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TRANSCRIPT
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I. INTRODUCTIONThe nervoussystem is an organ system containing a networkofspecialized
cells called neuronsthat coordinate the actions of an animal and transmit
signals between differentpartsof its body. In most animals the nervous system
consists of two parts, central and peripheral. The central nervous
systemofvertebrates (such as humans) contains the brain,spinal cord,
andretina.Theperipheral nervoussystem consistsofsensory neurons, clustersof
neurons calledganglia, and nerves connectingthemtoeachotherandtothe
central nervous system. These regions are all interconnected by means of
complex neural pathways. Theenteric nervous system, a subsystem of the
peripheral nervoussystem,hasthe capacity,even when severed fromthe rest
of the nervous system through itsprimary connection by the vagus erve, to
function independently in controlling thegastrointestinal system. (Accessed at:
http://www.merck.com/mmhe/sec06/ch086/ch086a.html on August 12, 2010)
The autonomic nervoussystemregulates certain bodyprocesses,such as
blood pressure and the rate of breathing. This system works automatically
(autonomously), without a person's conscious effort. The autonomic nervous
systemhastwomain divisions:thesympathetic andtheparasympathetic. After
the autonomic nervous system receives information about the body and
external environment, itresponds bystimulating bodyprocesses,usuallythrough
thesympathetic division,or inhibitingthem,usuallythroughtheparasympathetic
division.(Giraldo, Elias A., 2007)
An autonomic nervepathway involvestwo nerve cells.One cell is located
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bothsidesof it.Theganglia fortheparasympathetic division are located nearor
in the internal organs.(Giraldo, Elias A., 2007)
Generally, the sympathetic division prepares the body for stressful or
emergencysituationsfightor flight.Thus, it increasesheart rate andthe force
ofheart contractions andwidens (dilates)the airwaystomake breathingeasier.
It causesthe bodytoreleasestoredenergy. Muscularstrength is increased.This
division also causespalmstosweat,pupilstodilate, andhairtostandon end.It
slows bodyprocesses that are less important in emergencies,such asdigestion
andurination.
The parasympathetic division controls body process during ordinary
situations. Generally, it conserves and restores. It slows the heart rate and
decreases bloodpressure.Itstimulatesthegastrointestinal tracttoprocessfood
and eliminatewaste. Energy from theprocessed food is used to restore and
buildtissues.
Two chemical messengers (neurotransmitters), acetylcholine and
norepinephrine, are used to communicate within the autonomic nervous
system. Nerve fibers that secrete acetylcholine are called cholinergic fibers.
Fibers that secrete norepinephrine are called adrenergic fibers. Generally,
acetylcholinehasparasympathetic (inhibiting)effects and norepinephrinehas
sympathetic (stimulating)effects. However, acetylcholinehassomesympathetic
effects. Forexample, it sometimes stimulates sweatingormakes thehair stand
on end.(Giraldo, Elias A., 2007)
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basal ganglia and anterior limb ofthe internal capsule.Thevertebral and basilar
arteriessupplythe brain stem, cerebellum,posteriorcerebral cortex, andmedialtemporal lobe.Theposteriorcerebral arteries bifurcatefromthe basilararteryto
supply themedial temporal (including thehippocampus) andoccipital lobes,
thalamus, andmammillary andgeniculate bodies. The anterior andposterior
circulations communicate in the circleof Williswhich is atthe baseofthe brain.
(Accessed at: http://www.merck.com/mmhe/sec06/ch086/ch086a.html onAugust 12, 2010)
When an artery that carries blood to the brain becomes clogged or
blocked, an ischemic stroke can occur. Arteries may be blocked by fatty
deposits (atheromas, or plaques) due to atherosclerosis. Arteries in the neck,
particularly the internal carotid arteries, are a common site for atheromas.
Arteriesmay also be blocked by a blood clot (thrombus). Blood clotsmayform
on an atheroma in an artery.Clotsmay alsoform in theheartofpeoplewith a
heartdisorder. Partof a clotmay breakoff andtravel throughthe bloodstream
(becoming an embolus). Itmaythen blockan arterythatsupplies bloodtothebrain,such asoneofthe cerebral arteries. (Giraldo, Elias A., 2007)
Cerebrovascular accident (CVA) is the medical term for what are
commonlytermed asCVA, brain attack, cerebral infarction orstroke. Itrefersto
the acute neurological injury to the brain that occurswhen flow of blood to
brain tissue is interrupted by a cloggedor ruptured artery.The brain requires a
steadysupplyofoxygen in ordertopump bloodeffectively to all ofthe body.
Oxygen is supplied to the brain in the blood that flows through arteries. Total
ti f bl d fl d i ibl b i i f ti ithi 3 i t
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because of lack of nutrients andoxygen. (Lippincott Williams & Wilkins, 2003,
HandbookofDiseases)
CVA orStrokes can be classified intotwomajorcategories: ischemic and
hemorrhagic. Ischemic strokes arethosethat are caused by interruption ofthe
bloodsupply,whilehemorrhagic strokes are theoneswhich result from rupture
of a bloodvessel oran abnormal vascularstructure. 87% ofstrokes are caused
by ischemia and the remainder byhemorrhage. Somehemorrhagesdevelop
inside areasof ischemia ("hemorrhagic transformation").It isunknown howmany
hemorrhages actuallystartoff as ischemic stroke. Strokesymptoms lasting < 1 h
are termed a transient ischemic attack (TIA). Strokesdamage brain tissue; TIAs
often do not, andwhen damageoccurs, it is lessextensive than thatdue to
strokes. (Accessed on: http://www.eurekalert.org/pub_releases/2008-03/arrs-
wbm032808.php at August 2, 2010)
Risk factors for a cerebrovascularaccident includehavinghypertension,
heartdisease,diabetes,high cholesterol andobesity.Other risk factors include
beingof African-American ancestry, beingmale,drinkingexcessive amountsof
alcohol,smoking andhaving a familyhistoryofheartdiseaseorcerebrovascular
accident. Having a brain aneurysm puts a person at an extreme risk for a
hemorrhagic cerebrovascular accident. (Accessed
on:http://www.wrongdiagnosis.com/s/stroke/12153454636=xy.090970952075 at
July 29, 2010)
Another common cause of ischemic strokes is a lacunar infarction. In
lacunar infarction,oneofthesmall arteriesdeep in the brain becomes blocked
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partofthe brain isdamaged in lacunar infarction. (Lippincott Williams & Wilkins,
2003, HandbookofDiseases)
Rarely,small piecesoffatfromthemarrowof a broken long bone,such as
a leg bone, are released into the bloodstream. These pieces can clump
together and block an artery. The resulting disorder, called fat embolism
syndrome,mayresemble a stroke.
The incidenceofstroke increasesexponentiallyfrom 30 yearsof age, and
etiologyvaries by age. Advanced age isoneof themost significant stroke risk
factors. 95% of strokes occur in people age 45 and older, and two-thirds of
strokesoccur in thoseover the ageof 65. A person's riskofdying ifheor she
doeshave a stroke also increaseswith age. However,stroke can occurat any
age, including in fetuses. Mens stroke incidence rates are 1.25 timesgreater
thanwomens.Thedifference in incidencerates betweenthesexes issomewhat
higher at younger ages but nonexistent at older ages. The male/female
incidencewas 1.59 forages 6569;1.46 forages 7074; 1.35 forages 7579 and
0.74forage 80 andolder. (Barnett, H. J. M.; Mohr, J. P.; Stein, B.; and Yatsu, F. M.,
eds. (1998). Stroke: Pathophysiology, Diagnosis & Management. Philadelphia,
PA:Churchill-Livingstone.)
Hypertension accounts for 35-50% of stroke risk. Epidemiological studies
suggestthateven a small bloodpressurereduction (5 to 6 mmHgsystolic, 2 to 3
mmHgdiastolic)wouldresult in 40% fewerstrokes. Lowering bloodpressurehas
been conclusivelyshown toprevent both ischemic andhemorrhagic strokes.It is
equally important in secondary prevention. Even patients older than 80 years
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protection againstother formsof cardiovasculardiseaseshould be considered
and cost. (US Census Bureau,International Data Base, 2004)
An ischemic stroke can also result from any disorder that reduces the
amountof bloodoroxygen supplied to the brain,such assevere blood lossor
very low bloodpressure.Occasionally, an ischemic strokeoccurswhen blood
flow to the brain is normal but the blood does not contain enough oxygen.
Disordersthatreducetheoxygen contentof blood include a severedeficiency
of red blood cells (anemia), suffocation, and carbon monoxide poisoning.
Usually, brain damage in such cases iswidespread (diffuse), and coma results.
(Lippincott Williams & Wilkins, 2003, HandbookofDiseases)
An ischemic stroke can occur if inflammation of bloodvessels (vasculitis)
or infection (such asherpessimplex) narrows bloodvesselsthatsupplythe brain.
Migraineheadachesordrugssuch as cocaine and amphetamines can cause
spasmof the arteries,which can narrow the arteries supplying the brain and
cause a stroke. (Lippincott Williams & Wilkins, 2003, HandbookofDiseases)
ThegroupfoundCerebrovascularAccident as an interesting caseforthe
casestudy.Utilizingthe availableresources atthe library aswell asthe internet
toprovide accurate information about the saiddisease.Thegroup also chose
this case so thatexpand the familiarity andunderstanding thatwill also beof
assistance in thefuture.
A. ObjectivesAfter the completion of the study the student nurses shall be able to:
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y Enumeratethedifferentsigns andsymptomsofCerebrovascularaccidenty List down the different diagnostic procedures that would help in the
diagnosisofCerebrovascularaccident.
y Identify andunderstanddifferent typesofmedical treatment necessaryforthetreatmentofCerebrovascularaccident.
y Formulate nursing careplansutilizingthe nursingprocessy Formulate conclusions based on the findings and enumerated a
recommendations concerningCerebrovascularaccident.
Nurse Centered Objectives:
Attheendofthestudy,thestudent nurses:
y Shall have critical thinkingskills necessaryforprovidingsafe andeffectivenursing care.
y Shall have a comprehensive assessment and implement care baseon ourknowledge andskillsofthe condition
y Shall havefamiliarizeduswitheffective inter-personal skillstoemphasizedhealthpromotion and illnessprevention.
y Shall have impartedthe learningexperiencefromdirectpatient care.
Patient Centered Objectives:
Attheendofthisstudy,thepatient/familywill be ableto:
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3. Increase awarenesson theriskfactorsofCerebrovascularaccident.4. Developthefamilyssupportsystem anddistinguishtheirrespectiveroles
in improvingpatientshealthstatus.
5. Involvethem in promotingthehealth careofthepatient.
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II. NURSINGASSESSMENT
A. Personal HistoryTatay Stroke, isthefatherofseven children withhisfirstmarriage and
threestep-children fromhisfirstwife. He isthesecondeldest amongseven
children. He is currently living with his secondwife whom is his primary
caregiver. Hewas a overseasworker for 25 years at Saudi Arabia as a
Engineeringforan air-conditioning companyto be abletosupporthiswife
and children.
After all of his children graduated, he stopped working and
receiving support from his children who are currently overseas, three ofwhich areworking as nurses.Otherthatthesupporthe isreceivingfromhis
children,he also receivesmoney fromhispension whichhe andhiswife
are consumingfortheirexpenses like in hishospitalization.
A collegegraduate,hemethis firstwife at a churchwhilehearing
mass.Theyeloped aftergetting a stable job at a softdrinks company to
be abletosupporttheirfamily.Duringthetimethathewasmarriedwithhis
firstwifehewasworkingoverseas andwould comehome backonceor
twice a yeartoseehisfamily.Oncehestoppedworking and camehome
tothe countryhe andhisfirstwifehaveseparated andgot annulled.Thenhemethissecondwife,whowas a common friendofhim andoneofhis
friends, aftermeeting andgettingtoknoweachother,hemarriedherwho
he is livingwith now andtheonewho istaking careofhim. Hehas been a
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headaches, nape pain and dizziness. His blood pressurewasmonitored
andfinal diagnosedwith Hypertension.
B. Pertinent family history
Sister
(63y/o)
Brother
59(y/o)
Brother
72(y/0)
Brother
69(y/o)
Sister
66(y/o)
Brother
(78y/o)Tatay stroke
(75y/o)
Father
Mother
Grandfather
Grandmother
Grandfather
Grandmother
Male Female MarriedLegend:
HypertensionNo Known DeceasedDiabetes
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Tataystroke comesfrom a bigfamily. He isthesecondeldest amongthe
seven children. Four of them are males while two are females. Both his
grandfather in hisfatherandmotherssidedied becauseof Hypertension. While
one of her grandmother died due to Diabetes Mellitus and the other one
becauseofold age. His father suffered from asthma andunfortunately, ituntil
hegotdiagnosedwith Bronchitis anddied. Hismotherwas a smoker,with a lot
of vices such as excessive alcohol intake that brought up her condition andreason forherdeath. Therewere noother familymemberswho suffered from
CVA.
C.History of
Past i
llness
Thepatienthad noprevious hospital confinement. Though hiswife said
that, Tatay Stroke suffers from productive cough and colds whenever cold
weathersets in,medicinesforcommon cough and colds aregiven and if itwas
accompanied by fever, she would give him antipyretics. She assumed that
maybe, concurrent coughepisode is caused byherhusbandsdeadlypractice,
which is smoking. During his childhood days, Tatay stroke, have experienced
having Measles,Chicken Pox, Mumps andTonsillitis.
D. History of Present illnessTatay Stroke suffers from headache, right body weakness and has
difficulty in speaking brought about mainly by his current diagnosis which is
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Tatay Stroketo comewithherto local hospital nearbywherehewas admitted
with a chief complaintofrightsided bodyweakness.
CranialNerve
Type
andFunction
Assessm
entTechnique Normal
Response Clients Response
I.Olfactory Type:
Sensory
Function:
Senseof
smell
Ask the client to
smell and identify
the smell of
garlic/coffee
with each nostril
separately and
with the eyes
closed.
Client is able
to identify
different
smell with
each nostril
separately
and with
eyes closed
unless such
conditionlike colds is
present.
Tatay Stroke was
ableto identifythe
different scents
(garlic and coffee)
that he had
smelled.
II.Optic Type:
Sensory
The client is
instructed to
cover an eye
The client
should spot
the moving
Tatay Stroke was
able to spot the
moving object in
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clients nose). An
object is move
intovisual fields in
the periphery.
The client is
informed to tell
the examiner
when themoving
object isspotted.
III.Oculomotor Motor
Pupil
constriction,
movement
of eye up
anddown
Reaction to light:
Using a penlightand
approaching
from the side,
shine a light on
the pupil.
Observe theresponse of the
illuminated pupil.
Shine the lighton
the pupil again,
and observe the
response of the
otherpupil.
Reaction to
Illuminated
and non-
illuminated
pupil should
constrict.
Pupils
constrict
when
The illuminated
and non-
illuminatedpupil of
Tatay Stroke
constricted.
Tatay Strokepupils
constricted when
asked to look at a
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Alternate the
gaze from the
near to the far
object. Next,
move an object
towards the
clients nose.
object,
converge
when near
object is
moved
towards the
nose.
the nose, the iris
converged.
IV.Trochlear Motor
Downward,superior
and inferior
oblique,
lateral
Hold a penlight 1
ft. in front of the
clients eyes. Ask
the client to
follow the
movements of
the penlightwith
the eyes only.
Move the
penlight upward,
downward,sideward and
diagonally.
Clients eyes
should be
able to
follow the
penlight as it
moves.
BotheyesofTatay
Stroke are able to
move as
necessary.
V.Trigeminal Motor The patient is
asked to swallow
as being
observed by the
examiner
Client should
be able to
movehis jaw
and swallow
without
There is the
affectation of his
jaw movement
and has difficulty
in mastication
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Lateral
movementofeyes
clients eyes. Ask
the client to
follow the
movements of
the penlightwith
the eyes only.
Move the
penlight through
the six cardinalfieldsofgaze.
move in
unison with
parallel
alignment.
coordination.
VII. Facial Motorand
Sensory
Movement
of muscles
of the
faces.
Ask client to
smile, raise the
eyebrows, frown,
and puff out
cheeks, close
eyestightly.
Client should
be able to
smile, raise
eyebrows,
andpuffout
cheeks and
close eyes
without anydifficulty.
Tatay Stroke
wasnt able to
raise eyebrows,
and puff out his
cheek at the left
sideoftheface.
VIII.
Vestibulocochlear
Sensory
andmotor
Sense of
hearing
Have the client
occludeoneear.
Outofthe clients
sight, place a
tickling watch 2
to 3 cm. askwhat
the client can
hear and repeat
Client should
be able to
hear the
tickling of
thewatch in
bothears.
Tatay Stroke was
able to hear
tickling in both
ears.
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Glossopharyngeal andmotor
Sense oftasteon the
posterior
1/3 of the
tongue
Gagreflex
say ah and
have the patient
yawn to observe
upward
movementofthe
softpalate.
Elicit gag
response.
Note ability to
swallow.
be able to
elicit gag
reflex and
swallow
without any
difficulty.
able to elicit gag
reflex and able to
swallow with
difficulty.
X.Vagus Motor
Swallowing
and
speaking
and gag
reflex
Askthepatienttoswallow and
speak (note
hoarseness)
The clientshould be
able to
swallow
without
difficulty and
speak
audibly.
Tatay Stroke wasable to swallow
with difficulty and
has slurred
speech..
XI. Accessory Motor
Movement
of shoulder
muscle
Ask client to
shrug shoulders
against
resistance from
your hands and
turn head to side
against
i t f
Client should
be able to
shrug
shoulders
and turn
head from
sidetoside.
Tatay Stroke was
able to shrugonly
his left shoulders
and turn his head
fromoneside.
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XII. Hypoglossal Motor
Movement
oftongue.
Ask client toprotrude tongue
at midline and
then move itside
toside.
The clientshould be
able to
move
tongue
without any
difficulty.
Tatay Stroke hasrestricted
movement of the
tongue.
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Page | 17
DIAGNOSTIC AND LABORATORYPROCEDURES
DIAGNOSTIC OR
LABORATORY
PROCEDURES
DATE
OREDERED
DATE
RESULTSIN
INDICATIONS OR
PURPOSESRESULTS
NORMAL
VALUES
ANALYSIS AND
INTERPRETATION
COMPLETEBLOOD
COUNT (CBC) OR
HEMATOLOGY
> consistsofseveral
teststhat allowforthe
evaluation ofdifferent
cellularcomponentsof
the bloodon a broad
rangeof clients.The
items commonlyevaluated includehgb,
hct,RBC,RBC indices,
WBC, WBCdifferential,
platelets and
microscopic
examination ofstained
D.O:
7/22/10
D.R:
7/22/10
HEMOGLOBIN (HGB)
-tomonitorHgb
value in theRBC
-Iron status and
oxygen carrying
capacityoftheRBCs.
-tosuggestthe
presenceof body
fluiddeficitdueto
elevated Hgb level.
150g/dL
120-170g/dL
Thepatients Hgb is in
the normal rangewhich
meansthatthere is no
presenceof anemia and
there is adequate
oxygenation.There is
sufficientoxygen carried
bythe blood.
RBC COUNT
-itmeasuresthe
numberofRBCto
5.25 x 10 4.0-5.0 x 10 ThepatientsRBC count
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Page | 18
bloodsmears.
WBC DIFFERENTIAL
COUNT
determinesthe
percentageofeach
kindsofwhite blood
cells in thewhite blood
cell count
detecttheoxygen
carrying capacitythe
cells.
-itusedto assess
further ifthepatient
hadepisodesof
bleeding
ismoderatelyelevated
whichmeanspresence
of inflammation.
HEMATOCRIT (HCT)
- to aiddiagnosisof
abnormal statesof
hydration,
polycythemia and
anemia.
-Itmeasuresthe
concentration ofRBC
within the blood
volume and is
expressed as a
percentage.
0.45 % 0.37-0.54 %
Thepatients Hct count is
within the normal range
whichmeansthatthe
percentageofRBC in
blood iswithin the
normal range indicatingabsenceof conditions
which contributesto
hemoconcentration and
hemodilution of blood.
WBC COUNT
-todetect infection
8.2 x 10
g/L
5-10 x
10g/LThe WBC count iswithin
the normal range. WBCs
are cellsofthe immune
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Page | 19
or inflammation
-this bloodtestevaluatesthe
numberof condition
anddifferentiates
causesof alteration
in thetotal WBC
count including
inflammation,
infection andtissue
necrosis.
system involved in
defendingthe body
against both infectiousdisease andforeign
materials.
The bodyhasthe
adequate abilityto
defendthe body against
invadingmicroorganism
whichmeansthatthe
patients immune
defensespatients body.
LYMPHOCYTES
-todetermineviral
infection
-produces antibodies
andotherchemicals
responsiblefor
destroying
microorganisms;
contributesto allergic
reactions,graft
rejection,tumor
0.27 % 0.20-0.40 %
Thevalue iswithin the
normal rangewhich
meansthatthere is an
absenceofviral
infections.The bodyhas
the abilityproduce
antibodies andotherchemicalsresponsiblefor
destroying
microorganisms.
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Page | 20
control, and
regulation ofthe
immunesystem.
SEGMENTERS
-aremature
neutrophilswhich act
asphagocytes and
defendthe body and
if levels areelevated
it indicates
inflammation.
0.73 % 0.50-0.70 %
Segmenters areelevated
indicatingexistenceof
inflammation.
PLATELETS
-arespecial cell
fragmentsthatplay
an importantrole in
blood clotting.If a
patientdoes not
haveenoughplatelets,hewill be at
an increasedriskof
excessive bleeding
and bruising.
-theCBCmeasures
450 x
10/L
150 400 x
10/L
Platelets areelevated in
which causes
aggregation of clotting
andthrombusformation.
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Page | 21
NURSINGRESPONSIBILITIES:
Prior
1. Explain theproceduretothepatientssignificantother.2. Explain tothepatientthatthistestwill help in thepatientsresponsetotreatment.3. Tell thepatientssignificantotherthat nofasting isrequired.4. Explain tothepatientthatthetestrequires bloodsample andvenipuncturewill beperformed.5. Informthepatientthatthepatientwill experiencediscomfortfromthe needlepuncture andpressureof
thetourniquet.
6. Informthatshewill beexperiencingmildpain on sitewherethe needlewaspricked.7. Assurethat collectingthe bloodsampletake lessthan 3 minutes.
During:1. Maintain steriletechnique.2. Collect 5-7 ml ofvenous blood in a vacum.
andsizeofplatelets
present.
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Page | 22
After:1. Applypressureorpressuredressingtothevenipuncturesite.2. Checkthevenipuncturesiteforbleeding.3. Fill-upthe laboratoryformproperly andsend ittothe laboratorytechnician duringthe collection ofthe
sampleofthespecimen.
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Page | 23
DIAGNOSTIC
OR
LABORATORY
PROCEDURES
DATE
OREDERED
DATERESULTS
IN
INDICATIONS
ORPURPOSES RESULTS NORMAL VALUESANALYSIS AND
INTERPRETATION
COMPUTED
TOMOGRAPHY
SCAN (CT-scan,
Non-contrast)
- Anx-ray
procedurethat
combines
manyx-rayimageswiththe
aidof a
computerto
generate cross-
sectional views
and, if needed,
three-
dimensional
imagesofthe
internal organs
andstructures
ofthe body.
D.O: 7/22/10
D.R: 7/22/10
To identify
theextent
theextentof
the brain
injuryor
damage and
the areas
involvethat
are affected.
Lacunar infarct,
left
capsuloganglionic
region.
Microvascular
ischemic
changes, both
periventricular
whitematterandleftparietal white
matter,
agerelated
cerebral atrophy
changes,
atheromatousinternal carotid
arteries
Noevidenceof
mass lesion or
acute
parenchymal
hemorrhage,
hypodensefoci
areseen atthe left
capsuloganglionic
region, bothperiventritcular
whitematterand,
noevidenceof
subfalaine
herniation,
hydrocephalusorcerebral edema.
Noextraaxial fluid
collection orblood
isseen.The internal
carotid arteries are
TheresultoftheCT
scan dated 7/22/10
shows lacunar
infarct atthe left
capsuloganglionic
region.The
infarction may be
duetodecrease
cerebraloxygenation
becauseofthe
presenceofemboli
that impedes blood
supply in the brain.
TheresultoftheCTscan alsoshowsthe
affectation ofthe
leftsideofthe
brain,which iswhy
Tatay Stroke
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atheromatous.
Noteorage
related cerebralatrophy changes.
Orbits
petromastoids,
sella turnica,
includedsinuses
and bonycalvarium are
intact,
manifested
Contralateral
Hemiparesisorrightsidedweakness.
TheCTscan also
shows affectation
ofthe Frontal and
Parietal Lobe
wherein thepatientmanifestedslurred
speech and
change in mental
statuswith a GCS
scoreof 12 at July
26, 2010.
NURSINGRESPONSIBILITIES:
Prior:1.
Informthepatientthattheprocedure assessesthe brain.
2. Obtain a listofmedication thepatient istaking.3. Explain theprocedure to thepatient. Thepatients cooperation is necessary, becausehemust lie still
duringtheprocedure.
4. Obtain information consent ifrequired bythe institution.
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5. Tell thepatientthatfasting is notusuallyrequired.6. Review the procedurewith the patient. Explain the purpose of the test and how the procedure is
performed.
7. Shoe thepatient a pictureof theCTmachine andencourage thepatient to verbalize his concerns,becausesomepatientsmayhave claustrophobia. Mostpatientswho aremildly claustrophobic can be
scanned afterappropriatepremedication with anti-anxietydrugs.
8. Instruct the patients that wigs, hairpins, clips or partial dental plates cannot be worn during theprocedure becausetheyhampervisualization ofthe brain.
9. Tell thepatientthathemayheara clicking noise asthescanningmachinemoves aroundthehead. During:
1. Ensure that thepatienthas compliedwithmedications restrictions andpretestingpreparations. Ensurethatthepatienthasremoved all external metallic objectspriortoprocedure.
2. Haveemergencyequipmentreadily available.3. Instruct the patient to cooperate fully and to follow directions. Instruct the patient to remain still
throughouttheprocedure becausemovementproducesunreliableresults.
4. Administeran anti-anxiety agent, asordered, ifthepatienthas claustrophobia.5. Ask thepatient to inhaledeeply andholdhis breathwhile thex-ray images are taken, and then to
exhale afterthe images aretaken.
6. Instruct the patient to take slow deep breaths if nausea occurs during the procedure. Monitor andadministeran antiemetic agent ifordered.
7. Notethefollowingprocedureforthe brain CT-scan:
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Page | 26
y Thepatient lies in a supineposition on an examining tablewith the head restingon a snug-fittingrubbercapwithin a water-filled box.Thepatientshead isenclosedonlytothehairline.Theface is not
covered, andthepatient can seeoutofthemachine at all times. Sponges areplaced alongtheside
oftheheadtoensurethatthepatientsheaddoes notmoveduringthestudy.
8. The scanner passes an x-ray beam through the brain fromone side to theother. Themachine thenrotates 1 degree, andtheprocedure isrepeated ateachdegreethrough a 180-degree arc.
After:1. Instructthepatienttoresumemedications and activity, asdirected bythehealth carepractitioner.2. Monitorvital signs and neurologic statusevery 15 minutesfor30 minutes.
Documenttheproceduredone.
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III. ANATOMY ANDPHYSIOLOGY
CENTRAL NERVOUSSYSTEM
The central nervous system consists of the brain and spinal cord:
The brain plays a central role in the control of most bodily functions,
including awareness,movements, sensations, thoughts, speech, andmemory.
Some reflex movements can occur via spinal cord pathways without theparticipation of brain structures.
The spinal cord is connected to a section of the brain called the
*FIGURENO. 1: Lateral surface of the cerebral cortex
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Cerebrospinal fluid surrounds the brain and the spinal cord and also
circulateswithin the cavities (called ventricles)of the central nervous system.
The leptomeninges surround the brain and the spinal cord. The cerebrospinal
fluid circulates between 2 meningeal layers called the pia matter and the
arachnoid (or pia-arachnoidmembranes). The outer, thicker layer serves the
roleof a protective shield and is called thedura matter. The basic unitof the
central nervous system is the neuron (nerve cell). Billionsof neurons allow the
differentpartsof the bodyto communicatewitheachothervia the brain and
thespinal cord. A fattymaterial calledmyelin coats nerve cellsto insulatethem
andto allow nervesto communicate quickly.
Anatomy of the Brain
The Cerebrum
*FIGURENO. 2: Medial surface of the cerebral cortex
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Thesurfaceofthe cerebral cortexhasgroovesor infoldings (calledsulci),
the largestofwhich aretermedfissures. Somefissuresseparate lobes.
The convolutions of the cortex give it a wormy appearance. Each
convolution isdelimited by 2 sulci and is also called a gyrus (gyri in plural).The
cerebrum isdivided into 2 halves, known as the right and lefthemispheres. A
mass of fibers called the corpus callosum links the hemispheres. The right
hemisphere controlsvoluntary limb movementson the leftsideofthe body, and
the lefthemisphere controlsvoluntary limb movementson the right sideof the
body. Almosteveryperson hasonedominanthemisphere. Eachhemisphere is
divided into 4 lobes,orareas,which are interconnected.
y Thefrontal lobes are located in thefrontofthe brain and areresponsiblefor voluntary movement and, via their connections with other lobes,
participate in the execution of sequential tasks; speech output;
organizational skills; and certain aspectsof behavior,mood, andmemory.
y Theparietal lobes are located behindthefrontal lobes and in frontoftheoccipital lobes. They process sensory information such as temperature,
pain, taste, and touch. In addition, the processing includes information
about numbers, attentiveness to the position of ones body parts, the
space aroundones body, andone'srelationshiptothisspace.
y The temporal lobes are locatedon each sideof the brain.Theyprocessmemory and auditory (hearing) information and speech and language
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The cortex, also calledgraymatter, isthemostexternal layerofthe brain
andpredominantly contains neuronal bodies (thepartofthe neuronswherethe
DNA-containing cell nucleus is located).Thegraymatterparticipates actively in
the storage and processing of information. An isolated clump of nerve cell
bodies in thegraymatter istermed a nucleus (to bedifferentiated from a cell
nucleus).The cells in thegraymatterextend theirprojections, called axons, to
otherareasofthe brain.
Fibers that leave the cortex to conduct impulses towardotherareas are
termedefferent, and fibers that approach the cortex fromother areasof the
nervous system are termed afferent (nervesorpathways). Fibers thatgo from
themotorcortextothe brainstem (forexample,pons)orthespinal cordreceive
a namethatgenerallyreflectsthe connections (that is, corticopontinetractfor
the formerand corticospinal tract for the latter). Axons are surrounded in their
course outside the gray matter by myelin, which has a glistening whitish
appearance andthusgivesrisetothetermwhitematter.
Cortical areasreceivetheirnames accordingtotheirgeneral function or
lobe name.If in chargeofmotorfunction,the area is calledmotorcortex.If in
chargeof sensory function, the area is called a sensoryor somesthetic cortex.
The calcarine or visual cortex is located in the occipital lobe (also termed
occipital cortex) and receivesvisual input.The auditory cortex, localized in the
temporal lobe,processessoundsorverbal input. Knowledgeofthe anatomical
j ti f fib f th diff t t t d th l ti t ti f b d
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CentralStructures of the Brain
The central structures of the brain include the thalamus,hypothalamus,
andpituitary gland. The hippocampus is located in the temporal lobe but
participates in memory and emotions and is interconnected with central
structures.Other structures are the basal ganglia,which aremadeupofgraymatterand includethe amygdala (localized in thetemporal lobe),the caudate
nucleus, andthe lenticularnucleus (putamen andglobuspallidus). Becausethe
caudate andputamen are structurally similar, neuropathologistshave coined
forthemthe collectivetermstriatum.
The thalamus integrates and relays sensory information to the cortexof
theparietal,temporal, andoccipital lobes.Thethalamus is located in the lower
central partof the brain (that is,upperpartof the brainstem) and is located
mediallytothe basal ganglia.The brain hemispheres lieon thethalamus.Other
rolesofthethalamus includemotorandmemory control.
The hypothalamus, located below the thalamus, regulates automaticfunctions such as appetite, thirst, and body temperature. It also secretes
hormones that stimulate or suppress the release of hormones (for example,
growthhormones) in thepituitarygland.
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regulates the production of many hormones that have a role in growth,
metabolism,sexual response,fluid andmineral balance, andstressresponse.
The ventricles are cerebrospinal-fluidfilled cavities in the interior of the
cerebral hemispheres.
The Base of the Brain
The baseofthe brain containsthe cerebellum andthe brainstem.These
structures serve complex functions. Below is a simplifiedversion of these roles:
Traditionally,the cerebellum has been known to control equilibrium
and coordination and contributes to the generation of muscle tone. It has
recently become evident, however, that the cerebellum plays more diverse
roles such asparticipating in some typesofmemory andexerting a complex
influenceon musical andmathematical skills.
The brainstem connects the brain with the spinal cord. It includes the
midbrain, the pons, and themedulla oblongata. It is a compact structure in
whichmultiple pathways traverse from the brain to the spinal cord and vice
versa. For instance, nervesthat arisefrom cranial nerve nuclei are involvedwith
eye movements and exit the brainstem at several levels. Damage to the
brainstem can therefore affect a numberof bodilyfunctions. For instance, ifthe
corticospinal tract is injured, a lossofmotor function (paralysis)occurs, and it
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Themidbrain is located belowthehypothalamus. Some cranial nervesthat are
alsoresponsibleforeyemuscle control exitthemidbrain.
The pons serves as a bridge between the midbrain and the medulla
oblongata.Thepons also containsthe nuclei andfibersof nervesthatserveeye
muscle control,facial musclestrength, andotherfunctions.
The medulla oblogata is the lowest part of the brainstem and is
interconnectedwiththe cervical spinal cord.Themedulla oblongata alsohelps
control involuntary actions, includingvital processes, such asheart rate, blood
pressure, andrespiration, and it carriesthe corticospinal (that is,motorfunction)
tracttowardthespinal cord.
The Spinal Cord
The spinal cord is an extension of the
brain and issurrounded bythevertebral bodies
that form the spinal column (see Multimedia
File 3).The central structuresof thespinal cord
are made up of gray matter (nerve cell
bodies), andtheexternal orsurroundingtissues
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Within thespinal cord are 30 segmentsthat belongto 4 sections (cervical,
thoracic, lumbar,sacral), basedon their location:
y Eight cervical segments: These control signals from or to areas of thehead, neck,shoulders, arms, andhands.
yTwelvethoracic segments:These control signalsfromortopartofthe armsandthe anteriorandposteriorchest and abdominal areas.
y Five lumbar segments:These control signals fromor to the legs and feetandsomepelvic organs.
y Fivesacral segments:These control signalsfromortothe lowerbackandbuttocks,pelvic organs andgenital areas, andsome areas in the legs andfeet.
y A coccygeal remnant is located atthe bottomofthespinal cord
PERIPHERAL NERVOUSSYSTEM
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Nerve fibers thatexit the brainstem andspinal cord becomepartofthe
peripheral nervous system.Cranial nerves exit the brainstem and function as
peripheral nervous system mediators of many functions, including eye
movements,facial strength andsensation,hearing, andtaste.
Theoptic nerve is considered a cranial nerve but it isgenerally affected ina diseaseofthe central nervoussystemknown asmultiplesclerosis, and,forthis
andotherreasons, it isthoughttorepresent an extension ofthe central nervous
system apparatus that controls vision. In fact, doctors can diagnose
inflammation oftheheadoftheoptic nerve byusing an ophthalmoscope, as if
theperson'seyeswere a window intothe central nervoussystem.
Nerve roots leave the spinal cord to theexitpoint between 2 vertebrae
and are named accordingtothespinal cordsegmentfromwhichthey arise (a
cervical eight nerveroot arisesfrom cervical spinal cordsegmenteight).Nerve
roots are located anterior with relation to the cord if efferent (for example,
toward limbs)orposterior if afferent (forexample,tospinal cord).
Fibers that carry motor input to limbs and fibers that bring sensory
information from the limbs to the spinal cord grow together to form a mixed
(motor and sensory)peripheral nerve. Some lumbar and all sacral nerve roots
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Thespinal cord is also covered, like the brain, by thepia matterandthe
arachnoidmembranes. The cerebrospinal fluid circulates around thepia and
below theouter arachnoid, and this space is also termed the subarachnoid
space.Therootsofthe cauda equina andtherootletsthatmakeupthe nerve
rootsfromhighersegments are bathed in cerebrospinal fluid.Thedura surrounds
thepia-arachnoidofthespinal cord, as itdoesforthe brain.
CSF and the Ventricles
All exposed surfaces of the central nervous system are bathed in
cerebrospinal fluid (CSF),whichhasseveral importantfunctions:
1. Firstly, it acts to cushion the delicate brain structure by acting as abuffering system.This fluid is required because the skull is so rigid that for
the brain to enlarge at all (as happens with every heart beat, for
example)someofthefluidmust leave - eithervenous bloodorCSF.
2. CSF alsosupportstheweightofthe brain throughthe buoyantpropertiesof the fluid; the brain weighs 1400g in air, but as little as 50g when
supported byCSF.
3. The CSF also acts as a transport medium for nutrients, chemicalmessengers andwasteproducts.
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material of specialized cells and permeable capillaries (the smallest type of
bloodvessel). Eachventricle contains an area of choroidplexus.
CSF is formed bypushing individual substances (mostly salts) across the
wallsofthe choroidplexus, andwater follows.There aresomesubstances that
are then transported back from theCSF tothe blood, aswell assomespecific
transporters for nutrients,vitamins and someother substances. Thismeans that
whileCSF may be formed from blood, there are substantial differences in their
compositions.
TheCSF is released into a seriesofventricles that liewithin the brain. Aventricle is basically a small fluidfilled 'lake' in within the brain andthere arefour
ventricles in an adult brain. There are two lateral ventricles (one in each
hemisphere), a third ventricle in the diencephalon, and a fourth ventricle in
between thepons andthe cerebellum.
The lateral ventricles are separated from each other by a thin barrier
called theseptumpellucidum, and there is nodirect connection between the
two.Thethirdventricle is connectedtothe lateral ventriclesthroughsmall holes
called the interventricular foramen. This third ventricle lies within the
diencephalon.CSF then flowsoutof the thirdventricle through a small canalknown asthemesencephalic aqueduct (orthe aqueductof Sylviusorcerebral
aqueduct).This connectstothefourthventriclethat lies between thepons and
the cerebellum. Atthe baseofthefourthventricle,thespace becomes narrow
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The Meninges
Within the brain,there areseveral layersof cranial meningesthat act as
shockabsorbers, aswell aspreventingdirect contactwith bone. Meninges are
basically coatings,with the three layers having different thicknesses, textures
andpurposes.Thethree layers are namedthedura matter (mostexternal and
thetoughest),the arachnoid (middle) andthepia mater(innermost).The image
totherightprovides a general overviewoftheirstructure.
DuraMatter
Thedura mater is composedoftwofibrous layers;theoutermost is called
theendosteal layer as it is fused to the skull. The inner layer is known as the
meningeal, and in many areas bloodvesselsrun between them. Someofthese
bloodvessels arevery large,such asthedural sinusesthatdeliverbloodtothe
internal jugularveins.
There are four locations in which the dura extends into the brain itself,
stabilisingthestructure.They are:
1. The falx cerebri that dives between the cerebral hemispheres into thelongitudinal fissure. At the back it attaches to thedura that covers the
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2. The tentorium cerebelli separates and protects the cerebellum. It liesperpendiculartothefalx cerebri and containsthetransversesinus.
3. Thefalx cerebelli lies between thetwohemispheresofthe cerebellum.4. Thediaphragma sellae linespartof the skull called the sella turcica that
surroundsthe baseofthepituitarygland.
The Arachnoid
The arachnoid layerprovides a smooth covering for the brain thatdoes
notdivedeep into the sulci (thedips in the surfaceof the brain). Beneath this
layer is the subarachnoid spacewhere there is a delicate,weblike networkof
fibresthat linkthe arachnoidtothepia mater. Alongthesuperiorsagittal sinus,areasofthe arachnoid can beseen (called arachnoidgranulations)that allow
a passageofCSF intothevenoussystem.The arachnoid acts as a supporttothe
cerebral arteries and veins.
The PiaMater
Thepiamater isverytightly linkedtothesurfaceofthe brain, anchored by
theprocessesof astrocytes. Thepia materhas a very large blood supply and
actstosupportthe cerebral arteries asthey branchoverthe brain.
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Blood Supply in the Brain
The blood supply to the brain comes from the internal carotid and
vertebral arteries, lying in thesubarachnoid space.The internal carotid arteriesbranchfromthe common carotid arteries (that can befeltpulsing in the neck)
and enter the head. Each internal carotid artery ascends to the level of the
optic nerve,where each divides into three branches: the ophthalmic artery,
anteriorcerebral arterythatsuppliesthefrontal andparietal lobes and a middle
cerebral artery that supplies themidbrain and lateral surfacesof the cerebral
hemispheres.
The vertebral arteries start at the base of the neck and pass upward
*FIGURENO. 5: Inferior view of the cerebral circulation
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dividing into the posterior cerebral arteries. The vertebral arteries and their
branchessupplythe brain posteriortothe area supplied bythe internal carotids.
To keep flexibility in the circulatory system, there aremany connections
between thedifferent bloodsupplies, andthese connectionsform a loopthat is
known asthe circleof Willis.The circle ismadewhole bysmallerarteriessuch as
the posterior communicating artery and anterior communicating artery. The
purposeofthis isthat ifoneofthe arteries becomes blocked,orbloodsupply is
cutoff forwhatever reason, then blood supply can be increased fromoneof
theotherarteriesto compensate.
CARDIOVASCULARSYSTEM
The cardiovascular system is
sometimes called the circulatory
system. It consists of the heart,
which is a muscular pumping
device, and a closed system of
vessels called arteries, veins, and
capillaries. As the name implies,
blood contained in the circulatory
system is pumped by the heart
around a closed circuitofvessels as
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The Heart
Theheart isenclosed by a sac known asthepericardium.There arethree layersof tissues that form the heart wall. The outer layer of the heart wall is the
epicardium, the middle layer is the myocardium, and the inner layer is the
endocardium.The internal cavityoftheheart isdivided intofourchambers:
y Right atriumy Rightventricley Left atriumy Leftventricle
Thetwo atria arethin-walled chambersthatreceive bloodfromtheveins.
Thetwoventricles arethick-walled chambersthatforcefullypump bloodoutof
the heart. Differences in thickness of the heart chamber walls are due to
variations in the amountofmyocardiumpresent,which reflects the amountof
forceeach chamber isrequiredtogenerate.
Theright atriumreceivesdeoxygenated bloodfromsystemic veins;the left
atriumreceivesoxygenated bloodfromthepulmonaryveins.
Valves of the Heart
Pumps need a setofvalvestokeepthefluidflowing in onedirection and
theheart is noexception.Thehearthastwotypesofvalvesthatkeepthe blood
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The right atrioventricular valve is the tricuspid valve. The left atrioventricular
valve isthe bicuspid,ormitral,valve.Thevalve between therightventricle and
pulmonary trunk is thepulmonary semilunarvalve. Thevalve between the left
ventricle and the aorta is the aortic semilunar valve. When the ventricles
contract, atrioventricularvalves close toprevent blood from flowing back into
the atria. When theventriclesrelax,semilunarvalves closetoprevent bloodfrom
flowing back intotheventricles.
Pathway of Blood through the Heart
While it is convenienttodescribetheflowof bloodthroughtherightside
of theheart and then through the left side, it is important to realize that both
atria contract atthesametime and bothventricles contract atthesametime.
Theheartworks as twopumps,oneon the right andoneon the left,working
simultaneously. Bloodflowsfromtheright atriumtotherightventricle, andthen is
pumpedtothe lungstoreceiveoxygen. Fromthe lungs,the bloodflowstothe
left atrium, then to the left ventricle. From there it ispumped to the systemic
circulation.
Blood Supply to the Myocardium
The myocardium of the heart wall is a working muscle that needs a
continuous supplyofoxygen and nutrients to function withefficiency. For this
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The right and left coronary arteries, branches of the ascending aorta, supply
bloodtothewallsofthemyocardium. Afterbloodpassesthroughthe capillaries
in themyocardium, itenters a systemof cardiac (coronary)veins. Mostof the
cardiac veinsdrain intothe coronarysinus,whichopens intotheright atrium.
Blood Vessels
Blood vessels are the channels or conduits through which blood is
distributedto bodytissues.Thevesselsmakeuptwo closedsystemsoftubesthat
begin and end at the heart. One system, the pulmonary vessels, transports
bloodfromtherightventricletothe lungs and backtothe left atrium.Theother
system,thesystemic vessels, carries bloodfromthe leftventricletothetissues in
*FIGURENO. 7: Layers and functions of blood vessels
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Arteries
Arteries carry blood away from the heart. Pulmonary arteries transport
bloodthathas lowoxygen contentfromtherightventricletothe lungs. Systemic
arteries transportoxygenated blood from the leftventricle to the body tissues.
Blood is pumped from the ventricles into large elastic arteries that branch
repeatedly into smaller and smaller arteries until the branching results in
microscopic arteries called arterioles.The arteriolesplay a keyrole in regulating
bloodflow intothetissue capillaries. About 10 percentofthetotal bloodvolume
is in thesystemic arterial system at anygiven time.
The wall of an artery consists of three layers. The innermost layer, the
tunica intima (or just intima), contains simple squamousepithelium, basement
membrane and connective tissues.Theepithelium is in direct contactwith the
bloodflow.Themiddle layer,thetunica media, isprimarilysmoothmuscle and is
usually the thickest layer. It not only provides support for the vessel but also
changes vessel diameter to regulate blood flow and blood pressure. The
outermost layer,which attachesthevessel tothesurroundingtissue, isthetunica
externa ortunica adventitia.This layer is connectivetissuewithvarying amounts
of elastic and collagenous fibers. The connective tissue in this layer is quite
dense where it is adjacent to the tunic media, but it changes to loose
connectivetissue neartheperipheryofthevessel.
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Veins
Veins carry blood toward the heart. After blood passes through the
capillaries, itenters thesmallestveins, calledvenules. From thevenules, it flows
into progressively larger and larger veins until it reaches the heart. In the
pulmonary circuit,thepulmonaryveinstransport bloodfromthe lungstothe left
atriumof theheart. This bloodhas a highoxygen content because ithas just
been oxygenated in the lungs. Systemic veins transport blood from the body
tissuetotheright atriumoftheheart.This bloodhas a reducedoxygen content
becausetheoxygen has been usedformetabolic activities in thetissue cells.
Thewallsofveinshavethesamethree layers asthe arteries. Although all
the layers arepresent, there is less smoothmuscle and connective tissue. This
makes thewallsofveins thinner than thoseof arteries,which is related to the
fact that blood in theveinshas lesspressure than in the arteries. Because the
wallsof theveins are thinner and less rigid than arteries,veins can holdmore
blood. Almost 70 percentofthetotal bloodvolume is in theveins at anygiven
*FIGURENO. 8: Internal view of the brain
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Capillaries
Capillaries,thesmallest andmost numerousofthe bloodvessels,formthe
connection between thevesselsthat carry blood awayfromtheheart (arteries)
and thevessels that return blood to theheart (veins). Theprimary function ofcapillaries istheexchangeofmaterials between the blood andtissue cells.
Capillary distribution varies with the metabolic activity of body tissues.
Tissues such as skeletal muscle, liver, and kidney have extensive capillary
networks because they are metabolically active and require an abundant
supplyofoxygen and nutrients.Othertissues,such as connectivetissue,have a
less abundant supplyof capillaries.Theepidermisof the skin and the lens and
cornea oftheeye completely lacka capillary network. About 5 percentofthe
total bloodvolume is in the systemic capillaries at anygiven time. Another 10
percent is in the lungs.
*FIGURENO. 9: Arterialand venous ends of capillaries
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Role of the Capillaries
In addition to forming the connection between the arteries and veins,
capillarieshave a vital role in theexchangeofgases, nutrients, andmetabolic
waste products between the blood and the tissue cells. Substances pass
through the capillaries wall by diffusion, filtration, and osmosis. Oxygen and
carbon dioxide move across the capillary wall by diffusion. Fluid movement
across a capillary wall is determined by a combination of hydrostatic andosmotic pressure. The net result of the capillary microcirculation created by
hydrostatic andosmotic pressure isthatsubstances leavethe blood atoneend
of the capillary and return at the other end
*FIGURENO. 10: Hydrostatic and Osmotic pressures
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Discharge Planning
METHODS
M Instructedthepatienttotakethefollowingmedications:
Aspirin 80 mg. afteronce
B complexVID 5 capOD
Calci block10 mg SL PRN
E Encouragethe clientto:
Complete bedrestwith bathroomprivileges.
Passiveexercise
T Advise and SOthat nottoperformvalsalva maneuver.
H Encourageduseofrelaxation techniquessuch as assumingof comfortable
position andto changeposition everytwohours
Encouragedpatientto complywiththetreatmentregimen
D Instructedpatienttohave lowsalt and lowfatdiet
VIII. Conclusion
Hypertension is well known disease all over the world. Most people
acquire it from sedentary lifestyle and improperdiet. It can also behereditary
which could affect certain races more than others. Usually, the African
ki d f di h ld b t k b d th d ti f th d t
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kindsofdiseaseshould betaken basedon therecommendation ofthedoctor
toproperly and totallyeradicatetheproblem. Severehypertension can cause
cerebrovascular accident,CVA is a sudden neurological incident related to
impaired cerebral bloodsupplywhich can cause ischemia tothe brain.It could
paralyzethe body affectingtheperception,sensory, andthemotormovement
oftheperson.
As a nurse, the student should be knowledgeable enough
regardingthediseaseprocess;however, learningthrough lectures andtheories
is not enough to completely understand this disease. Through interaction,
knowledge acquiredfromtheorieswasmuch appreciated bythestudentssince
heor she can actually asses thepatients condition. Withenough information
and enhanced skills, he or she may be able to handle patients with these
conditions andeasily identifyingproblems and treatment alike. It is important
that thepatient isgiven enough information about thedisease condition and
theunderlying complications. As nurses, it isour responsibilitytomakesure that
the patient is disclosed with adequate information.I have also learned the
importanceof taking careofoneself;eachpart belongs to an intersystemof
physiologically functioning body. We were able to reflect about our own
activity,diet andof course the stress thatwe are facingeachdaywhen we
madethis casestudy, becausewehavethoughtthatwhatwedotoourbody
nowmayhave badeffectstous in thefuture.
As a conclusion may these piece of work serve as a guide or
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Page | 52
V.THEPATIENT AND HIS CARE
A. MEDICAL MANAGEMENT
Medical
management/
Trea
tm
ent
Date ordered
Date
performed
Date ch
anged
GeneralDescriptionIndication(s) or
PurposesClients response to treatment
PLAIN NORMAL
SALINE SOLUTION
(PNSS) 1 Liter X 20-
21 gtts/min
DO: 07-23-10
DR: 07-23-26,2010
DC:The clientwas
notyetdischarged
Isotonic crystalloidsolution
containingsame amounts
of sodium and chloride
found in plasma.
Indicated for
restoringthe lossof
bodyfluids.
FluidReplacement
Thepatientwas kepthydrated as
evidenced by normal skin turgor
(assessed through the clavicle
area) andthe administration ofIV
medications also becamepossible
as a form of treatment of the
patient condition. No untoward
effects were noted such as any
signsoffluidvolumeexcessorfluid
overload.
\
Nursing Responsibilities:
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Page | 53
Nursing Responsibilities:
Priortotreatment:1. Verifythephysiciansorder indicatingthetypeofsolution,the amountto be administered,therate
offlowofthe infusion, and any client allergies
2. Considerhow longthepatient is likelytohavetheIV,whatkindsoffluidswill be infused, andwhatmedicationsthepatientwill bereceivingor is likelytoreceive.
3. Preparethe client. Explain theproceduretothe client.4. Arrangeequipments neededforthetherapy5. Observe aseptic technique
Duringtreatment:1. Ensurethatthe correctsolution is being infused2. Observetherateoffloweveryhour3. InspectthepatencyoftheIVtubing and needle4. Inspectthefluidsiteforfluid infiltration5. Inspectthe insertion siteforphlebitis6. Inspectthe intravenoussiteforbleeding7. Teachthepatientwaystomaintain the infusion system8. Document all relevant information
Aftertreatment:1. Reviewthephysiciansorder2. Assessthe appearanceofthevenipuncturesite
3 Inspect the appearance of IV catheter
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3. Inspectthe appearanceofIV catheter4. Coverthevenipuncturesite5. DiscardtheIVsolution containerproperly6. Document all
b. Drugs
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b. Drugs
Name of
Drug
Date ordered
Date performed
Date changed
Route of adminDosage &
frequency of
admin
General Action
Functional
Classification
Mechanism of
Action
Indication(s) or
Purposes
Client Response to
Treatment and Actual
Side Effect
Generic name:
Clonidine
hydrocholoride
Brand name:
Catapres
DO: 07-22, 2010
DP: 07-22-25, 2010
75 mcg./tab SL stat
Anti hypertensive
Thought to stimulate
alpha 2 receptors and
inhibit the central
vasomotor centers,
decreasing sympathetic
outflow to the heart,
kidneys and peripheralvasculature and
lowering bloodpressure.
To decrease blood
volume and bloodpressure.
The client complied
with the medication
and did notmanifest
further increase in
blood pressure and
side effects/adverse
reactions were not
manifested aswell.
Blood Pressure
Readings:
Before Administration:
July 22, 2010: 180/100
After:
July 22, 2010: 120/90
July 23, 2010: 140/ 70
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y , /
July 24, 2010: 120/70
July 25, 2010: 130/90
Nursing Responsibility:
Priortotreatment:1. Checkthedoctorsorderforthedrug name,dosage,frequency androuteof administration2. Observe aseptic technique3. Organizetheequipments neededforadministeringmedication4. Preparethemedication5. Informthe clientofthe nameofthedrug, its action andpurposeofgivingthedrug6. Assess BP andpulse.7. Instructtotake atthesametimeeachday.8. MonitorI&O
Duringtreatment:1. Lastdose: administerat bedtime.
Aftertreatment:1. MonitorBP andpulse, adviceto notifyhealth careprofessional ofsideeffects.
2. Fordrymouthprovidegodoral hygiene andsugarlessgum.
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Name of Drug
Date ordered
Date performed
Date changed
Route of admin
Dosage &
frequency of
admin
General Action
Functional
Classification
Mechanism of Action
Indication(s) or
Purposes
Client Response to
Treatment and
ActualSide Effect
Generic name:
Furosemide
Brand name:
Lasix
DO: 07-22-10
DP: 07-22-26, 2010
DC: clientwas not
yetdischarged
20 gTID now
then every 8
hours
Loopdiuretic
Inhibitsthere
absorption ofsodium
and chloride in the
proximal anddistal
tubules andthe loopof
henle leadingto a
sodiumrichdiuresis
Topromotediuresis
that can helpto
decreasethe
bloodvolume and
bloodpressure
The clientsurine
output increased
anddid notmanifest
further increase in
bloodpressure.
Blood PressureReadings:
Before
Administration: July
22, 2010: 180/100
After:
July 22, 2010: 120/90
July 23, 2010: 140/ 70
July 24, 2010: 120/70
July 25, 2010: 130/90
July 26, 2010: 130/90
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Nursing Responsibility:
Priortotreatment:1. Checkthedoctorsorderforthedrug name,dosage,frequency androuteof administration2. Observe aseptic technique3. Organizetheequipments neededforadministeringmedication4. Preparethemedication5. Informthe clientofthe nameofthedrug, its action andpurposeofgivingthedrug.6. Assess clientsVS especially BP.
Duringtreatment:1. IV: clean theport/sitewerethedrugwill be injected.2. Assess clientsreaction whilegivingthedrug.
Aftertreatment:
1. MonitorUrineoutput
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2. MonitorVS especially BP3. Monitorweight4. Increase intakeof K richfoods
Name of DrugDate ordered
Date performed
Date changed
Route of
admin
Dosage &
frequency of
admin
General Action
Functional
Classification
Mechanism of
Action
Indication(s) or
Purposes
Client Response
to Treatment and
ActualSide Effect
Generic
name:
Losartan
potassium
Brand name:
Cozaar
DO: 07-22-2010
DP:07-22-25, 2010
DC:Clientwas not
yetdischarged
50 mg./tab 1
tab nowthen
OD
Antihypertensive
Undergoessignificant
first-passmetabolism
(byCYP2C9 and
CYP3A4) in the liver,
where it is converted
to an active
carboxylic and
metabolitethat is
Antihypertensive,
aloneor in
combination with
other
antihypertensive
drug.
The client complied
withthe
medication and
manifested a
stable blood
pressure as
evidenced by
bloodpressure
readingsof:
responsibleformostof Blood Pressure
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the angiotensin
receptorblockade.Selectively blocksthe
bindingof Angiotensin
IItoreceptorsites in
thevascularsmooth
muscles and adrenal
glands.
Readings:
Before
Administration: July
22, 2010: 180/100
After:
July 22, 2010:
120/90
July 23, 2010: 140/
70
July 24, 2010:
120/70
July 25, 2010:
130/90
July 26, 2010:
130/90
Nursing Responsibility:
Priortotreatment:1. Checkthedoctorsorderforthedrug name,dosage,frequency androuteof administration2. Observe aseptic technique
3. Organizetheequipments neededforadministeringmedication
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4. Preparethemedication5. Informthe clientofthe nameofthedrug, its action andpurposeofgivingthedrug.
Duringtreatment:1. Assess bloodpressure andpulseperiodicallyduringtherapy.
2. Assessforsignsof angioedema.
Aftertreatment:1. Monitor input andoutput anddailyweight.
2. Encouragedthepatientto complywith additional interventionsforhypertension.
Name of Drug
Date ordered
Date performed
Date changed
Route of admin
Dosage &
frequency of
admin
General Action
Functional
Classification
Mechanism of Action
Indication(s) or
Purposes
Client Response to
Treatment and
ActualSide Effect
Generic name:
Aspirin
DO: 07-25,2010
DP: 07-25-26,2010
80 mg once a
day, taken after
meals.
Nonsteroidal, anti-
inflammatorydrug
Exhibits antipyretic, anti-
inflammatory, and
analgesic effects. The
To act as an
anticoagulant so
as to prevent
formation of
thrombus and
The client did not
manifest any signs
and symptoms
such asdifficulty in
breathing and
Brand name:
A ASA/
DC:Clientwas notyet
di h d
antipyretic effect isdueto
ti th
embolus that alteration in
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Apo- ASA/
Novasen
discharged. an action on the
hypothalamus, resulting in
heat loss by vasodilation
ofperipheral bloodvessels
andpromotingsweating.
could further
aggravate the
clients condition
circulation that
could indicate
formation of
thrombus/emboli.
Nursing Responsibility:
Priortotreatment:1.Informthe clientofthe nameofthedrug, its action andpurposeofgivingthedrug.
2.Take a completedrughistory and note anyevidenceofhypersensitivity.
Duringtreatment:1. Monitorserumsalicylate levelsperiodically.
2. Monitorfortheonsetoftinnitus,headache,hyperventilation,diarrhea andsweating.
3. Administermealsorwithfood.
Aftertreatment:1.Taperdose.
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Name of Drug
Date ordered
Date performed
Date changed
Route of admin
Dosage &
frequency of
admin
General Action
Functional
Classification
Mechanism of Action
Indication(s) or
Purposes
Client Response to
Treatment and
ActualSide Effect
Generic name:
Vitamin B
complex
Brand name:
Theravite
DO: 07-22,2010
DP: 07-22-26,2010
DC:Clientwas notyet
discharged
1 capsuleonce a
day.Vitamin supplements Vitamin B
complex was
given tothe client
to further
enhance nerve
functions which
may be impaired
due to the
infarction causing
an alteration in
the sensory and
motor abilities of
the client.
The client complied
with the therapy
and did not
manifest further
aggravation of the
sensory and motor
deficits of the
client.
Nursing Responsibility:
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Priortotreatment:1. Checkthedoctorsorderforthedrug name,dosage,frequency androuteof administration2. Observe aseptic technique3. Organizetheequipments neededforadministeringmedication4. Preparethemedication5. Informthe clientofthe nameofthedrug, its action andpurposeofgivingthedrug.6. AssessVitamin levels as indicated.
Duringtreatment:
1. Monitor levelstoensurerequirements aremet and levels are as2. Takewithfoodforbest absorption andutilization.
Aftertreatment:1. Complywithdietaryrecommendations.2. Avoidself-medicatingthatexceedstheRDAs
Name of Drug
Date ordered
Date performed
Date changed
Route of admin
Dosage &
frequency of
General Action
Functional
Classification
Indication(s) or
Purposes
Client Response to
Treatment and
admin Mechanism of Action ActualSide Effect
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Nursing Responsibility:
Priortotreatment:7. Checkthedoctorsorderforthedrug name,dosage,frequency androuteof administration
Generic name:
Nifedipine
Brand name:
Calcibloc
DO: 07-22,2010
DP: 07-22-26, 2010
DC:Clientwas notyet
discharged
10 mg SL PRN Calcium channel blocker
Inhibits the influx of
calcium through the cell
membranes, resulting in a
depression of
automaticity and a
conduction velocity
leadingto a depression of
contraction.
Decreasestotal peripheral
resistance thus reducing
energy and oxygen
requirementsoftheheart.
The medication was
given to the client to
decrease the
patients blood
pressure and cardiac
workload.This isdone
by decreasing the
clients peripheral
resistance and
contractions.
The clients blood
pressure was stabilized
and did not further
increased as
evidenced by blood
pressurereadingsof:
Before Administration:
July 22, 2010: 180/100
After:
July 22, 2010: 120/90
July 23, 2010: 140/ 70
July 24, 2010: 120/70
July 25, 2010: 130/90
July 26, 2010: 130/90
8. Observe aseptic technique9 Organize the equipments needed for administering medication
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9. Organizetheequipments neededforadministeringmedication10.Preparethemedication11.Askthe nameofthe cient.12.Informthe clientofthe nameofthedrug, its action andpurposeofgivingthedrug.
Duringtreatment:
3. Monitor levelstoensurerequirements aremet and levels are as4. AdministerSL atthe buccal mucosa to avoid aspiration
Aftertreatment:3. Complywithdietaryrecommendations.4. Avoidself-medicatingthatexceedstheRDAs5. Do notgivewaterafteradministration6. Performroutineoral care.
c. Diet
Date ordered
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Type of Diet
Date ordered
Date performed
Date changed
GeneralDescription Indication(s) or
Purposes
Clients response and/or
reaction to diet
Low fat and low
salt dietwith strict
aspiration
precaution
DO: 07-22,2010
DP: 07-22-26, 2010
DC: Client was
notyetdischarged
Law salt, low fatdiet
is a dietthat isrich in
fruits and
vegetables, low fat
dairy products and
low in saturated and
total fat. This usually
includes
unprocessed and
white meats, bread
and cereals, skim
milk and fruits and
vegetables.
Aside from the
anti-hypertensive
drugs being taken
by the client it is
also essential to
provide diet
restrictions which
can help in further
stabilizing the
clients blood
pressure. Fat
usually deposits in
blood vessels
whichmay narrow
its lumen causing
a higherresistance
The client complied with
the diet and the clients
blood pressure did not
further increase and was
stabilized as evidenced
by:
Blood PressureReadings:
Before Administration: July
22, 2010: 180/100
After:
July 22, 2010: 120/90
July 23, 2010: 140/ 70
July 24, 2010: 120/70
July 25, 2010: 130/90
July 26, 2010: 130/90
needed by the
blood to get
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blood to get
through the vessel
while excessive
salt (sodium) can
cause an
elevated blood
volume because
of its ability to
retain water in the
body thus also
increasing the
clients blood
pressure. Limiting
intake of foods
which excessively
contain these
substances may
greatly help in
managing
hypertension.
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Nursing Responsibilities:
Priortotreatment:1. Checkthedoctorsorder.2. Explain thepurposeofdiet andthespecific foodsto betaken.3. Educatethe clientregardingthefoodsthat is allowed andfoodthat arerestricted.
During:1. Monitorcomplianceofthepatienttotheprescribeddiet.
After:1. Monitorpatientfortolerancetofood.2. Documentpatientsresponse.
d. Activity/ Exercise
Type of
exercise
Date Ordered
Date Performed
Date Change
General
description
Indication/purposes Clients Response and/or
reaction to treatment
Complete
bed rest with DO: 07-22, 2010
-The client is
confined in bed
-to minimize clients
movement which may
The client complied with the
therapeutic regimen and did
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bathroom
privileges
Passive
exercise
DP: 07-22-26,2010
DC: client was not yet
discharged
DO: 07-22,2010
DP: 07-22-26,2010
DC: The client was not yet
discharged
and is not
allowed to get
up to perform
his bathroom
necessities.
-There aresetof
exerciseswhere
in the nurse
provides
assistance for
the clients
performance of
movements.
further increase oxygen
demands that could
compromise the clients
condition, to minimize
clientsriskforinjurydueto
sensory andmotordeficits
caused bythe infarction.
-to facilitate movement
and circulation of the
different bodyparts.
not manifest any signs and
symptoms such asdifficultyof
breathing, fatigue, formation
of thrombi/emboli, pressure
sores, and contractures that
indicates increase in oxygen
demand and presence of
injury.
- the client complied andwasable to perform the exercises
properly. He alsotoleratedthe
activity and did not manifest
difficulty of breathing and
fatigue.
-no further complication was
notedon the client.
Nursing Responsibilities:
P i t t t t
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Priortotreatment:4. Checkthedoctorsorder.5. Explain thepurposeofdiet andthespecific foodsto betaken.6. Educatethe clientregardingthefoodsthat is allowed andfoodthat arerestricted.
During:2. Monitorcomplianceofthepatienttotheprescribeddiet.
After:3. Monitorpatientfortolerancetofood.4. Documentpatientsresponse.
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IX. RECOMMENDATION:
Health is a majorconcern thatshould begiven adequate attention; it is
notsomethingthatshould betaken forgranted.Thepublic should be awareof
howtopreventoccurrenceof illness. Although it is inevitableforanyonetoget
sickmore than once in his lifetime, it is a must thatpeople take careof their
healthtopreventoccurrenceofdiseases.
Tothepublic:
Properdiet isvery crucial in achievingoptimal healthstatus. Prevention
isvery importantwiththisdisease andweshouldwatchoutforthefoodthatwe
eat. We should avoid fatty foods andhigh sodium because these can cause
harmful effects and could elevate blood pressure. The people should know
what istoomuch and learn howto control themselves.
Proper weight management should be observed since obesity can
cause hypertension. Ideal weight decreases the rate of having hypertension
relatedCVA. By beingobese,there could behyperlipidimia and itwill behard
forthe bloodtopassthrough.
Smoking and other sedentary lifestyle is prohibited because smoking
Tohealth carepractitioner:
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CVA related to hypertension, like any other diseases are highlypreventable. In the health care practice, we are well equipped with the
knowledge aswell astheskills in theprevention. A majorproblem isthegeneral
publics lack of information about the strategies of how to do so. It is our
responsibility on how to educate them properly. Monitoring patients
compliance to treatment regimen isvery crucial for thepatient.Nurses should
inform the clients regarding the reasonsofevery intervention andmedication
beinggiven tothem.
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X. Learning Derived
This case studymade us realize the importanceofobtaining accurate
patienthistory becausefromthis alone,thehealth careteammembercan be
directed to the propermanagement of the patient togetherwith his family.
Assessment of a patient experiencing a neurologic disorder is a challenge.
Neurologic assessment establishes baseline data that are used to compare
ongoing assessments,diagnose actual andpotential healthproblems,manage
client care, and evaluate the outcome. Because of the complexity of the
nervoussystem, neurologic assessment is bothmultifaceted and lengthy.
Lastly, the group also learned from the case study presented that a
number of health problems present and can be identifiedwith patientswith
CVA. With the case study, thegroupprofoundlyexplored the roleof nurses in
preserving the qualityof lifeof thepatientswithCVA and the importanceof
familysupport in theircare andrecovery.
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VIII. BIBLIOGRAPHY
Internet:
y http://www.wisegeek.com/what-is-anemia.htmy http://www.faqs.org/abstracts/Health/Current-trends-CDC-Criteria-for-
anemia-in-children-and-childbearing-aged-women.html
y http://www.jstor.org/pss/3454306y Foundation foreducation andresearch in Neurological Emergenciesy http://tigger.uic.edu/com/ferne/pdf/subarachnoidhem0501.pdfy http://www.hmnews.org/article2767.htmly http://www.sciencedaily.com/releases/2004/06/040622014818.htmy http://www.sciencedaily.com/releases/2006/04/060429125428.htmy The internet Stroke center- http://www.strokecenter.org/pat/sah.htmy EmedicinefromwebMD -
http://www.emedicine.com/emerg/topic559.htm
y Emedicine.comy http://www.emedicine.com/aaem/topic239.htmy Wakeforestuniversity Medical Center-
http://www1.wfubmc.edu/neurosurgery/Brain+Tumor+Center+of+Excellen
ce/Subarachnoid+Hemorrhage+of+Unknown+Etiology htm
y http://www.surgeryencyclopedia.com/Ce-Fi/Craniotomy.htmly http://uscneurosurgery.com/infonet/surgery/procedures/aneurysm_clip.ht
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m#surgical%20indications
Books:
Stanleyet. al. Pathology and PathophysiologyofUterine Smooth-MuscleTumors.
TheNational Instituteof Environmental Health Sciences (NIEHS). 2000
Black, Joyce. Medical Surgical Nursing. (Philadelphia: Lippincott Williams &
Wilkins, 2004
Braunwaldet.al. Harrisons PrinciplesofInternal Medicine 2. 11thedition. McGraw
Hill BookCompany.Copyright 1987.
Seeleyet. al. Essentialsof Anatomy and Physiology. 5thedition. McGraw Hil Book
ofCompany.Copyright 2003.
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