UNIVERSITY OF CEBU - BANILAD

Gov. M. Cuenco Ave, Cebu City, 6000 Philippines

College of Nursing

CEREBROVASCULAR DISEASE INFARCT

In Partial Fulfillment of the Requirements for

Medical Surgical Nursing Case
Related Learning Experience

Submitted to:

Marites C. Tarucan, MAN, RN, LPT

Clinical Instructor

Submitted by:

Norlainie B. Pangandaman

Trisha Faye Y. Pasay

Trisha Cameer P. Pude

Quezilyn Mae K. Quezon

Jesse Steven A. Quirante

ii

TABLE OF CONTENTS

I. INTRODUCTION …………………………………………………………1

II. GENERAL DATA …………………………………………………………1

III. HEALTH ASSESSMENT …………………………………………………2

A. HEALTH HISTORY……………………………………………….2

A.1 Current Health Status

A.2 Reason for Seeking Consultation

A.3 Past Health History

A.4 Family Health History

B. PHYSICAL ASSESSMENT ……………………………………….3

B.1 Review of Systems

B.2 Psychosocial Profile

IV. ANATOMY AND PHYSIOLOGY OF THE INVOLVE SYSTEM…….6

V. CONCEPTUAL FRAMEWORK OF THE PHYSIOLOGY OF

CEREBROVASCULAR DISEASE ………………………………………10

VI. CLINICAL MANAGEMENT …………………………………………….11

A. MEDICAL MANAGEMENT ……………………………………..11

A.1 Laboratory and Diagnostic Examinations

A.2 Treatment and Procedures

A.3 Medications

A.4 Diet

B. NURSING MANAGEMENT ………………………………………

B.1 Nursing Care Plan

B.2 Discharge Plan

iii

VII. CONCLUSION ………………………………………………………………..

VIII. RECOMMENDATION ………………………………………………………

IX. IMPLICATION OF THE STUDY

A. NURSING EDUCATION

B. NURSING PRACTICE

C. NURSING RESEARCH

X. APPENDICES ………………………………………………………………...

APPENDIX A – PHYSICAL ASSESSMENT

XI. REFERENCES ……………………………………………………………….

1

I. INTRODUCTION

Patient A.C.C, 50 years old, male, married, a Roman Catholic, works

as a delivery man of sand and gravel, was born on October 26, 1972, in

Cabadiangan, Liloan, Cebu. He came in for admission on April 11, 2023, at

the University of Cebu Medical Center. He underwent laboratory and

diagnostic examinations to confirm the admitting diagnosis of cerebrovascular

disease infarct and was referred for medical management in the hospital. There

was no previous hospitalization and surgical history noted by the patient.

Patient claims to have not received any immunizations/vaccinations

since childhood at the local health center. He only completed the adult

immunization including 2 doses of SARS-CoV-2 vaccine (Pfizer). Patient has

a significant history of chronic alcohol and tobacco use. He claims to have

drunk alcohol for most of his life since his teenage years. He continues to

drink alcohol and smoke cigarettes regularly. Patient appears to have been at

his baseline state of health until a day prior to admission when he developed

weakness of right extremities and lower back pain.

This case study aims to gather significant information that contributes

to giving nursing care to the patient diagnosed with cerebrovascular disease

infarct. This also intends to help the patient achieve the maximum level of

health within his capability.

II. GENERAL DATA

The patient is A.C.C, a 50-year-old, Filipino, male, married, a Roman

Catholic and currently residing in Sanica, Cabadiangan, Liloan, Cebu. He

works as a collector and delivery man of sand and gravel. He was admitted via
2

the emergency department at University of Cebu Medical Center on April 11,

2023, at 5:33 pm. From the emergency room, the patient was then transferred

to the medical surgical floor room MM-8. Upon admission, the patient’s

height is 160 cm and weight is 53.6 kg. The patient was under the care of Dr.

Rhodzanne Valleser Suazo.

III. HEALTH ASSESSMENT

A. HEALTH HISTORY

A.1 Current Health Status

The patient noted weakness of the right extremities. The patient

has elevated blood pressure that persists despite given medications.

The patient had a series of vomiting episodes and complained of

dizziness and feeling of fatigability.

A.2 Reason for Seeking Consultation

A day prior to admission, the patient noted a sudden onset of

weakness of the right extremities. No nausea, no vomiting, and the

patient tolerated his condition. Morning prior to admission, the patient

sought consultation due to persistence of symptoms and blood pressure

taken was noted to be elevated.

A.3 Past Health History

The patient has no past medical history of hypertension,

diabetes, and bronchial asthma. There was no indicated history of

occurrence of the illness in childhood. Also, there was no evidence of

previous health conditions relating to present health illness from the

patient’s chart.
3

A.4 Family Health History

The patient verbalized that he does not recall any health history

of hypertension, diabetes, bronchial asthma, tuberculosis, coronary

artery disease (CAD), kidney disease, and cancer in their family. The

genogram presented indicates no occurrence of the illness on both

paternal and maternal side.

B. PHYSICAL ASSESSMENT

B.1 Review of Systems

Ears - Patient is hard of hearing, left greater than right. Bony

protrusion noted. No earaches or infections recently. No discharge. No

tinnitus or vertigo.

Nose & Sinuses - No nosebleeds and masses noted, no sinus pain, no

nasal discharge or drainage.

Mouth - Patient has dark gums with no presence of mouth sore and no

signs of lesions.

Throat & Neck - Positive hoarseness of voice and sore throat in the

early mornings frequently. No presence of lumps and goiter noted,

lymph nodes nonpalpable, and throat is intact.

Breast & Axilla - No lumps and tenderness noted. No abnormalities

noted in the breasts bilaterally and no masses or nipple discharge is

seen.

Respiratory - Unlabored breathing with normal breath sounds and

equal chest expansion. Patient is not in respiratory distress.

4

Cardiovascular / Peripheral Vasculature - Lungs are clear to

auscultation and percussion bilaterally. Blood pressure is elevated to

140/100 mmHg.

Gastrointestinal - No nausea, vomiting, or diarrhea. No constipation.

No dysphagia or odynophagia. No abdominal pain. Positive for

heartburn intermittently. No changes on bowel habits or stool. No

history of jaundice.

Urinary - Positive history of nocturia approximately 3 times per night.

Positive polyuria, hesitancy and post void dribbling and intermittency.

Positive weak stream. No dysuria. No UTIs. No incontinence.

Musculoskeletal - No myalgias. Positive arthralgias in his knees

bilaterally worse on the right. Worse with ambulation and prolonged

standing. No history of gout. No significant joint stiffness. No red

swollen joints.

Neurological - Patient complains of weakness, numbness, and

incoordination. Reflexes are slightly delayed and unilateral in both

extremities.

Psychological - No recent depressive symptoms. No anxiety. No

changes in mood. No history of mental illness.

Male Reproductive System - No history hernias, no testicular pain.

Negative scrotal swelling as mentioned and no history of epididymitis

or prostatitis. Uncircumcised with no history of complications.

Nutrition - Low fat, low cholesterol, full diet appropriate for patient’s

condition.
5

Endocrine - No heat or cold intolerance, excessive sweating. No

history of thyroid problems or goiter. No polydipsia or polyphagia.

Lymph nodes - No palpable nodes in the cervical, supraclavicular,

axillary, or inguinal areas.

Hematological - No history of anemia, frequent infections, or

excessive bleeding. No easy bruising.

B.2 Psychosocial Profile

The patient works as a collector and a delivery man of sand and

gravel. He walks for 30 minutes from home to get to work. He lives

near the creek and describes his home as rural, safe, clean, not

crowded, and free of noise. He claims he visited his relatives in

Dumaguete last February 12, 2023.

The patient smokes and consumes alcohol on a regular basis.

He consumes ten sticks of lomboy (a hand-rolled cigarette made from

dried duhat leaves) and two bottles of beer daily. He admits that he still

engages in sexual activity despite his age. As a pastime, he plays a

coconut volley game. He also adds that even if it were not time for

work, his everyday activity of living would still be collecting sand.

6

IV. ANATOMY AND PHYSIOLOGY OF THE INVOLVE SYSTEM

Figure 1. Structure of the Human Brain

The brain is an organ composed of nervous tissue that commands task-

evoked responses, movement, senses, emotions, language, communication,

thinking, and memory. The three main parts of the human brain are the

cerebrum, cerebellum, and brainstem.

The cerebrum is divided into the right and left hemispheres and is the

largest part of the brain. It contains folds and convolutions on its surface, with

the ridges found between the convolutions called gyri and the valleys between

the gyri and sulci (plural of sulcus). If the sulci are deep, they are called

fissures. Both cerebral hemispheres have an outer layer of gray matter called

the cerebral cortex and inner subcortical white matter.

Located in the posterior cranial fossa, above the foramen magnum, the

cerebellum's primary function is to modulate motor coordination, posture, and

balance. It comprises the cerebellar cortex and deep cerebellar nuclei, with the

cerebellar cortex being made up of three layers; the molecular, Purkinje, and
7

granular layers. The cerebellum connects to the brainstem via cerebellar

peduncles.

The brainstem contains the midbrain, pons, and medulla. It is located

anterior to the cerebellum, between the base of the cerebrum and the spinal

cord.

Each side of the brain has different lobes (sections). While all the lobes

work together to ensure normal functioning, each lobe plays an important role

in some specific brain and body functions:

 Frontal lobes: This is the largest lobe, and it controls voluntary

movement, speech, and intellect. The parts of the frontal lobes that

control movement are called the primary motor cortex or precentral

gyrus. The parts of the brain that play an important role in memory,

intelligence and personality include the prefrontal cortex as well as

many other regions of the brain.

 Occipital lobes: These lobes in the back of the brain allow people to

notice and interpret visual information. Occipital lobes control how

people process shapes, colors, and movement.

 Parietal lobes: The parietal lobes are near the center of the brain. They

receive and interpret signals from other parts of the brain. This part of

the brain integrates many sensory inputs so that people can understand

the environment and the state of the body. This part of the brain helps

give meaning to what's going on in the environment.

 Temporal lobes: These parts of the brain are near the ears on each

side of the brain. The temporal lobes are important in being able to
8

recall words or places. It also helps recognize people, understand

language, and interpret other people’s emotions.

 Limbic lobes: The limbic lobe sits deep in the middle portions of the

brain. The limbic lobe is a part of the temporal, parietal and frontal

lobes. Important parts of the limbic system include the amygdala (best

known for regulating your “fight or flight” response) and the

hippocampus (where short-term memories are stored).

 Insular lobes: The insular lobes sit deep in the temporal, parietal and

frontal lobes. The insular lobe is involved in the processing of many

sensory inputs including sensory and motor inputs, autonomic inputs,

pain perception, perceiving what is heard and overall body perception

(the perception of the environment).

9

PATHOPHYSIOLOGY

Figure 2. Pathophysiology of Cerebrovascular Disease

10

V. CONCEPTUAL FRAMEWORK OF THE PHYSIOLOGY OF

CEREBROVASCULAR DISEASE

Figure 3. Conceptual Framework

This conceptual framework appears to provide a reasonable approach

for the development of implementation strategies for physiotherapist practice

in stroke rehabilitation. Factors included in the Physiology of Cerebrovascular

Disease are the body functions: Geriatric Depression Scale (CDS), Fugi Meyer

Scale (FMS), Ashworth Modified Scale (AMS), Hand Grip Strength (HGS),

Mini-Mental State (MMS); Activities: Berg Balance Scale (BBS), Manual

Ability (ABILHAND), Time “Up and Go” Test (TUG), Natural Gait Speed

(NGS), Maximal Gait Speed (MGS); these activities are divided into two

parts: Environmental and Personal Factors. These factors test individuals with
11

disabilities, as changes in emotional function, muscle strength, and mobility,

risks of falling during functional activities, negative self-perception of quality

of life, and perception of the environment factors will be perceived as

obstacles. Furthermore, it might be the first that reflects the real value of the

CVA framework and tests it empirically.

VI. CLINICAL MANAGEMENT

A. MEDICAL MANAGEMENT

A.1 Laboratory and Diagnostic Examinations

Cerebral angiography (also called vertebral angiogram,

carotid angiogram): Arteries are not normally seen in an X-ray, so

contrast dye is utilized. The patient is given a local anesthetic, the

artery is punctured, usually in the leg, and a needle is inserted into the

artery. A catheter (a long, narrow, flexible tube) is inserted through the

needle and into the artery. It is then threaded through the main vessels

of the abdomen and chest until it is properly placed in the arteries of

the neck. This procedure is monitored by a fluoroscope (a special X-

ray that projects the images on a TV monitor). The contrast dye is then

injected into the neck area through the catheter and X-ray pictures are

taken.

Carotid duplex (also called carotid ultrasound): In this

procedure, ultrasound is used to help detect plaque, blood clots or other

problems with blood flow in the carotid arteries. A water-soluble gel is

placed on the skin where the transducer (a handheld device that directs

the high-frequency sound waves to the arteries being tested) is to be

12

placed. The gel helps transmit the sound to the skin surface. The

ultrasound is turned on and images of the carotid arteries and pulse

waveforms are obtained. There are no known risks, and this test is

noninvasive and painless.

Computed tomography (CT or CAT scan): A diagnostic

image created after a computer reads x-rays. In some cases, a

medication will be injected through a vein to help highlight brain

structures. Bone, blood, and brain tissue have very different densities

and can easily be distinguished on a CT scan. A CT scan is a useful

diagnostic test for hemorrhagic strokes because blood can easily be

seen. However, damage from an ischemic stroke may not be revealed

on a CT scan for several hours or days and the individual arteries in the

brain cannot be seen. CTA (CT angiography) allows clinicians to see

blood vessels of the head and neck and is increasingly being used

instead of an invasive angiogram.

Doppler ultrasound: A water-soluble gel is placed on the

transducer (a handheld device that directs the high-frequency sound

waves to the artery or vein being tested) and the skin over the veins of

the extremity being tested. There is a "swishing" sound on the Doppler

if the venous system is normal. Both the superficial and deep venous

systems are evaluated. There are no known risks, and this test is

noninvasive and painless.

Electroencephalogram (EEG): A diagnostic test using small

metal discs (electrodes) placed on a person's scalp to pick up electrical

impulses. These electrical signals are printed out as brain waves.

13

Lumbar puncture (spinal tap): An invasive diagnostic test that

uses a needle to remove a sample of cerebrospinal fluid from the space

surrounding the spinal cord. This test can be helpful in detecting

bleeding caused by a cerebral hemorrhage.

Magnetic Resonance Imaging (MRI): A diagnostic test that

produces three-dimensional images of body structures using magnetic

fields and computer technology. It can clearly show various types of

nerve tissue and clear pictures of the brainstem and posterior brain. An

MRI of the brain can help determine whether there are signs of prior

mini strokes. This test is noninvasive, although some patients may

experience claustrophobia in the imager.

Magnetic Resonance Angiogram (MRA): This is a

noninvasive study which is conducted in a Magnetic Resonance

Imager (MRI). The magnetic images are assembled by a computer to

provide an image of the arteries in the head and neck. The MRA shows

the actual blood vessels in the neck and brain and can help detect

blockage and aneurysms.

A.2 Treatment and Procedures

To treat an ischemic stroke, blood flow must be restored

quickly to the brain. This may be done with:

Emergency IV medication. Therapy with drugs that can break up a

clot has to be given within 4.5 hours from when symptoms first started

if given intravenously. The sooner these drugs are given, the better.

Quick treatment not only improves the chances of survival but also
14

may reduce complications.

An IV injection of recombinant tissue plasminogen activator (TPA) —

also called alteplase (Activase) or tenecteplase (TNKase) — is the gold

standard treatment for ischemic stroke. This drug restores blood flow

by dissolving the blood clot causing the stroke. By quickly removing

the cause of the stroke, it may help people recover more fully from a

stroke. Risks such as potential bleeding in the brain must be considered

to determine whether TPA is appropriate for the patient.

Emergency endovascular procedures. Endovascular therapy has

been shown to significantly improve outcomes and reduce long-term

disability after ischemic stroke. These procedures must be performed

as soon as possible:

○ Medications delivered directly to the brain. Doctors insert a long,

thin tube (catheter) through an artery in the groin and thread it to

the brain to deliver TPA directly where the stroke is happening.

The time window for this treatment is somewhat longer than for

injected TPA but is still limited.

○ Removing the clot with a stent retriever. Doctors can use a device

attached to a catheter to directly remove the clot from the blocked

blood vessel in the brain. This procedure is particularly beneficial

for people with large clots that can't be completely dissolved with

TPA. This procedure is often performed in combination with

injected TPA.

The time window when these procedures can be considered has

been expanding due to newer imaging technology. Doctors may order

15

perfusion imaging tests (done with CT or MRI) to help determine how

likely it is that someone can benefit from endovascular therapy.

Other procedures

To decrease the risk of having another stroke or transient

ischemic attack, a procedure to open an artery that's narrowed by

plaque may be recommended. Options vary depending on the situation,

but include:

Carotid endarterectomy. This surgery removes the plaque

blocking a carotid artery and may reduce the risk of ischemic stroke. A

carotid endarterectomy also involves risks, especially for people with

heart disease or other medical conditions.

Angioplasty and stents. In an angioplasty, a catheter is

threaded to the carotid arteries through an artery in the groin. A

balloon is then inflated to expand the narrowed artery. Then a stent can

be inserted to support the opened artery.

A.3 Medications

Medications that can help reduce the risk of serious

complications from cerebrovascular disease include anticoagulants,

blood pressure and cholesterol-lowering medications. Anticoagulants,

in this, the doctor may prescribe a blood thinner such as aspirin to

reduce the risk of blood clots. Blood pressure medications include

diuretics, ACE inhibitors, beta blockers and other medications that are

used to lower blood pressure reduces the risk of hemorrhaging.

16

Cholesterol- lowering medications such as statins can help prevent

further buildup of arterial plaque that causes stenosis and clotting.

A.4 Diet

While getting the right nutrition is essential for stroke recovery,

many stroke patients have trouble eating. This could be primarily a

result of loss of appetite, problems using the arms and hands, memory

issues related to when to eat, and challenges eating and swallowing.

Following these dietary and nutritional advice may help your loved one

heal if they just suffered a stroke. These are ways to ensure that your

loved one takes food, offering recipe ideas for soft meals that are

simple to chew and swallow, dietary advice for stroke victims with

diabetes, and suggestions for supplements to aid in stroke recovery.

Fruit and vegetables contain antioxidants, which can help

reduce damage to blood vessels. They also contain potassium which

can help control blood pressure.

The fiber in fruit vegetables can lower cholesterol. Folate –

which is found in green leafy vegetables – may reduce the risk of

stroke. Whole Grains and cereals also contain fiber and folate.

Dairy foods are another source of potassium, along with

calcium, which can also help control blood pressure. Alternatives to

dairy include calcium-enriched soy or rice milks. Other sources of

calcium include fish with bones, almonds, and tofu.

Things to limit after stroke are:

17

A. Salt. Too much salt can raise your blood pressure. Read

labels and choose lower salt options. Don’t add salt when

cooking or at the table. Use herbs and spices to increase flavor

instead. If you reduce your intake gradually, your taste buds

will adjust in a few weeks.

B. Sugar. Too much sugar can damage blood vessels. Read

labels and choose lower sugar options. Even foods you may not

think of as sugary can have added sugar.

C. Saturated fats. These cause high cholesterol. Eat mostly

polyunsaturated and monounsaturated oils and spread. Try nut

butter or avocado.

D. Alcohol. Drinking alcohol increases your risk of having

another stroke. Your doctor can give you advice on alcohol.

1

B. NURSING MANAGEMENT

B.1 Nursing Care Plan

1

B.2 Discharge Plan

University of Cebu – Banilad

College of Nursing
Cebu City

DISCHARGE PLAN

Patient’s Name : A.C.C. Hospital No. : __352080_______________

Age : 50 YEARS OLD Room No. :___MM8________________
Impression/Diagnosis: TO CONSIDER CEREBROVASCULAR INFARCT
Physician : RHODZANNE VALLESER SUAZO, MD__

PATIENT’S OUTCOME CRITERIA NURSING ORDER

Expected behavior of the patient when Nurse’s action to help patient do
discharged. expected behavior when discharged.

ASSESSING:

1.) The patient will be able to assess the - Teach the patient on how to take
vital signs and closely monitor the blood blood pressure, the normal range for his
pressure. condition, and the importance of
monitoring blood pressure.
(Williams [Link].,2019)

2.) The patient will be able to assess - Encourage the patient to restrict
nutritional food intake. sodium and fat intake to prevent
worsening the condition. (West,2016)

3.) The patient will develop and adhere to - Encourage the patient to exercise like
an appropriate exercise regimen. cardio and strength training to help
lower the blood pressure. (WHO, 2022)

4.) Observe for the presence of any - Discuss with the significant other the
individual who can help and assist the importance of someone monitoring the
patient with his activities of daily living. patient.
(Doenges [Link], 2016)

5.) The patient will be able to - Encourage participation in self-care;

demonstrate improvement in spontaneous occupational, diversional or
movements. recreational activities.
(Doenges [Link], 2016)

PLANNING:
- Advise patient to lessen physical
1.) Plan for continuity of care. stress and tension that affect blood
pressure and the course of
hypertension. (Comerford [Link], 2021)
2

- Instruct the patient to take prescribed

2.) Adhere to the medications that are medications. Also, discuss with the
prescribed by the physician. family the importance of strict
compliance in maintaining and
completing the medications at the right
time, route, and dosage.
(Case-10, 2019)

- Instruct the patient to take the

3.) Make a drug administration plan. required intake drug. (Comerford [Link],
2021)

4.) Plan for any recreational activities for - Encourage patient to have an
the patient as tolerated. appropriate exercise or activities
regimen to help manage hypertension.
(Arroyo [Link], 2021)

5.) Plan for a return visit. - Encourage the patient to return for a
follow-up visit to ensure that there are
no complications and that his doctor
will monitor him. (Wimble , 2012)
IMPLEMENTING

Considerations: METHODS

M – Medication should be taken exactly - Explain to the patient and significant

as prescribed by the physician. other the importance of taking
medications at the right time and dose.
Monitor the blood pressure first before
taking medications. (Arroyo [Link],
2021)
E – Provide a quiet, clean and safe
environment conclusive for the patient. - Encourage the patient and significant
other to do environmental sanitation
routinely and maintain proper hygiene
to prevent any infections. Encourage
them also to maintain a calm and
peaceful environment to promote rest
periods.
(Stone [Link], 2008)
T – As directed, adhere to the treatment
and medication recommendations. - Talk about the condition’s medical
management with the patient and his
significant other. Encourage the patient
to only engage in safe exercise, such as
walking. (Say & Thompson, 2003)
H – Health teaching on how to do proper
hygiene and proper monitoring of the
- Explain to the patient and his
3

patient’s vital signs. significant other how to maintain a

good hygiene and how to regularly
check their vital signs, particularly
blood pressure. Indicate adequate rest
at home and promote deep breathing
O – Follow-up check-up should be techniques. (Goldenhart & Nagy, 2021)
scheduled.
- Inform the patient and significant
other the importance of follow-up
check-up. Advise patient to seek
immediate help if he experiences
D – A proper diet must be maintained by unusual feeling. (Arroyo [Link], 2021)
the patient.
- Explain to the patient the proper diet
that is suitable for his condition. This
include low sodium diet and low fat
S – Spiritual beliefs of the patient. diet. (Grillo [Link]., 2019)

- Encourage the patient and significant

other to pray for the patient’s fast
recovery in accordance with their
religious beliefs. (Puchalski, 2001)

EVALUATING:

1.) The patient will be able to verbalize

understanding about the discharge
instructions. - Give the patient the opportunity to ask
questions about the health teachings
and instructions provided.
2.) Patient will be able to attend regular (Paterick [Link], 2007)
follow-up appointments.
- Encourage the patient to return to the
physician for a follow-up examination
3.) Patient will be aware of his condition so that his condition can be re-
and will take necessary measures to examined. (Arroyo [Link], 2021)
improve it.
- Encourage the patient to verbalize
understanding regarding his condition
(Arroyo [Link], 2021)
4

VII. CONCLUSION

The loss of mobility with stroke increases with delayed treatment. The

chances of maximum recovery depend on how quickly the patient gets to a

hospital’s stroke or emergency department. The ‘golden hour’ or the first hour

from the time stroke symptoms appear is critical for a stroke patient. Doctors

can quickly treat the patient with an effective clot-busting drug (in case of

ischemic stroke). This decreases the chances of brain damage and stroke-

related complications. Recovery from a stroke is a lengthy process. It can take

months to regain strength and control over the body.

A stroke is associated with many risk factors, some of which are non-

modifiable like age and race. Modifiable risk factors related to lifestyle like

hypertension (high blood pressure), high cholesterol, diabetes, smoking, and

drinking alcohol also contribute to strokes and should be controlled through

lifestyle modifications made sooner rather than later.

Overall, the patient had a difficult start following his stroke. He was

not placed in an appropriate intensive rehab facility possibly due to his low

tolerance of activity and co-morbidities. Though there could have been both

changes and additions to treatment interventions and evaluation procedures,

the patient's case was managed well. Through medical and nursing

management, he reached a functional level appropriate for improved wellness.

With intensive therapy, the patient will be able to ensure the greatest potential

to recover and return to his home.

5

VIII. RECOMMENDATION

After an in-depth analysis to the patient’s condition, BSN Level 3-A

students would like to recommend the following:

1. Patient should modify lifestyle including cessation of smoking, observe a

healthy diet appropriate for his condition, and perform physical activity

independently or within the limits of the disease to reduce the risk of another

stroke.

2. Due to the diagnosis, the patient and their significant other/s should keep

emergency numbers within reach.

3. The patient and their significant other/s should reach their physician if

unusual signs and symptoms occur.

4. Patient should reside in an environment that is safe and conducive for

healing and rest. Safety measures for risk of falls must be implemented.

IX. IMPLICATION OF THE STUDY

A. NURSING EDUCATION

Despite the fact that nurses play a critical role in lowering

mortality and disability among stroke victims, some may not have the

educational background necessary to handle the complicated issues

associated with this condition. To maintain patient safety and the

ability to maximize patient recovery from the potentially fatal and

long-lasting effects of stroke, nurses must continuously assess patients

(monitoring and managing performance indicators, stroke signs, and

symptoms) (Lindsay et al., 2005). The ability to evaluate novel

therapies and modes of care delivery with current practice is made

6

possible through clinical research and education, which helps to

increase the effectiveness and caliber of patient care (McCormack &

Reay, 2013). In order to make decisions regarding health interventions

and priorities stronger, assessment is a crucial nursing skill. A focused

education program on stroke could increase nurses' knowledge, lower

admissions, mortality, and medical expenses. The cornerstone for early

diagnosis, adequate prognostic evaluation, and best care to achieve

positive patient outcomes is neurological examination of the acute

stroke survivor. All stroke workers can share a vision of excellence

through multidisciplinary work and a commitment to the development

of stroke services that offer the best in clinical care to patients and their

families by promoting stroke-specific education within a wide range of

disciplines associated with stroke services.

B. NURSING PRACTICE

In patients with cerebrovascular disease infarct, anticipating,

preventing, early detection, and management of potential poststroke

medical complications are essential because they may negatively or

favorably affect clinical outcomes. Nurses are essential in identifying

patients at risk of clinical deterioration through ongoing observation

and assessments, including taking timely and appropriate action in

response to changes in patient health status. Nurses are expected to

perform thorough and deliberate physical assessments, which include

monitoring the body's temperature, blood pressure (BP), breathing

effort (rate, patterns, and chest expansion), oxygen saturation, and

mental status/level of consciousness. To reduce negative outcomes for

7

patients following a stroke, evidence-based nursing treatment and

continued assessment are required. One of the most vulnerable and

important times in the continuum of care for stroke patients and their

families is the transfer from the acute setting to the community

following discharge. As a result, effective organization, and

communication between the members of the healthcare team are

crucial.

C. NURSING RESEARCH

During the creation of this scientific assessment, a number of

significant gaps in nursing research about acute stroke care have come

to light. One is that consensus is required on what qualifies as

specialized stroke nursing care because it is not explicitly defined in

evidence-based practice or the literature. Another gap is the absence of

well-planned nursing studies describing the precise contribution that

nurses make to patient and family outcomes after stroke and if

certification in a subspecialty area matters. Although some researchers

contend that specialty certification can improve certain patient

outcomes, such as lower patient fall rates and fewer specific hospital-

acquired infections, the impact and advantages of stroke certification

are yet unstudied. One small study found that registered nurses with

stroke certification provided patients with strokes with more prompt

care. Specialized nurses can influence outcomes, reduce length of stay,

lower expenditures, and reduce event recurrence by using evidence-

based best practices (“Organized Inpatient (Stroke Unit) Care for

Stroke,” 2013). A pillar of nursing practice, knowledge, and evidence-

8

based care for stroke patients and their families continues to be nursing

research.

X. APPENDICES

APPENDIX A – PHYSICAL ASSESSMENT

UNIVERSITY
UNIVERSITY OF CEBU OF CEBU – BANILAD
UNIVERSITY
- BANILAD OF CEBU - BANILAD
Gov. M. Cuenco Ave, Cebu City, 6000 P h ilip p ine s M. Cuenco Ave, Cebu City, 6000 Philippines
COLLEGE OF NURSING
College of Nursing
Gov.
College of Nursing
CEBU CITY Telephone No: (032) 231- 8631
Telephone No: (032) 231- 8 6 31

PHYSICAL ASSESSMENT FINDINGS

Date of Interview: April 14, 2023

Information given by: Avaquito C. Cavan
Interviewer:Trisha Cameer P. Pude

I. PATIENT’S PROFILE

Patient’s Name Avaquito C. Cavan Age 50 years old Sex Male CS

Married
Nationality Filipino Religion Roman Catholic Occupation
Contractor
Date of Birth October 26, 1972 Place of Birth Liloan,
Cebu
Hospital University of Cebu Medical Center Room No. MM8
Date of Admission April 11, 2023 Physician Rhodzanne Valleser Suazo,
MD
Medical/Surgical Diagnosis To consider Cerebrovascular Disease Infarct

II. VITAL SIGNS

Temperature 36.4 °C / / oral /X/ axilla / /

rectal
Pulse 67 bpm /X/ regular / / irregular
Blood pressure 140 / 100mg /X/ lying / / sitting / /
standing
Respiration 22 cpm /X/ regular / / irregular
Height 160 cm. BMI 20.9 kg/m2
Weight 53.6 kg. Waist to hip ratio 0.81

III. GENERAL OBSERVATION

9

Received patient lying on bed, awake, conscious, responsive, afebrile with weakness
and fatigability noted. Patient has ongoing IVF #5 PNSS 1L @ 90 cc/hr infusing well
at right hand.

IV. CHIEF COMPLAINTS/ REASON FOR HOSPITALIZATION

Right sided weakness, headache, elevated blood pressure, cough, lower back pain.

V. HISTORY OF PRESENT ILLNESS (Focus Assessment)

Character Sudden onset of weakness accompanied with headache.

Onset Sudden onset last 04-10-23when the patient was carrying sack of
sand
Location Night extremities
Description Weakness causes lack of energy, tiredness, stabbing headache
Severity Headache with a pain score of 8/10
Pattern Weakness of R extremities; headache intervene even when at rest.
Aggravating When the patient is exposed to sunlight
Alleviating Sleep

VI. PAST HEALTH HISTORY

A. MEDICAL/SURGICAL HISTORY

X Unremarkable _______ Remarkable

If remarkable:
________________________________________________________________________

Date Diagnosis Intervention

NA NA NA

Hospitalization (including operation)

Date Diagnosis Intervention
NA NA NA

B. PAST & CURRENT MEDICATION

Drug & Dose Frequency Last Dose

10

Citicoline PO B.I.D April 14, 2023 8am

Clonidine PO 94n April 14, 2023 6 pm
OTC___________________ _______________________
_________________

C. CHILDHOOD ILLNESS Date

No childhood illnesses _________________

D. PREVIOUS HOSPITALIZATION (Illness, Accident, Injury, Surgery, Blood

Transfusion)

No previous hospitalization

E. IMMUNIZATION - Patient has not been given any vaccinations.

BCG ______________ MMR _______________

OPV ______________ DPT _______________
HEP. A ______________ HEP. B _______________
MENINGO ______________ Hib _______________

VII. FAMILY HEALTH HISTORY

YES NO WHO
Heart Disease ________ x _______________
Hypertension ________ x _______________
Stroke ________ x _______________
Tuberculosis ________ x _______________
Diabetes Mellitus ________ x _______________
Cancer ________ x _ _______________
Kidney Disease ________ x ________________
Blood Disorder ________ x ________________
Asthma _________ x _ ________________

VIII. SOCIAL HISTORY

NO YES 2 bottles/day
Alcohol Use _______ x (Type Beer Amt. / Day_
_)
Drug Use x _______ (Type _____ Amt. / Day_
_)
Tobacco Use _______ x _ (No. of Packs/Day 10
_)
Sexual Practice _______ __ x ___
11

Work Environment 80 minutes walk from home, near the creek

Travel History Patient went to Dumaguete last February 12, 2023.
Home Environment safe, clean, not crowded, no voice disturbances,
rural
Domestic Violence no signs of domestic violence
Hobbies & Leisure Activities coconut valley game
Economic Status middle class
Education college
ADL collecting of sand – work related

IX. HEALTH MAINTENANCE ACTIVITIES

Sleep more than 5 hours of sleep, no insomnia

experienced
Elimination Pattern three times a day
Diet patient eats anything with no moderation
Exercise walking
Rest taking a nap
Stress Management drink alcohol, sleep
Health Check-ups patient refuses to attend a health check-up
Use of Safety Measures NA

X. REVIEW OF SYSTEMS

Ears no discharge, lesions, discoloration, body protrusion noted,

symmetrical
Nose & Sinuses no swelling, discharge, and masses noted, normal septum and in
midline
Mouth no signs of lesions, dark gums, no presence of mouth sore
Throat & Neck no lumps, no goiter noted, lymph nodes not palpable, throat intact
Breast & Axilla no lymph nodes and tenderness noted
Respiratory not in respiratory distress
Cardiovascular / Peripheral Vasculature blood pressure is elevated, 140/100 mmHg
Gastrointestinal no abdominal pain and no problem with digestion
Urinary normal urinary output
Musculoskeletal decreased muscle control or strength
Neurological coherent and responsive
Psychological no psychological problem
Female Reproductive ___________________________________________
Male Reproductive no problem in male reproductive system
Nutrition eats anything with no moderation
Endocrine no endocrine abnormalities
Lymph Nodes non tender
Hematological no hematologic problem

ADDITIONAL INFORMATION
12

Patient was then referred to University of Cebu Medical Center due to an

elevated blood pressure.

University of Cebu – Banilad

College of Nursing
Cebu City

ADULT PHYSICAL ASSESSMENT FINDINGS

Patient’s Name: Avaquito C. Cavan Age: 50 years old Sex: Male

Civil Status: Married
Date of Birth: October 26, 1972 Place of Birth: Liloan, Cebu

STEPS FINDINGS
SKIN
1. Odor No odor noted
2. Color Even skin color, brown complexion,
no pigmentation noted
3. Lesions No lesions noted
4. Texture Normal, warm, dry
5. Temperature Warm to touch
6. Thickness Fair complexion
7. Mobility Mobile
8. Turgor When skin is pinched, it goes back
immediately to its previous state
9. Edema No edema noted
HEAD AND FACE
1. Inspect and palpate the head for Head is firm, proportional to size,
size, shape, and configuration. midline, no palpable mass noted
2. Note consistency, distribution, and Hair is black, thin, and fairly
color of hair. distributed
3. Observe face of symmetry, facial Face is symmetrical, skin is smooth,
features, expressions, and skin no moles or freckles seen
condition.
4. Check function of CN VII: Have CN VII is intact as patient can smile,
the client smile, from, show teeth, frown, show teeth, blow out cheeks,
blow out cheeks, raise eyebrows, raise eyebrows, and tightly close eyes
and tightly close eyes.
5. Evaluate function of CN V: using
the sharp and dull sides of a paper CN V is intact as patient can feel
clip, rest sensation of forehead, sensation of touch.
cheeks and chin.
6. Palpate the temporal arteries for No tenderness noted
elasticity and tenderness.
7. As the client opens and close her
mouth, palpate the No swelling or tenderness noted
13

temporomandibular joint for

tenderness, swelling, and
crepitation.

EYES
1. Determine Function:
Test vision using Snellen Chart 20/20 vision
Test visual Fields Visual field for each eye is intact in
all directions
Assess corneal light reflex Cornea are centered on both pupils
Perform cover and position tests Not performed due to unavailability of
instrument
2. Inspection external Eye:
Position and alignment of the Eyeball is aligned at center
eyeball in the eye socket
Bulbar conjunctiva No unusual discharge noted
Lacrimal apparatus No swelling noted, puncta patent
Cornea, Lens, Iris, and Pupil Transparent cornea, iris is visible, has
deep black round pupils
3. Test pupillary reaction to light Pupil constrict when looking at near
object, and dilates at far
4. Test accommodation of pupils PERRLA (pupils are equal, round,
reactive to light and accommodation)
5.
Retinal background for color and no lesions noted
lesion
Fovea centralis (sharpest area of Not performed due to unavailability of
vision) and macula instrument
Anterior chamber for clarity Anterior chamber is clear with no
redness noted.
EARS
1. Inspect the auricle, tragus, and No lesions, discolorations, no purulent
lobule for shape, position, lesions discharge, and no bony protrusion
discolorations, and discharge. noted.
2. Palpate the auricle and mastoid No tenderness noted.
process for tenderness.
3. Use the otoscope to inspect:
External auditory canal for color Not performed due to unavailability of
and cerumen (ear wax) instrument – otoscope
Tympanic membrane for color, Not performed due to unavailability of
shape, consistency, and landmarks. instrument – otoscope
4. Test hearing:
Whisper Test Patient has no problem with hearing.
Weber’s Test Not performed due to unavailability of
instrument – tunning fork
Rinnes’ Test Not performed due to unavailability of
instrument – tunning fork
NOSE AND SINUSES
1. Inspect the external nose for color, Appeared symmetrical, straight and
14

shape, and consistency. Palpate the uniform in color. No swelling and

external nose of tenderness tenderness noted.
2. Check patency of airflow through Nostrils are patent.
nostrils (occlude one nostril at a
time and ask client of sniff)
3. Test CN I: ask the client to close Patient wasn’t able to identify the
his eyes and smell for soap, coffee, smell of alcohol.
or vanilla (occlude each nostril).
4. Use an otoscope with a short while Not performed due to unavailability of
tip to inspect internal nose for color instrument – otoscope
and integrity of nasal mucosa,
nasal septum, and inferior and
middle turbinate.
5. Transilluminate maxillary sinuses No signs of fluid or pus present
with a penlight to check for fluid or
pus.
MOUTH AND THROAT
1. Inspect lips for consistency, color Client’s lips are dark due to cigarette
lesions. smoking.
2. Inspect the teeth for number and Teeth is yellowish in color, has
conditions. missing teeth in upper and lower area.
3. Check the gums and buccal Dark gums, no lesions noted
mucosa for color, consistency,
lesions.
4. Inspect the hard (anterior) and soft Anterior and posterior palate are pink
(posterior) palates for color and in color
integrity.
5. Ask the client to say “ahh” and Vulva is positioned in the midline and
observe the rise of the vulva. rises when patient sabs “ahh”.
6. Test CN X: touch the soft palate to Not performed due to unavailability of
assess for gag reflex. instrument – tongue depressor
7. Inspect the tonsils for color, size, Tonsils are pink, no lesions noted and
lesions, and exudates. has a normal size.
8. Inspect the tongue for color, Tongue is centrally positioned, pink in
moisture, size, and texture. color, with white spots and has a
normal size.
9. Inspect the ventral surface of There’s a presence of thin whitish
tongue for frenulum, color, coating
lesions, and Wharton’s ducts.
10. Palpate the tongue for lesions. No lesions palpated
11. Test CN IX and CN X: assess Not performed due to unavailability of
tongue strength by asking client to instrument – tongue depressor
press tongue against tongue blade.
12. Assess CN VII and CN IX: have CN VII and CN IX are intact as
the patient close her eyes. Check patient can identify and taste sugar.
taste by placing salt, sugar, and
lemon on tongue.
NECK
1. Inspect neck for appearance of No lesions, no palpated masses, no
15

lesions, masses, swelling and swelling

symmetry.
2. Test range of motion (ROM). Able to move neck without difficulty
3. Palpate the pre-auricular, occipital, Lymph nodes are not palpable
tonsillar, submandibular, and
submental nodes.
4. Palpate the trachea. Trachea is in the midline, no tracheal
deviation noted.
5. Palpate the thyroid gland for size, No irregularity or palpable masses,
irregularity, or masses. normal in size
6. Auscultate and enlarge thyroid for No enlargement of thyroid being
bruits. auscultated
7. Palpate carotid arteries and Carotid artery can be palpated easily
auscultate for bruits. with normal breathing and no bruits
upon auscultation.
ARMS, HANDS, AND FINGERS
1. Inspect the upper extremities for Brown complexion, smooth, dry, no
overall skin coloration, texture, abnormal masses and lesions noted.
moisture, masses, and lesions.
2. Test function of CN XI – spinal by Can perform shoulder shrug and
shoulder shrug and turning head turning head with slight resistance.
against resistance.
3. Palpitate shoulders and arm for Non-tender, no swelling, warm
tenderness, swelling and
temperature.
4. Assess epitrochlear lymph nodes. No epitrochlear lymph nodes noted.
5. Assess ROM of the elbows/ Can perform all the ROM of elbows
6. Palpate the brachial pulse. Present, steady rhythm
7. Palpate ulnar and radial pulse. Ulnar and radial pulse are easily
palpated
8. Test ROM of the wrist. Patient has IV line in the right hand,
patient can move the left wrist without
discomfort.
9. Inspect palms of hands and palpate Palms of hands are warm to touch,
the temperature. wounds and cuts are noted.
10. Test ROM of the wrist. Patient has IV line in the right hand,
patient can move the left wrist without
discomfort.
11. Use a reflex hammer to test biceps, Not performed due to unavailability of
triceps, and brachioradial reflexes. instrument – reflex hammer

12. Test rapid alternating movements IV line on the right hand, left hand
of hands. able to do alternating movements
without difficutly.
13. Ask the patient to close her eyes; The patient can feel sensation
test sensation.
16

XII. REFERENCES

Books

Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (2021). NANDA International

Nursing Diagnoses: Definitions & Classification, 2021-2023. Thieme.

Hinkle, J. (2021). Brunner & Suddarth’s Textbook of Medical-Surgical

Nursing

(15th ed.). Lippincott Williams & Wilkins. ‌

Tortora, G. J., & Derrickson, B. H. (2018). Principles of Anatomy and

Physiology. John Wiley & Sons.

Wilkins, L. W. &. (2020). Nursing2021 Drug Handbook. Lippincott Williams

& Wilkins.

Journals

Kuriakose, D., & Xiao, Z. (2020). Pathophysiology and Treatment of Stroke:

Present Status and Future Perspectives. International journal of

molecular sciences, 21(20), 7609.

[Link]

Lindsay, P., Kelloway, L., & McConnell, H. (2005). Research to practice:

nursing stroke assessment guidelines link to clinical performance

indicators. (2005, June 1). PubMed.

[Link]

Maldonado KA, Alsayouri K. Physiology, Brain. [Updated 2023 Mar 17]. In:

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;

17

2023 Jan-. Available from:

[Link]

McCormack, J., & Reay, H. (2013). Acute stroke research: Challenges and

opportunities for nurses. Nursing Standard, 27(32), 39-45.

doi:10.7748/ns.2013.[Link].e7142.

Organised inpatient (stroke unit) care for stroke. (2013). The Cochrane

Library. [Link]

Other sources

Brain: Definition, Function, Anatomy & Parts. (n.d.). Cleveland Clinic.

[Link]

Cerebrovascular Disease – Classifications, Symptoms, Diagnosis and

Treatments. (n.d.).[Link]

Conditions-and-Treatments/Cerebrovascular-Disease.

Diet after stroke fact sheet. (n.d.). Stroke Foundation - Australia.

[Link]

after-stroke-factsheets/diet-after-stroke-fact-sheet#:~:text=And

%20drink%20plenty%20of%20water,crisps%20and%20other

%20savoury%20snacks.

Stroke - Diagnosis and treatment - Mayo Clinic. (2022, January 20).

[Link]

treatment/drc-20350119

Webdev. (2020, April 27). How to Help Your Loved One With Eating and

Nutrition After a Stroke. Accessible Home Health Care.

[Link]

nutrition-tips
18
19

Name: Norlainie B. Pangandaman

Birthday: 21 yrs. old

Age: July 21, 2001

Address: Purok 1-

Fatima, Ubay

Bohol, 6315

Nationality: Filipino

Religion: Islam

E-mail Address: norpangandaman21@[Link]

Mother: Elizabeth A. Boyles

Father: Aslani U. Pangandaman

EDUCATIONAL BACKGROUND

Primary: Bulua Central School

Secondary: Blessed Mother College

Tertiary: University of Cebu – Banilad Campus

Program: Bachelor of Science in Nursing

Major: Nursing
20

Name: Trisha Faye Y. Pasay

Birthday: September 16, 2000

Age: 22 years old

Address: Babag, Lapu-Lapu City, Cebu

Nationality: Filipino

Religion: The Church of Jesus Christ of Latter-

day Saints

E-mail Address: trishapasay@[Link]

Mother: Carla Y. Pasay

Father: Roland B. Pasay Sr.

EDUCATIONAL BACKGROUND

Primary: Lipata Central Elementary School

Secondary: Minglanilla Science High School

Tertiary: University of Cebu – Banilad Campus

Program: Bachelor of Science in Nursing

Major: Nursing

Name: Trisha Cameer P. Pude

Birthday: December 5, 2001

Age: 21 years old

21

Address: Magosilom, Cantilan, Surigao del Sur

Nationality: Filipino

Religion: Roman Catholic

E-mail Address: pudetrisha6@[Link]

Mother: Charina P. Pude

Father: John Laurence U. Pude

EDUCATIONAL BACKGROUND

Primary: Cantilan Pilot School

Secondary: Saint Michael College

Tertiary: University of Cebu - Banilad Campus

Program: Bachelor of Science in Nursing

Major: Nursing
22

Name: Quezilyn Mae K. Quezon

Birthday: April 30, 2002

Age: 20 years old

Address: Poblacion,

Pinamungajan,

Cebu City

Nationality: Filipino

Religion: Roman Catholic

E-mail Address: [Link]@[Link]

Mother: Chilica K. Quezon

Father: Deldom O. Quezon

EDUCATIONAL BACKGROUND

Primary: Pinamungajan Central Elementary School

Secondary: University of Cebu - Maritime Education

and Training Center

Tertiary: University of Cebu – Banilad Campus

Program: Bachelor of Science in Nursing

Major: Nursing
23

Name: Jesse Steven A. Quirante

Birthday: August 04, 2001

Age: 21 years old

Address: South

Poblacion, City

of Naga, Cebu

Nationality: Filipino

Religion: Roman Catholic

E-mail Address: quirantejessestevena@[Link]

Mother: Vivencia A. Quirante

Father: Joselito G. Quirante

EDUCATIONAL BACKGROUND

Primary: Naga Central Elementary School

Secondary: Naga National High School

Tertiary: University of Cebu – Banilad Campus

Program: Bachelor of Science in Nursing

Major: Nursing