atherosclerosis, which is associated with stroke.
Dietary fat and cholesterol may be reduced by
limiting fat or oil added in cooking, trimming
fat and skin from meats and poultry, using
low-fat or non-fat dairy products, broiling and
baking foods rather than frying, and limiting eggs
to no more than three a week.

2) Avoid excess sodium: Excess sodium in the diet
is linked to hypertension. Table salt is the primary
source of dietary sodium. There is also "hidden"
salt in most processed and canned foods. Dis
odium phosphate, monosodium glutamate, sodium
nitrate, or any similar compounds in the list of
ingredients indicate high sodium content. Try to eat
fresh food whenever possible.

Reduce Stress
Because stress may increase blood pressure, it
is linked indirectly to stroke risk. A one -time
stressful event rarely causes a stroke, but
long-term unresolved stress can contribute
to high blood pressure. Stress management,
including relaxation techniques, biofeedback,
exercise and counseling, appear to be useful in
the treatment of high blood pressure, thus
lowering the risk of stroke.

Family or Individual History
A history of cerebrovascular disease in a family
appears to be a contributing factor to stroke.
While you have no control over your family
history, you can take steps to decrease your
risk through diet, exercise and other means
discussed in this guide. If you have
experienced a stroke or TIA in the past, you are
at increased risk for having a stroke in the
future.