FAR EASTERN UNIVERSITY INSTITUTE OF NURSING

B S N Case Presentation 1 Cerebrovascular Accident 3 7

Submitted by: Aldrin Ian O. Alpe Jericho D. Arago Kris M. Arcenio Jessica L. Cabbuag Krisslene H. Cuevas Kristine Jane G. Garcia Janine S. Gonzaga Regie S. Gonzaga Evalyn A. lacsamana Chiberie R. Orgino Adrian O. Orpia Sandra L. Quiambao

Submitted TO:

G R O U P 1 4 5

Prof. Marilou Choa RN, MAN

CASE PRESENTATION
I. Introduction This is an interesting case since it is one of the top leading causes of mortality among adult in our country nowadays. We have chosen this case so that we may be able to enhance our knowledge, understanding and gain information. Thus, to give us an idea on how we could give proper nursing care for our clients with this condition and to apply it on our future exposures as student nurses and eventually as future registered nurses. By discussing this study, we will be able to: (1) identify what is Cerebral Infarction, (2) know the etiology and risk factors, (3) give appropriate nursing intervention for the clients with this condition, and (4) to help the client and the family in health teaching regarding with patients with cerebral infarction. II. Overview of the disease A Cerebral Infarction is the formation of an area of necrosis in the cerebrum caused by an insufficiency of arterial or venous blood flow, as by thrombosis or embolism. It is the ischemic kind of stroke due to a disturbance in the blood vessels supplying blood to the brain. It occurs when a blood vessel that supplies a part of the brain becomes blocked or leakage occurs outside the vessel walls. This loss of blood supply results in the death of that area of tissue. Causes of Cerebral Infarction A blood vessel carrying blood to the brain is blocked by a blood clot. This is called an ischemic stroke.

A blood vessel breaks open, causing blood to leak into the brain. This is a hemorrhagic stroke. High blood pressure is the number one reason that you might have a stroke. The risk of stroke is also increased by age, family history of stroke, smoking, diabetes, high cholesterol, and heart disease.

Men have more strokes than women. But, women have a risk of stroke during pregnancy and the weeks immediately after pregnancy. Cocaine use, alcohol abuse, head injury, and bleeding disorders increase the risk of bleeding into the brain.

Symptoms of Cerebral Infarction

Weakness or paralysis of an arm, leg, side of the face, or any part of the body Numbness , tingling , decreased sensation Vision changes Slurred speech, inability to speak or understand speech, difficulty reading or writing Swallowing difficulties or drooling Loss of memory Vertigo (abnormal sensation of movement) Loss of balance or coordination Personality changes Mood/emotion changes (such as depression or apathy ) Drowsiness , lethargy , or loss of consciousness Uncontrollable eye movements or eyelid drooping Mood changes ( depression , apathy)

There are two major types of cerebral infarction: Cerebral ischemia It occurs when a blood vessel that supplies blood to the brain is blocked by a blood clot. This may happen in two ways:

A clot may form in an artery that is already very narrow. This is called a thrombus. If it completely blocks the artery, it is called a thrombotic stroke. A clot may break off from somewhere in the body and travel up to the brain to block a smaller artery. This is called an embolism. It causes an embolic stroke.

Cerebral ischemia may result from clogged arteries, a condition called atherosclerosis. This may affect the arteries within the brain or the arteries in the neck that carry blood to the brain. Fat, cholesterol, and other substances collect on the wall of the arteries, forming a sticky substance called plaque. Over time, the plaque builds up. This often makes it hard for blood to flow properly, which can cause the blood to clot. Cerebral ischemia may also be caused by blood clots that form in the heart. These clots travel through the blood and can get stuck in the small arteries of the brain. This is known as a cerebral embolism. Cerebral hemorrhage Cerebral hemorrhage occurs when a blood vessel in part of the brain becomes weak and bursts open, causing blood to leak into the brain. Some people have defects in the blood vessels of the brain that make this more likely. The flow of blood that occurs after the blood vessel ruptures damages brain cell.

INITIAL DATA BASE

I. BIOGRAPHIC DATA Name: Patient PMV Nationality: Filipino

Address: Block II lot 20 Villa Magdalena II Novaliches Caloocan City Age: 49 years old Religious Affiliation: Roman Catholic Occupation: Housewife Chief complain: Slurring of Speech Birthdate: May 3, 1961 Gender: Female Marital Status: Married Room and Bed #: Room 323

Attending Physician: Dr. Joson, Dr. Pecho, Dr. Magnaye, Dr. Abbarido Provisional Diagnosis: CVA infarction, HCVD

II. Nursing History

A. Past Health History The client is hypertensive for almost 5 years but she doesnt have any medication for her maintenance, whenever she is hypertensive she dont take any medications. The client had completed her immunization. Her childhood illness includes tigdas and she doesnt have any allergies. She met some accidents like fall in stairs. She had her hospitalization when she gave birth to her children. She also had cough, colds, fever and headache before and she takes Mefenamic Acid for relief. B. History of Present Illness The clients present condition started few hours prior to admission when the client had a sudden onset of slurring of speech associated with right upper extremity weakness, no other associated symptoms noted such as loss of consciousness, headache, vomiting, drooling of saliva and numbness of extremities. The client was first brought to Bernardino Hospital where the Blood pressure was 220/100 wherein the client had given Clonidine 75 mcg/ tablet sublingually, her ECG revealed sinus tachycardia with QRS widening, T wave Abnormality, consider inferior wall ischemia. The client opted to transfer at NRMF and was subsequently admitted. C. Family History The client father died from Heart attack and the clients mother died cause of Diabetes Mellitus. According to our client her grandfather in her father side suffers from Hypertension. Other than the said illness there is no hereditary illness has been further said.

GENOGRAM
Jose Enriquez 79 yrs old (Hypertention) Macaria Enriquez 89 years old Prudencio Cardeta 83 years old Pacencia Cardete 90 yrs old

Ernesto Enriquez 60 yrs old (Heart attack)

Pilar Enriquez 69 yrs old (Diabetes)

Rolando Enriquez
25 yrs old

Mrs. J.A 49 yrs old

(CVA infarct HCVD)

Lailani Enriquez
28 yrs old

Legend: Female

Male

Patient

Deceased

PATTERNS OF FUNCTIONING
A. Psychological Health
1. Coping Pattern Whenever the client has problems, she walks alone, pray to God and thinks ways to solve it. She sometimes shares it to her friends and seeks advices. She somewhat feel relieved after sharing it to others. She always tries to feel positive. Interpretation: She looks for an alternative ways of dealing with any stress and tries to be optimistic. Analysis: Coping mechanisms which are behaviors used to decrease stress and anxiety. Many coping behaviors are learned, based on ones family past experiences, and sociocultural influences and expectations.(Fundamentals of Nursing 5 th edition by Taylor, page 855) 2. Interaction Pattern

She has many friends in their village and she knows all his neighbors in Leyte (her province). She has never encountered any major problem with her friends as far as she remembers. She is always in good terms with them. She loves socializing with people and she always laughs and tells fun stories as well as throws old jokes. Interpretation: Interacting with people makes you aware of what kind of person who you are, whether you are good or bad. In his case, she had never encountered any major problem with her friends and it signifies that she has a good interaction pattern. Analysis: Communication can be a transmission of feelings or a more personal and social interaction between people. Self-concept develops as a result of social interaction with others. (Kozier &Erbs Fundamental of Nursing Eight Edition Volume two. Self-concept, page 1003.) 3. Cognitive Pattern She finished until first year college with a course of BS in Accountancy. She is well mannered and literate. She loves reading pocket books and broad sheets. Also, she likes to read Readers digest whenever she is free. Interpretation: Even if she didnt finish her study, she is determined to learn more things and update herself. Analysis: Cognition is greatly affected by education. Those who study and develop their skills have better cognitive performances because insdevelop their self. Perception is affected the sensory diseases. Presence of any sensory abnormalities affects or halters perception that would affect proper communication. (Black, Medical Surgical Nursing7th edition, page 1880). Cognition involves a persons intelligence, perceptual ability and ability to process information. It represents a progression of mental abilities from illogical to logical thinking, from simple to complex problem solving and from concrete to abstract ideas. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 359). 4. Self-Concept She always tries to look on a brighter side whenever she is faced with problems as what she is experiencing now that she is confined in the hospital. She has a positive self-concept in life. Instead of thinking that she is ill, she thinks that in some way or another, the medical team will help her feel more relax. She feels good about herself as long as she is with her family especially with his grandson and of course with God. Interpretation: She is very optimistic and it can help her reduce the pain and tension that she might encounter with her entire stay in the hospital. Analysis: Self concept is ones mental image of oneself. A positive self concept is essential to a persons mental and physical health. Individuals with a positive self concept are better able to develop and maintain interpersonal relationship and resist psychological and physical illness. Self concept involves all of these self perceptions, that is, appearance, values and beliefs that influences behaviors and that are referred to when using the words I or me. Body image is ho the person perceives the size, appearance and functioning of the body. If a persons body image closely resembles ones ideal body, the individual is more likely to think positively about the physical and non-physical concept of self. Self concept is also affected by role-strains. People undergoing role-strains are frustrated because they feel or made to feel inadequate or unsuited to a role. Illness and trauma can also affect the self-concept. People responds to different stressors such as illness and alterations in function related to aging in a variety of ways: acceptance, denial, withdrawal and depression are common. (Kozier et.al, Fundamentals of Nursing 7th ed. Pages 957-962).

5. Emotional Patterns As for her emotions, she has still the same mood. She is friendly, approachable and very accommodating. She tells stories, laughs with her friends who is visiting her. She is always seen to be relaxed and worry-free. Interpretation: She has a good coping mechanism that helps her reduce emotional stress. Analysis: Emotion-focused coping includes thoughts and actions that relieve emotional distress. (Kozier &Erbs Fundamental of Nursing Eight Edition Volume one. Stress and Coping, page 1068.) 6. Family Coping Patterns She is very open to her family. Whenever they have problems they talk about it immediately and try to resolve it at once. They never make it a big deal as long as it can be resolved. They practice close family ties. Interpretation: Communication to one another is an important way to solve the problem that is being misunderstood Analysis: Family coping mechanisms are the behaviors families used to deal with stress or changes imposed from either within or without. Internal resources, such as knowledge, skills, effective communication patterns, and a sense of mutuality and purpose within the family are the one mostly utilized by the family to assist them in their problem-solving process.

B. Socio-Cultural Pattern
1. Cultural pattern She belongs to no tribe. They celebrate fiestas, Christmas, mourning of the dead and anything of Roman Catholic beliefs. She loves Filipino cuisines as well as delicacies found in her province. Interpretation: The client has a normal cultural pattern. She patronizes Filipino cuisines and delicacies. She also practices what the Filipino ancestors did then. Analysis: Culture is a complex whole in which each part is related to every other part. It is learned, and the capacity to learn culture is genetic, but the subject matter is not genetic and must be learned by each person in his or her own family. (Kozier &Erbs Fundamental of Nursing Eight Edition Volume one. Culture and Heritage, page 315.) 2. Significant Relationship She is 25 years happily married, and has 3 children and 4 grandchildren. According to her, she became productive with the help of his husband. She values each of her significant family members. She is contented with how she brought her happy family at present. Interpretation: The client values her significant family members. She is satisfies enough with her relationship to them. For this matter, the client has a normal significant relationship pattern. Analysis: Children and adults in healthy, functional families receive support, understanding, and encouragement as they progress through predictable developmental stages, as they move in or out of the family unit, and as they establish new family units. (Kozier &Erbs Fundamental of Nursing Eight Edition Volume one. Promoting Family Health, page 429.) 3. Recreational Patterns

She loves watching teleserye and noontime show such as Eat Bulaga. Sometimes, she plays mahjong with her neighbors. According to her, during her spare time, she visits her floral garden and talks to her orchids. She loves nature and so does orchids and euphorbia. She feels relaxed whenever she is doing her recreations. Interpretation: The client feels refreshed whenever doing his leisure activities. She really loves orchids. She happened to have garden full of orchids and euphorbia. In line with this, she enjoys her recreation. Analysis: People learn to initiate, recognize, and repeat pleasurable experiences in the environment. They anticipate pleasurable events, fun and enjoyable activities that release tension to every individual. (Maternal and Child Health Nursing p. 819) 4. Environment She lives in a multiple type of dwelling in Caloocan. Their house is just right with the size of her family; they have three bedrooms and have good ventilation. Their environment is vector-free. They see to it that they observe proper waste disposal. According to her, they are very satisfied to the environment they are living in. Interpretation: The client lives in a very conducive environment. She describes it as safe and good enough for his family. They are satisfied in the kind of environment they are staying in. Analysis: People are becoming increasingly aware of their environment and how it affects their health and level of wellness. (Kozier &Erbs Fundamental of Nursing Eight Edition Volume one. Health Wellness and Illness, page 301.) 5. Economic Although she only stays at home as a full housewife, she is financially prepared. Her husband works and supports his family. She propagates orchids and sells them as one of his income. She earns just enough for their living but not for luxury. Interpretation: Her relation lasts because of her being productive in a simple way she can as well as protecting her family and providing their basic needs. Analysis: The economic resources needed by the family are secured by adult members. (Kozier &Erbs Fundamental of Nursing Eight Edition Volume one. Promoting Family Health, page 429.)

C. Spiritual Pattern
1. Religious Beliefs and Practices The client attends mass every Sunday. She sees to it that she does not fail to hear the gospel every week. The client is religious over spiritual person. She is somewhat active in their village during Holy week. She even does fasting. Interpretation: The client is very religious person. She obeys Christian beliefs and practices. She attends mass regularly. In this matter, the client has a normal spiritual pattern. Analysis: Spiritual well-being is manifested by a generally feeling of being alive, purposeful and fulfilled. People nurture or enhance their spirituality in many ways. Some focus on development of the inner self or world; others focus on the expression of their spiritual energy with others or outer world. Relating to ones inner self or soul may be achieved through conducting an inner dialogue with a higher power or with ones self through prayer or medications. The expression of a persons spiritual energy to others is manifested in loving relationship with and service to others, joy and laughter and participation in religious services and associated fellow gatherings and activities and by

expression of compassion, empathy, forgiveness and hope. (Kozier et.al, Fundamentals of Nursing 7th ed. Pages 996). 2. Values and Valuing Whenever there are Christian events, like Holy week, she participates in some activities like reading pasyon. She does not believe in ghosts and elementals for she knows that God is always there to guide and protect her and her family. She seldom reads the bible but does always pray the rosary and respects and obeys the rules of God and sets a good example of being a Christian. Interpretation: The client believes of Gods existence and it is good to be part of a Christian family. Also, she knows Gods rules and obeys them. Analysis: Spiritual well-being is the condition that exists when the universal spiritual needs for meaning and purpose, love and belonging, and forgiveness are met. O Briens conceptual model of spiritual well-being in illness identified three empirical referents of spiritual well-being: personal faith, religious practice and spiritual contentment. Spiritual beliefs are of special importance to nurses because of the many ways they can influence a patients level of health and self-care behaviors. (Kozier et.al, Fundamentals of Nursing 7th ed. Pages 975,979).

ACTIVITIES OF DAILY LIVING

ADL 1. Nutrition Before Hospitalization The client verbalized ang mga usual na kinakain ko eh fish, karne at gulay. Hindi naman ako mahilig kumain ang matataba at matatamis. Kung kumakain man ako, konti konti lang. Height: 52 Weight: 60kg BMI:24.4(overweight) IBW:52kg Breakfast: 1 cup fried rice 1 serving fried egg During Interpretation and Analysis Hospitalization The client is on low A healthy diet with adequate calories, salt low fat diet. protein and other nutrients is important to maintain good immune She verbalized function and increase resistance to bawal na daw disease. High salt intake can affect talaga akong blood pressure and contribute to the kumain ng maalat development of hypertension. at matataba (Fundamentals of Nursing 8th edition ngayon. Vol. 2 by Kozier and Erb, p.1411) The client has a good diet; she should Breakfast: maintain not eating foods that are 3 slices wheat rich in sodium and high in cholesterol bread because these foods can trigger 1 lakatan increase in blood pressure. 1 glass water Overweight or obesity is one of the risk factors of cerebral infarction. Lunch:

1pc. Hotdog 1 cup coffee

1 cup rice The client should maintain her ideal 1 serving adobong body weight and maintain a low salt, manok (breast part) low fat diet. Am snack: 1 serving chopsuey 1 serving chicken 2 glasses water sandwich 6pcs. Longgan 1 glass orange juice Supper: Lunch: 1 cup rice 1 cup rice 1 serving bangus 1 serving pork sinigang with sinigang with vegetables vegetables 1 serving papaya 2 glasses water 1 glass water 1pc latundan Supper: 1 cup rice 1 serving igado 1 glass water

2. Elimination

Client urinates 6-7 She urinates 8-9 times a day. She times a day in the doesnt feel any pain hospital. She and difficulty in defecates once a urinating. day. The client verbalized araw-araw akong dumudumi, kadalasan kada umaga.

Normal fecal elimination should be brown in color, formed, soft, semisolid, and moist in terms of consistency, cylindrical in shape, and aromatic in terms of odor. The amount of stool depends on the diet of the person. As to urinary elimination, the normal amount of urine in 24 hours for adult is about 1200 to 1500 ml, straw amber and transparent in terms of color and faint aromatic for odor. We should respond to the urge to the void as soon as possible to avoid voluntary urinary retention. (Fundamentals of Nursing by Kozier, 7th ed., p.1264, 1268-1269.) The client doesnt have any problem related to her elimination pattern.

3. Exercise

She said hindi ako

The client is on The normal frequency of exercise is

nag-eexercise. Nanuuod lang ako ng t.v, higa tapos paikotikot sa bahay. Lakad lang siguro ang pinaka exercise ko at paglilinis na din paminsan minsan.

complete bed rest three times per week and the duration without bathroom is 30 minutes. (Fundamentals of privileges. Nursing by Kozier pg. 1065) Physical activity is associated with a reduction in the risk of death. Physical exercise or activity increases the heart rate and hence the supply of oxygen in the body. With regular vigorous exercise, the heart muscle becomes more powerful and efficient. Aerobic exercise slows the atherosclerotic process, reducing the risk of cerebral infarction. Sedentary people, by contrast are on higher risk. (Fundamentals of Nursing 8th edition Vol. 2 by Kozier and Erb, p.1409) The client doesnt have adequate time for exercise. Possibly, this is one of the reasons why she had a CVA which is one of its risk factors. The client must maintain a regular physical activity to promote circulation and vascular health.

4. Hygiene

Client takes a bath every day and maintains proper health hygiene.

Since client was admitted, she cannot take a bath in the bathroom and prefer a sponge bath. hindi nga ako makaligo, pinupunasan lang ako ng anak ko.

Even though sick role hinders client to take care of herself, guardians could help them in doing a bed bath or sponge bath. Measure for personal cleanliness and grooming, called personal hygiene, promote physical and psychological well-being. Various studies have confirmed that improved personal hygiene practices reduce illness rates. (Larson and Aiello, 2001). The client has a good hygiene.

5.Substance Use

The client said naku,

No substance abuse Nicotine increases the heart rate,

hindi talaga umiinom naninigarilyo nuon pa.

ako at kahit

during hospitalization.

blood pressure, and peripheral vascular resistance, increasing the hearts workload. Smoking causes vasoconstriction. (Fundamentals of Nursing 8th edition Vol. 2 by Kozier and Erb, p.1409) Recent studies suggest that moderate alcohol use may actually reduce the risk of heart disease; however, excessive alcohol intake affects oxygenation several ways. Alcohol is a respiratory depressant, slowing respirations. Excess alcohol intake also increases the risk of hypertension. (Fundamentals of Nursing 8th edition Vol. 2 by Kozier and Erb, p.1411)

6. Sleep Rest

The client has no vices which can greatly cause cerebral infarct. and The client verbalized The client Most healthy adults need 7 to 9 hours ang usual na tulog ko verbalized tulog of sleep a night. However, there is eh siguro 9pm tapos ako ng tulog kasi individual variation as some adults nagigising ako kapag wala naman akong may be able to function well with 6 5am pero natutulog ginagawa dito. hours of sleep and others may need din naman ako sa 10 hours of sleep to function tanghali. Kuntento optimally. naman ako sa (Fundamentals of Nursing 8th edition nakukuha kong tulog. Vol. 2 by Kozier and Erb, p.1168) The client has a normal sleep pattern. And the hours of sleep she gets is adequate.

PHYSICAL ASSESSMENT
Norms Actual findings Interpretation and Analysis

General Appearance
Relaxed, erect posture; coordinated movement The client is lying on bed postural and gait, standing, sitting and walking has not been assessed. Varies from light to deep brown. Generally uniform except in areas exposed to the sun. There is no presence of body and breath odor. Having Bed rest is good for hospitalized patient for the patient can get more energy but 24 hrs. in bed is not healthy also for the patient may have any other complications such as sores, or pneumonia. (http://www.sicknesssymptoms.org/hypertensionrecovery.html)

Postural/Gait

Skin Color

The color of the skin is light brown and uniform with the other body parts Clean and neat No body odor or minor body odor relative to work or exercise: no breath odor Healthy appearance

Normal Skin Color

Personal Hygiene/Grooming

Normal Personal Hygiene/Grooming

The client is weak in appearance

Weak in appearance is one of manifestations that is very observable in a hospitalized client (http://www.sicknesssymptoms.org/hypertensionrecovery.html)

Nutritional Status

Height and weight appropriate to the age Age Appropriateness Speech is understandable, moderate pace; exhibits thought association. Logical sequence; makes sense: has sense of reality Cooperative Affect/mood is appropriate to the situation

Verbal Behavior

The clients height and weight is not proportionate to his age and varies with his lifestyle. The clients speech is understandable, in slow pace, in clear tone and inflection. The thoughts are appropriate to the situation Cooperative Mood and affect are appropriate to situation

Not Normal Age Appropriateness BMI: 30.1 indicates Obesity

Normal Verbal Behavior

Non-Verbal Behavior

Normal Non-Verbal Behavior

Measurements
Temperature 36.5-37.5 oC 37.2 C Tachycardia Tachycardia is a faster than normal heart rate. A healthy adult heart beats 60 to 100 times a minute when a person is at rest. If you have tachycardia, the rate in the upper chambers or lower chambers of the heart, or both, are increased significantly. (http://www.mayoclinic.com/health/tachycardia/DS00 929) Normal Respiratory Rate Normal Temperature

Pulse rate

60-100 bpm

110bpm

Respiratory Rate

12-20 cpm

20cpm

Hypertension III Factors affecting Blood Pressure Heredity-Those with a family history of hypertension are twice as likely to develop it as others. Many children of hypertensive parents have slightly elevated blood pressure even as infants. (http://newfitness.com/Blood_Pressure/hypertension.h tml) Blood Pressure 120/80 mmHg 200/110 mmHg Stress- Stimulation of the sympathetic nervous system increases cardiac output and vasoconstriction of the arterioles, thus increase the blood pressure reading; however severe pain can increase blood pressure greatly by inhibiting the vasomotor center and producing vasoconstrictions. Disease Process- Any condition affecting the cardiac output, blood volume, blood viscosity, and/or compliance of the arteries has a direct effect on the blood pressure. (Fundamentals of Nursing by Kozier and Erbz 8th edition pg. 552) Weight Height 170lbs 53 Obese I BMI Categories: BMI 30.1 Underweight = <18.5 Normal weight = 18.5-24.9 Overweight = 25-29.9 Obesity = BMI of 30 or greater (http://www.nhlbisupport.com/bmi/)

General Appearance
Relaxed, erect posture; coordinated movement The client is lying on bed postural and gait, standing, sitting and walking has not been assessed. Varies from light to deep brown. Generally uniform except in areas exposed to the sun. There is no presence of body and breath odor. Having Bed rest is good for hospitalized patient for the patient can get more energy but 24 hrs. in bed is not healthy also for the patient may have any other complications such as sores, or pneumonia. (http://www.sicknesssymptoms.org/hypertensionrecovery.html)

Postural/Gait

Skin Color

The color of the skin is light brown and uniform with the other body parts Clean and neat No body odor or minor body odor relative to work or exercise: no breath odor Healthy appearance

Normal Skin Color

Personal Hygiene/Grooming

Normal Personal Hygiene/Grooming

The client is weak

Weak in appearance is one of manifestations that is

in appearance Nutritional Status

very observable in a hospitalized client (http://www.sicknesssymptoms.org/hypertensionrecovery.html)

Height and weight appropriate to the age Age Appropriateness Speech is understandable, moderate pace; exhibits thought association. Logical sequence; makes sense: has sense of reality Cooperative Affect/mood is appropriate to the situation

Verbal Behavior

The clients height and weight is not proportionate to his age and varies with his lifestyle. The clients speech is understandable, in slow pace, in clear tone and inflection. The thoughts are appropriate to the situation Cooperative Mood and affect are appropriate to situation

Not Normal Age Appropriateness BMI: 30.1 indicates Obesity

Normal Verbal Behavior

Non-Verbal Behavior

Normal Non-Verbal Behavior

INTEGUMENTARY SKIN Inspect for color uniformity of color Inspect for presence of edema Inspect for lesions The color of the skin is light brown and it is uniform with the other body parts There is no edema Freckles, some birthmarks some flat and raised nevi, no abrasions or other lesions There are moisture The clients skin color is fair, dry, elastic There is a presence of edema in the hands There is a presence of scar in the right forearm. There is no presence of excessive dryness, there is a moist in the skin folds and axillae Temperature is uniform within normal range When pinched skin springs back to previous state The nails Normal

Normal Normal

Palpate skin moisture

Normal

Palpate skin temperature Palpate skin turgor

The skin is warm, and uniform in all body parts The skin returns to its position

Normal Normal

NAILS Inspect fingernail plate shape to determine its curvature and angle Inspect fingernail and toenail bed color Palpate fingernail and toenail texture Inspect tissues surrounding nails Perform blanch test of capillary refill

The fingernail plate shape has a 160 degree angle and convex in shape The color is pinkish The nails are smooth The epidermis are intact The color of the nail return from being white to pinkish after less than 4 seconds HEAD

Normal

Pinkish in color Nails is smooth in texture The epidermis are intact Normal color of nails is able to go back in its original color in 4 second

Normal Normal Normal Normal

SKULL Inspect the skull for size shape and symmetry

The skull is rounded and it is symmetric

Palpate for nodules, masses, and depressions SCALP Inspect for color and appearance

No nodules, no masses

The skull of the client is round it is normocephalic, it is symmetrical, it has smooth skull contour. There is no masses, and nodules upon palpation There are no nodules, masses and depressions, it is lighter than the areas exposed to the sun, it has no lesions and no dandruffs. No tenderness upon palpation Evenly distributed hair thin hair, black in color, there is no lice and no dandruffs. Silky resilient hair

Normal

Normal

The Scalp is free of dandruff and lice, its color is lighter than the skin color because it is not exposed in the sun

Normal

Palpate for areas of tenderness HAIR Inspect for evenness of growth ,thickness or thinness

There are no tenderness

Normal

The hair is thick and it evenly distributed

Normal

Palpate for texture and oiliness over the scalp FACE Inspect the facial feature symmetry of facial movements

The hair is silky

Normal

There are symmetric facial features and symmetric facial movements

The facial features are symmetric, palpebral fissures are equal in size, the nasolabial folds are symmetric and the facial movements is symmetric

Normal

EYES VISUAL ACUITY Test near vision EYEBROWS Inspect for hair distribution , alignment, skin and quality and movement Able to read a letter in the newspaper The hair in the eyebrow is evenly distributed & it is symmetric ally aligned and has a equal movement Able to read the article Normal

Hair evenly distributed and skin intact. Eyebrow symmetrically aligned and has equal movement. Eyelashes are evenly distributed, curved slightly outward

Normal

LACRIMAL SAC & LACRIMAL SAC & NASOLACRIMAL DUCT Inspect and palpate the lacrimal gland EYELIDS Inspect for the surface characteristic position in relation to the cornea, ability to blank and frequency of blinking

There are no tenderness

No tenderness upon palpation, no swelling, no edema, no tearing Skin intact, it has no discharge, no discoloration. Lids close symmetrically. Has 18 involuntary blinks per minute, has bilateral blinking. When eyes are open, there is no visible sclera above corneas, and

Normal

The skin is intact and there are no discharges and discoloration

Normal

upper and lower borders of cornea are slightly covered CONJUNCTIVA Inspect the bulbar conjunctiva (lining over the cornea ) for color , texture, and presence of lesions Inspect the palpebral conjunctiva (lining the eyelids) for color texture and presence of lesions SCLERA Inspect the color and clarity CORNEA Inspect for clarity and texture IRIS Inspect for shape and color PUPILS Inspect for color , shape and symmetry of size The conjunctiva is transparent and its color is white Transparent, capillaries are visible, it has no lesions Pinkish in color, smooth and there is no lesions Normal

It is smooth and color pinkish or red

Normal

No presence of lesions

Appears white and clear there is no lesions Transparent, shiny and smooth in texture Iris is dark brown in color and it is round Black in color, equal in size, in about 4 mm in diameter, it is round,

Normal

It s transparent and smooth

Normal

It is round in shape color brown It is round in shape black in color and symmetric with each other

Normal

Normal

Test each pupil for light reaction and accommodation

The pupil constructs when focused on a near objects and it dilates when focused on a far object

Pupils constrict in about 3 mm. when looking at near objects, pupils dilate in about 5 mm. when looking at far objects; pupils converged when near objects move toward the nose, illuminated pupils constricts. Both eyes are coordinated, moves unison, has a parallel alignment The client is able to see the object in her periphery when looking straight.

Normal

EXTRAOCULAR MUSCLES Test each eye for alignment and coordination VISUAL FIELDS Test peripheral fields

Both eyes are coordinated and aligned

Normal

When the Client see the object in periphery EARS

Normal

AURICLES Inspect color, symmetry and position

The color is the same as the facial skin and it is symmetrical

Palpate for texture, elasticity and areas for tenderness EXTERNAL EAR CANAL Inspect ear canal for cerumen,skin lesions pus and blood

There are no tenderness, it is firm and returns back as result of elasticity There are no lesions, pus and blood

Color same as facial, symmetrical, auricle aligned with the outer canthus of eye about 10 degree from vertical It is mobile, firm and not tender; pinna recoils after it is folded Distal third contains hair follicles and glands, there is no presence of blood,

Normal

Normal

Normal

lesions, pus. There is a presence of wet cerumen HEARING ACUITY TEST Asses clients response to normal voice tones Perform watch tick test Perform Webers test The client is response correctly to normal voice tone The client is able to hear the ticking sound in both ear The client heard the sound in both ears and able to feet vibrations The duration of the an conduction is longer than in home conduction NOSE It is symmetric and its color is same with the facial skin and it has no flaring or discharges There are no redness, swelling or any discharges in the nose The nasal septum is seated at the middle part The client is able to smell correctly one specially thing with both of the nasal cavities There are no tenderness and there are no displacement of bones Normal voice tones audible in both ears Able to hear ticking in both ears Sound is heard in both ears, she is able to feel the vibration, it is weber negative Air-conduction hearing is greater than boneconduction hearing, it is positive Rinne Symmetric and straight no discharge or flaring It is uniform in color Mucosa in pink, it is clear there is no Lesions, it has watery discharges. Nasal septum is intact and in the middle Air moves freely as the client breath through nares No tenderness No displacement of masses of bones and cartilages Normal Normal Normal

Conduct Rinnes test

Normal

Inspect for any deviations in shape or color and flaring or discharge from nares Inspect the nasal cavities for the presence of redness, swelling growths discharge using the flashlight Inspect the nasal septum between the nasal chambers Test patency of both nasal cavities Palpate for any tenderness, masses displacement of bone and cartilage

Normal

Normal

Normal Normal

Normal

Locate /palpate/identify the sinuses and note for tenderness

SINUSES There are no tenderness No tenderness upon palpation in the frontal and maxillary sinuses MOUTH The lip are symmetric, its color is pinkish and it has a smooth texture Uniform pink color, soft, moist, smooth texture, symmetrical, ability to purse lips Uniform pink color soft, moist, smooth, soft, glistening and elastic texture,. The client has dentures, it is yellowish in color

Normal

LIPS Inspect for symmetry of contour, color and texture

Normal

BUCCAL MUCOSA Inspect for color, moisture, texture and presence of lesions

Its color is pinkish, it has moist, the texture is soft and there are no presence of lesions The color of the teeth is white. The client has a complete number f teeth, and there is presence of dentures The color of the gums is pink and it has a firm texture

Normal

TEETH Inspect for color, number and condition and presence of dentures GUMS Inspect for the color and condition TONGUE/FLOOR OF THE

Normal

Pink gums, has Moist, firm texture to gums. No reaction of gums

Normal

MOUTH Inspect for color and texture of the of the mouth floor and frenulum

Its texture is slightly rough and it is pink in color

Inspect and palpate the position color and texture movement and base of the tongue

The color is pink

Palpate for any nodules lumps or excoriated areas PALATES AND UVULA Inspect and palpate for color texture and the presence of bony prominences

There are no nodules and lamps Its color is light pink it is smooth and soft

The frenulum and mouth floor is pink in color, the base of the tongue is smooth with prominent veins It is in central position, pink in color, has raised papillae, smooth, no lesions, it moves freely, no tenderness, the base of the tongue is smooth with prominent veins Smooth with no palpate nodules Soft palate: is light pink and it is soft Hard palate: Much lighter in pink and it has irregular texture Positioned in midline of soft palate

Normal

Normal

Normal

Normal

Inspect for position of the uvula and mobility of examining the palates OROPHARYNX & TONSILS Inspect and palpate for color, texture(one side at a time to avoid eliciting gag reflex) Inspect the size of the tonsils color and discharge

The uvula is centered and is freely movable

Normal

It is pink in color

It is pink in color and there are no discharge noted. Its size s normal which is grade 1 NECK AND LYMPH NODES There are no tenderness

Uniformly pink in color, and has smooth posterior walls. Pink and smooth, no discharge, grade 1

Normal

Normal

LYMPS NODES Locate/Palpate/identify lymph nodes and note for tenderness TRACHEA Inspect and palpate for placement THYROID GLAND Inspect symmetry and visible masses

No tenderness upon palpation It is in central position in midline of neck spaces are equal on both sides No visible masses the glands ascend as the client swallow but it is not visible lobes are small, smooth centrally located, it is painless and raise freely as the client swallow

Normal

The trachea is placed at the midline of the neck

Normal

It is symmetric and there are no visible masses

Normal

Palpate for smoothness and areas of enlargement masses or nodules

There are no masses or nodules It is smooth and no areas of enlargement THORAX

Normal

POSTERIOR THORAX Inspect the shape and symmetry. Compare the anteroposterior diameter to the transverse diameter

The Thorax has an equal downward slope, it is symmetry and its diameter has the ratio of 1:2

Inspect the spinal alignment

The spine is vertically aligned

Clients Anteroposterior is about 6 inches and her transverse is about 12 inches it has a ratio of 1:2, and the Chest is symmetric The clients spine is

Normal

Normal

Palpate the temperature, tenderness, and masses

There is a uniform temperature there are no tenderness.

Assess respiratory excursion

Palpate the vocal fremitus

It is normal because the thumbs separated when the client breathe deeply There are equal mild vibratory sensations palpated

vertically aligned The chest skin is intact, the temperature is uniform within the normal range, the chest wall is intact, there is no tenderness upon palpation, there is no masses. Full and symmetric chest expansion The vibration is much felt in the apex of the lungs, and as it goes down the vibration decreases There is a resonance sound in the scapula, it decreases as it goes down to the diaphragm, there is a dull sound in the ribs. There is a bronchovesicular sound in between the scapulae, there is a vesicular sound in the peripheral of the lung. Quiet, rhythmic and effortless respirations Temperature is uniform w/ in the normal range, no tenderness upon palpation no masses. Full symmetric excursion The fremitus decreases ver the heart and breat tissues.

Normal

Normal

Normal

Percuss the posterior thorax

The sound heard is a resonance sound

Normal

Auscultate the posterior thorax

Vesicular and bronchovesicular breath sounds are heard

Normal

Anterior thorax Inspect breathing patterns Palpate the temperature, tenderness, masses

The client have a quiet breathing pattern Uniform temperature

Normal Normal

Asses respiratory excursion Palpate vocal fremitus

When the client breathe, the thumbs separated There are equal mild vibratory sensations palpated.

Normal Normal

Percuss the anterior thorax

The sound heard are flat,dull sounds, resonance sounds

Auscultate the anterior thorax Auscultate the anterior thorax

The sound heard are flat, dull sounds, resonance sounds Bronchovesicular and vesicular breath sounds are heard

There are resonance sound down to the sixth rib at the level of the diaphragm but there are flat over areas of heavy muscle and bone, dull on areas over the heart and the liver, and tympanic over the underlying stomach Bronchial sound over the trachea Bronchovescular in the lateral to the sternum and vesicular breath sounds in the peripheral of the lungs Adynamic precordium, tachycardic, regular rhythm, no murmurs S1 is heard in the apex of the heart, S2 is heard in

Normal

Normal Normal

CARDIOVASCULAR Auscultate the aortic pulmonic, tricuspid, apical valves

There are sounds heard in the aortic, pulmonic and tricuspid areas but the sound in louder at the apical area in both S1 and S2

From the clients previous VS he had a cardiac rate of 110 that leads to his tachycardia

the base of the heart. CAROTID ARTERIES Palpate carotid arteries with extreme There are symmetric pulsations It has full and symmetric pulsations, there is no thrusting qualities, the qualities remain as the client breathes, she turn her head and as she change position. No sound heard on auscultation Veins not visible It is round, slightly unequal in size, it is symmetrical it has a striae Normal

Auscultate the carotid arteries JUGULAR VEINS Inspect jugular veins BREST AND AXILLAE Inspect breast for size, symmetry, contour or shape

No sound heard

Normal

There are visible veins The clients breath is round in shape and it is slightly unequal to the other one that it is symmetric in right to left breast The skin ins uniform in color, There are no discolorations, hyperpigmentation localized hypervascular areas swelling or edema The clients areola is round in shape, its color is brownish. There are no masses or lesions.

May be caused by CVA Normal

Inspect the skin of the breast for localized discolorations, hyperpigmentation, retraction, dimpling hypervascular areas, swelling or edema Inspect the areola for size, shape, symmetry, color, surface characteristics and any mass or

Inspect the nipples for size, shape, position, color, discharge and lesion

The nipples are equal in size, it round and its position is pointing to the same direction. Its color is pink and there are no discharges and lesions.

The clients breast is the same as the color of the abdomen, it is smooth, there is presence of striae, it is skin intact. The areola is round in color it is light brown in color, it is uniform, it has an irregular distribution of sebaceous glands in the surface of the areola. The nipples of the client is round, it is brown in color, it is everted, it I equal in size, it points in the same direction, there is no discharge and no lesions.

Normal

Normal

Normal

Palate the axillary, subclavicular lymph nodes Palpate for breast for masses and tenderness Palpate nipples for tenderness and discharge

Inspect the abdomen for skin integrity

Inspect the abdominal contour ( profile line fro rib margin to public bone) while standing at the clients side while the client is in dorsal recumbent position Inspect for an enlarge liver or spleen Asses the symmetry of contour while standing at the foot of the

There are no tenderness, No tenderness, masses, masses, or nodules nodules There is no nodules, no Not tender, no masses, no masses, no tenderness nodules upon palpation There are n tenderness, No tenderness, masses, masses, nodules, or nipple nodules, or nipple discharge discharge ABDOMEN The client has an The abdomen has unblemished skin, unblemished skin, it is The skin is uniform in color. uniform in color and it is symmetrical The abdominal contour is lat Flat, rounded, flabby, soft, and rounded. non-tender

Normal Normal Normal

Normal

Normal

There are no signs of enlargement of liver or spleen It has symmetric contour

No evidence of enlargement or liver or spleen The abdomen is symmetric

Normal

Normal

bed Inspect the abdominal movements associate with respiration, peristalsis or aortic pulsation Observe vascular patterns Auscultate the abdomen for bowel sound, vascular sounds and peritoneal friction rubs Percuss several areas in each of the four quadrant

The abdominal movements are symmetric. No visible peristalsis There are no visible vascular pattern There are no bruits and friction rubs When percussed, dull sounds are heard

Abdomen has symmetric movements while breathing. No visible vascular pattern There is no arterial bruits, no friction rubs, the client has There is tympanic sounds all over the abdomen except in the upper right and left quadrant because it is where the liver and spleen is located No tenderness, relaxed abdomen with smooth, consistent tension No tenderness Not palpable

Normal

Normal Normal

Normal

Perform light palpation

No tenderness

Normal

Perform deep palpation Palpate above the area of symphysis pubis to determine possible urinary retention.
Inspect the muscles for size. Compare the muscles on one side of the body( arm, thigh, calf) to the same muscle on the other side Inspect the muscle and tendons the contractures ( shortening) Inspect the muscle fasciculation and tremors Inspect the tremors of the hands, And arms and out of a body Palpate muscle Test the strength (neck)

No tenderness Not palpable

Normal normal

MUSCULO-SKELETAL SYSTEM
The muscles have equal size on both sides the body Equal size on both sides of body Normal

There are no contractures No Fasciculation or tremors

No contractures No fasciculation or tremors

Normal Normal

Firm There is presence of resistance. The body part both gave equal strength when resisting the force exerted There is presence of resistance. The body part both gave equal strength when resisting the force exerted There is presence of resistance. The body part both gave equal strength when resisting the force exerted BONES No deformities No tenderness or swelling JOINTS

Muscles are firm when in tension. Equal strength on each body side

Normal Normal

Test the Strength (upper extremities)

Equal strength on each body side

Normal

Test the strength (lower extremities)

Equal strength on each body side

Normal

Inspect the skeleton for normal structure and deformities Palpate the bones to locate any areas of edema or tenderness

No deformities No tenderness swelling no masses

Normal Normal

Inspect the joints for swelling Palpate each joint for tenderness, smoothness of movement, swelling, crepitation and presence of nodule

No swelling There are no tenderness and swelling. The joints move smoothly. And there are no presence of nodules

No swelling No tenderness, swelling, crepitation, or nodule Joints move smoothly

Normal Normal

Assess range to motion Upper extremities(shoulder and scapula)

Upper extremities ( Elbow)

Upper extremities hands)

Upper extremities (acetabulum inguinal area)

Upper extremities (popliteal)

Lower extremities (ankles)

The body parts are coordinated with each other. There is no limited range of more joints The body parts are coordinated with each other. There is no limited range of more joints The body parts are coordinated with each other. There is no limited range of more joints The body parts are coordinated with each other. There is no limited range of more joints The body parts are coordinated with each other. There is no limited range of more joints The body parts are coordinated with each other. There is no limited range of more joints

Full range motion of joints

Normal

Full range motion of joints

Normal

Full range motion of joints

Normal

Full range of motion

Normal

Full range motion of joints

Normal

Full range motion of joints

Normal

GLASGOW COMA SCALE

1. Best Motor Response (6 grades) 1. No response to pain. 2. Extensor posturing to pain: The stimulus causes limb extension (adduction, internal rotation of shoulder, pronation of forearm) - "decerebrate posture" 3. Abnormal flexor response to pain: Pressure on the nail bed causes abnormal flexion of limbs "decorticate posture". 4. Withdraws to pain: Pulls limb away from painful stimulus. 5. Localizing response to pain: Put pressure on the patient's finger nail bed with a pencil then try supraorbital and sternal pressure: a purposeful movement towards changing painful stimuli is a 'localizing' response. 6. Obeying command: patient did simple things you ask (beware of accepting a grasp reflex in this category). 2. Best Verbal Response (5 grades) Record best level of speech. If patient is intubated, a "derived verbal score" is calculated via a linear regression prediction. 1. None. 2. Incomprehensible speech: Moaning but no words. 3. Inappropriate speech: Random or exclamatory articulated speech, but no conversational exchange. 4. Confused conversation: Patient responds to questions in a conversational manner but some disorientation and confusion. 5. Orientated: Patient knows who she is, where she is and why, the year, season, and month. 3. Eye Opening (4 grades) 1. No eye opening; 2. Opening to response to pain to limbs as above 3. Eye opening in response any speech (or shout, not necessarily request to open eyes); 4. Spontaneous eye opening. Interpretation of Symptoms: Severe: less than 8; Moderate: 9-12; Score: 6

Score: 5

Score: 4

Total Score:15

Mild: 13-15)

Interpretation The patients grade in regards with the eye movement is 4 which mean the patient opens her eyes spontaneously. In her verbal she scored 5 where the patient is knows who she is, where she is and why, the year, season, and month oriented and still responds appropriately to questions being asked. And with the Motor reflex the patient scored 6 which indicates that she obeys commands. Norms and standard GCS is a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment. A patient is assessed against the criteria of the scale, and the resulting points give a patient score between 3 (indicating deep unconsciousness) and either 14 (original scale) or 15 (the more widely used modified or revised scale). Generally, brain injury is classified as: Severe, with GCS 8 Moderate, GCS 9 12 Minor, GCS 13.

LABORATORY RESULTS
TEST RESULT NORMAL VALUE INTERPRETATION AND ANALYSIS

SERUM CREATININE TEST

Creatinine: 67.20 mol/L

50.40-98.06 mpl/L

INTERPRETATION: Normal ANALYSIS: Increased blood creatinine levels occur in the following conditions: Impaired renal function Chronic nephritis Obstruction of urinary tract Congestive heart failure. Decreased creatinine levels occur in the following conditions: Advanced and severe liver disease Inedequate protein intake

COMPLETE BLOOD COUNT RBC: 5.82 4.5-5.5 x 10 12/L Interpretation: Increased Analysis: Decreased RBC may indicate anemia and if increase may indicate erythremic erythrocytosis

Hgb: 17.20

M: 14-17 F: 12-16 g/dL

Interpretation: Increased Analysis: Decreased Hemoglobin indicates anemia while increased hemoglobin indicates COPD, polycythemia vera

Hct: 0.50

0.37-0.47 L/L

Interpretation: Increased Analysis: Increased: may indicate polycythemia vera Decreased Hct indicates anemia while

MCV: 85.9

80-100 fL

Interpretation: Normal Analysis: MCV is the basis of the classification system used to evaluate anemia.

MCH: 29.6

27-33 pg

Interpretation: Normal Analysis: MCH measeure the average weight of Hb per RBC. If increase it is associated with macrocytic anemia and decrease is associated with microcytic anemia

Interpretation: Normal MCHC: 34.4 31-36g/dL Analysis: An increase in MCHC means that RBS cant accommodate Hb anymore Decreased MCHC signifies that a unit volume of packed RBC contains less Hb than normal.

Platelet: 240

160-380x10 9/L Interpretation: Normal Analysis: If increased: it occurs on polycythemia, renal failure and other diseases while if decreased may indicate hemolytic anemia, bacterial infection and other diseases.

DIFFERENTIAL COUNT Lymphocyte: 0.13 0.27-0.33 Interpretation: decreased Analysis: If decreased, may indicate allergies, skin disease and some infection while if increased may indicate increased in adrenal steroid production associated in cushings syndrome.

Monocyte: 0.02

0.2-0.05

Interpretation: decreased Analysis: This serves as second line of defense for infection

Triglycerides: 1.49

0.00-5.17 mmol/L

Interpretation: normal Analysis: Increase triglycerides occurs in the ff conditions: 1.liver disease due to alcoholism 2. MI If decreased may indicate

brain infarction Cholesterol: 6.21 0.00-5.17 mmol/L Interpretation: Increased Analysis: If icrease may signify: 1.chronic renal failure 2.alcoholism 3.obesity If decreased may occur on the ff conditions 1.hyperthyroidism 2.malnutrition.

HDL: 38.61

40.15-59.84 mg/dL

Interpretation: decreased Analysis: If increased may occur in chronic liver disease. If decreased may indicate chronic renal failure.

LDL: 174.06

96-153 mg/dL

Interpretation: Increased Analysis: If increase may indicate: 1.DM 2.chronic renal failure If decreased may indicate chronic anemias.

ECOLOGIC MODEL

HYPOTHESIS In the case of our patient, she is suffering from the disease called cerebrovascular event this is probably due to hypertension, High cholesterol and sodium, sedentary lifestyle, elderly ages 50 and above, history of hypertension, diabetes and cardiovascular disease.

PRE-DISPOSING FACTOR HOST

Family history of HPN, DM and CVA Elderly ages 50 and above Sedentary lifestyle AGENT

Hypertension High Cholesterol and Na ENVIRONMENT

Air pollution & chemical irritants

High Cholesterol and Sodium

Elderly ages 50 & above and Sedentary lifestyle

CVA
Family history of HPN, DM and CVA

Hypertension

Air pollution and chemical irritants

ANALYSIS

Cerebrovascular Accident or CVA is the formation of an area of necrosis in the cerebrum caused by an insufficiency of arterial or venous blood flow, as by thrombosis or embolism. It is the ischemic kind of stroke due to a disturbance in the blood vessels supplying blood to the brain. It occurs when a blood vessel that supplies a part of the brain becomes blocked or leakage occurs outside the vessel walls. This loss of blood supply results in the death of that area of tissue. Signs and symptoms of cerebral infarction are sudden numbness or weakness of face, leg or arm especially on one side of the body, sudden confusion or trouble speaking or understanding speech, sudden dimness or loss of vision in one or both eyes, sudden severe headache with no known cause, sudden dizziness and loss of balance or unsteadiness.

I choose web for the epidemiological model of Cerebrovascular Accident because the Agent-Host-Environment of CVA interact with each other. The Web model shows the relationship among the three predisposing factors mainly agent, host and environment which also determine their imbalance that may lead to an occurrence of a disease. This primarily talks of the multiple causation of the disease. It that diagrams it shows that the 3 elements are not balance because the risk factors and pre disposing factor of CVA arise.

CONCLUSION
In conclusion, improper lifestyle of the patient which embraces sedentary lifestyle or lack

of exercise, and unhealthful eating habits including too much consumption of cholesterol and salty foods, infrequent drinking of water, too much drinking of soft drinks and occasional eating of fish and vegetables led to the occurrence of the patients condition of cerebral infarction. A history of diabetes, hypertension and heart attack in the clients family may have also contributed to the occurrence of the disease. Hypertension, smoking cigarette and being alcohol abuser in addition, her stressful environment such as her exposure to air pollution and chemical irritants may trigger the risk factors of cerebral infarction.

RECOMMENDATION
I strongly suggest that the main treatment for CVA or cerebral infarction is to get the

person to the emergency room immediately to determine if the stroke is due to bleeding or a blood clot so appropriate treatment can be started within 3 hours of when the stroke began, because it is a medical emergency. Immediate treatment can save lives and reduce disability. Treatment depends on the severity and cause of the stroke. A hospital stay is required for

most strokes. For hospital care clot-busting drugs (thrombolytic therapy) may be used if the stroke is caused by a blood clot. Such medicine breaks up blood clots and helps restore blood flow to the damaged area. However, not everyone can receive this type of medicine. For these drugs to work a person must be seen and treatment must begin within 3 hours of when the symptoms first started. A CT scan must be done to see whether the stroke is from a clot or from bleeding. If the stroke is caused by bleeding rather than clotting, clot-busting drugs (thrombolytic) can cause more bleeding. Other treatments depend on the cause of the stroke: Blood thinners such as heparin or warfarin (Coumadin) are used to treat infarction due to blood clots. Aspirin of clopidogrel (Plavix) may also be used. Other medications may be needed to control other symptoms, including high blood pressure. Painkillers may be given to control severe headache. In some situations, a special stroke team and skilled radiologists may be able to use angiography to highlight the clogged blood vessel and open it up. Nutrients and fluids may be necessary, especially if the person has swallowing difficulties. These may be given through a vein (intravenously) or a feeding tube in the stomach Gastrostomy Tube or Nasogastric Tube. Swallowing difficulties may be temporary or permanent. Physical therapy, occupational therapy, speech therapy, and swallowing therapy will all begin in the hospital. To help prevent a stroke you must to avoid fatty foods. Follow a healthy, low-fat and low salt diet, do not drink more than 1 to 2 alcoholic drinks a day, exercise regularly: 60 - 90 minutes a day because our client is overweight, get your blood pressure checked every 1 - 2 days, especially if high blood pressure runs in your family, Have your cholesterol checked. Follow your doctor's treatment and recommendations because she has high blood pressure, diabetes and heart disease.

ANATOMY and PHYSIOLOGY

The Central Nervous System The central nervous system is composed of the brain and the spinal cord.

The Spinal Cord The spinal cord conducts sensory information from the peripheral nervous system, both somatic and autonomic, to the brain. It also conducts motor information from the brain to our various effectors which are the skeletal muscles, cardiac muscle, smooth muscle, glands, and serves as a minor reflex center The Brain The brain is a large soft mass of nerve tissue that is contained inside a vault of bone called the cranium. It is the cranial portion of the CNS. The brain is also called the "encephalon." The brain is composed of neurons (nerve cells) and neuroglia (supporting nerve cells). The brain consists of gray and white matter. The gray matter is nervous tissues of a grayish color that forms an "H" shaped structure and is surrounded by white matter. The cerebrum or cortex is the largest part of the human brain, associated with higher brain function such as thought and action. The cerebral cortex is divided into four sections, called "lobes":

1. The frontal lobe is located at the front of the brain and is associated with reasoning, motor skills, higher lever cognition, and expressive language. At the back of the frontal lobe, near the central sulcus, lies the motor cortex. This area of the brain receives information from various lobes of the brain and utilizes this information to carry out body movements. 2. The parietal lobe is located in the middle section of the brain and is associated with processing tactile sensory information such as pressure, touch, and pain. A portion of the brain known as the somatosensory cortex is located in this lobe and is essential to the processing of the body's senses. 3. The temporal lobe is located on the bottom section of the brain. This lobe is also the location of the primary auditory cortex, which is important for interpreting sounds and the language we hear. The hippocampus is also located in the temporal lobe, which is why this portion of the brain is also heavily associated with the formation of memories. 4. The occipital lobe is located at the back portion of the brain and is associated with interpreting visual stimuli and information. The primary visual cortex, which receives and interprets information from the retinas of the eyes, is located in the occipital lobe. The human brain has more than 10 billion nerve cells and over 50 billion other cells and now weighs on an average of 3 1/8 pounds, where it used to weigh less than 3 pounds. The Major Blood Vessels of the Brain As other organs of the human body, brain is also dependent on the supply of oxygen and nutrients brought by the blood through a dense network of blood vessels. The brain, face and scalp are supplied by blood via two major sets of blood vessels which are the right and left common carotid arteries and the right and left vertebral /vertebrobasilar arteries, (see the image below).

The common carotid arteries are then divided into two divisions, the external and internal carotid arteries. The table below shows what these major arteries supply which will then help us to identify what organ or area of the brain is affected due to insufficient supply of oxygen and nutrients.
Common Carotid Arteries External Carotid Internal Carotid Arteries Arteries > Face > Three-fifths of cerebrum > Scalp (except for parts of the Vertebrobasilar Arteries

temporal and occipital lobes)

> Posterior two-fifths of the cerebrum > Part of the cerebellum > Brain stem

The other important arteries which supply blood to brain are the arteries of the Circle of Willis. The Circle of Willis comprises the following arteries, (see the images below): 1. 2. 3. 4. 5. Anterior cerebral artery (L & R) Anterior communicating artery Internal carotid artery (L & R) Posterior cerebral artery (L & R) Posterior communicating artery (L & R)

PROBLEM PRIORITIZATION
Nursing Diagnosis
Ineffective tissue perfusion related to interruption of blood flow secondary to CVD/CVA as manifested by: Subjective: mejo mahirap igalaw ang kanang kamay at paa ko as verbalized by the client Objective: -Dizziness -Right sided weakness -Jugular vein distention -Facial asymmetry -Speech slurring -Dyspnea -Headache Measurement: - BP:200/110 -PR: 110bpm Increased cardiac output related to elevated blood pressure secondary to hypertension as manifested by: Subjective: - The client verbalized hindi ako nag-eexercise. Nanuuod lang ako ng t.v, higa tapos paikot-ikot sa bahay. Lakad lang siguro ang pinaka exercise ko at paglilinis na din paminsan minsan. Objective: - Dizziness - Dyspnea - Headache Measurement: - BP:200/110 - Height: 53 -Weight: 170lbs -BMI:30.1(obese) -IBW:52kg

Rank
High Priority 1

Justification
This is the most prioritized problem among the four identified problems because it is an actual problem. This is a high priority since it is a life threatening which needs immediate attention. The client is suffering from hypertensive cardio vascular disease (HCVD) which hinders the client in performing some task and the reason why the client cant move easily. Resolution of the identified problem will further improve clients health situation which can also lead to resolution of other identified problems thus further improve clients health during her stay in the hospital.

High Priority 2

This is an actual problem. This is a high priority since it is a health threatening. According to the client her father died from heart attack and her grandfather has a history of hypertension which puts our client at a high risk to have hypertension. The client also recognizes this as a problem and she wants to do something about it.

Imbalanced nutrition more that body requirements related to excessive intake in relationship to metabolic needs Subjective: - The client verbalized hindi ako nag-eexercise. Nanuuod lang ako ng t.v, higa tapos paikot-ikot sa bahay. Lakad lang siguro ang pinaka exercise ko at paglilinis na din paminsan minsan. Objective: - Refer to Activities of daily living and Physical Assessment. Measurement: - Height: 53 -Weight: 170lbs -BMI:30.1(obese) -IBW:52kg Sedentary lifestyle related to lack of interest and motivation secondary to low physical activity. Subjective: - The client verbalized hindi ako nag-eexercise. Nanuuod lang ako ng t.v, higa tapos paikot-ikot sa bahay. Lakad lang siguro ang pinaka exercise ko at paglilinis na din paminsan minsan. Objective: - Height: 53 -Weight: 170lbs -BMI:30.1(obese) -IBW:52kg

High Priority 3

This is an actual problem. This is a high priority since it is a health deficit, resolution to this problem will promote the clients health status. Resources from health care provider and client is equally available. The client recognizes this as a problem and she wants to do something about it. Resolution of the identified problem will further improve clients health situation which can also lead to resolution of other identified problems.

Medium Priority 4

This is an actual problem. This is a medium priority since it is a health deficit, resolution to this problem will help improve the clients health status. Resources from health care provider and client is equally available such as time money and man power. The client did not recognize this as a problem.

DISCHARGE PLAN
M (Medicine) Drugs such as alpha- and beta-blockers decrease nerve impulses to blood vessels, and decrease the heart rate, slowing blood flow through the arteries, resulting in a decreased blood pressure. Diuretics may also be used to manage hypertension. They work by flushing excess water and sodium from the body, causing a decrease in blood pressure.

E (Exercise)

Regular aerobic exercise Regular dynamic isotonic (aerobic) exercise, such as walking, running, swimming, or cycling, has been shown to decrease BP and improve cardiovascular well-being.27 It also has additional favorable cardiovascular effects, including improved endothelial function, peripheral vasodilatation, reduced resting heart rate, improved heart rate variability, and reduced plasma levels of catecholamines. Regular aerobic exercise sessions of at least 30 minutes for most days of the week can produce an average reduction in BP of 4-9 mm Hg. Isometric and strenuous exercise should be avoided.

T (Treatment)

Medical treatment for the patient with angina includes risk factor modification, consumption of a diet low in saturated fats and cholesterol, and administration of pharmacological agents. Medications commonly used to treat chest pain or heart attacks include drugs that decrease cholesterol levels, alter platelet aggregation, enhance the supply of oxygenated blood to the heart, or decrease the heart's need for oxygenated blood. Additionally, the person experiencing an acute angina attack or a heart attack may also receive supplemental oxygen. Thrombolytic medications may be used to treat a patient experiencing a attack, as they may dissolve the blood clot, thus restoring blood flow to the heart.

 H (Health Teaching)

The lifestyle modifications recommended to control hypertension include diet, exercise, and weight reduction for the overweight individual. Hypertensive individuals limit their consumption of alcohol to one to two drinks per day, and decrease or stop smoking. Smoking causes hardening of the arteries, which may increase blood pressure.

O (Out-patient)

The patient must comply with the follow-up check-up.

D (Diet)

The recommended dietary modifications include increasing consumption of fruits, vegetables, low-fat dairy products, and other foods that are low in saturated fat, total fat, and cholesterol. Furthermore, the individual with hypertension is advised to decrease intake of foods high in fat, red meats, sweets, and sugared beverages. It is advisable for hypertensive individuals to decrease their intake of sodium to less than 1,500 mg/day. Not adding table salt to foods and avoiding obviously salty foods may accomplish this restriction. Doctors suggest that hypertensive individuals limit their consumption of alcohol to one to two drinks per day.

S (Sex)

N/A