CASE PRESENTATION OF CEREBROVASCULAR DISEASE,

THALAMIC INFARCT

Presented to the Faculty of the School of Nursing

Adventist Medical Center College

Brgy. San Miguel, Iligan City

In Partial Fulfilment

Of the Requirements for the Degree

BACHELOR OF SCIENCE IN NURSING

Mangubat, Danica
Medina, Doneva Lyn
Mejia, Aira Shanelle
Mondelo, Ara Mae
Montes, Rhea Mae
Retita, Elinor Faith
Salvan, Lynitte
Sam, Suzzaine Fritz
Talaroc, Melanie Kaye
Valenzuela, Reynette

Presented to

Codizar, Akikuh
Evalaroza, Faith

May 2023

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 TABLE OF CONTENTS

Page

TITLE PAGE i

TABLE OF CONTENTS ii

LIST OF TABLES iii

LIST OF FIGURES iv

OBJECTIVES 1

GENERAL

SPECIFIC

DEFINITION OF TERMS 2

INTRODUCTION 3

NORMAL ANATOMY AND PHYSIOLOGY 7

ASSESSMENT 10

VITAL INFORMATION 10

SOURCE OF INFORMATION 10

CHIEF COMPLAINTS 10

PHYSICAL ASSESSMENT 10

HISTORY OF PRESENT ILLNESS 11

HISTORY OF PAST ILLNESS 11

ALLERGIES 11

PREVIOUS HOSPITALIZATION 11

MEDICATION AND DRUG STUDY 12

PHYSICAL ASSESSMENT AND REVIEW OF SYSTEMS 16

GORDON’S ASSESSMENT OF FUNCTIONAL HEALTH PATTERNS 23

CONCEPT MAP 29

NURSING CARE PLAN 31

HEALTH TEACHINGS 37

ii
PROGNOSIS 40

REFERENCES 46

LIST OF TABLES

Page

ASSESMENT 10

MEDICATION AND DRUG STUDY 12

PHYSICAL ASSESSMENT 20

DIAGNOSTIC TESTS 26

NURSING CARE PLAN 31

DISCHARGE PLAN 42

iii
 LIST OF FIGURES
Page

NORMAL ANATOMY AND PHYSIOLOGY 8

GENOGRAM 28

CONCEPT MAP 29

iv
v
 OBJECTIVES

General Objectives

At the end of the one and a half-hour case presentation, the student nurses will be able to

provide comprehensive knowledge and proper information towards caring for the patient with

Thalamic Infarct.

Specific Objectives

At the end of the one and half-hour case presentation, the student nurses will be able to:

1. State the background of the disease process of Thalamic Infarct;

2. Explain the relevant terminology;

3. Determine the risk factor for a patient with Thalamic Infarct;

4. Trace the pathophysiology of the disease;

5. Classify the different clinical manifestations that can be manifested by the patient;

6. Recognize the appropriate laboratory and diagnostic test performed on the patient and

its significance and nursing responsibilities;

7. Identify and enumerate the various drugs prescribed and its actions, dosage,

frequency, route, nursing implications and indication;

8. Formulate and prioritise an individualised nursing care plan for the patient;

9. Implement a health teaching plan; and

10. Acknowledge the prognosis of the disease.

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 DEFINITION OF TERMS

Agraphia. An impairment or loss of a previous ability to write. Agraphia can occur in isolation,

although it often occurs concurrently with other neurologic deficits such as alexia, apraxia, or

hemispatial neglect.

Brain Parenchyma. Refers to the functional tissue in the brain that is made up of the two types

of brain cell, neurons and glial cells. It is also known to contain collagen proteins. Damage or

trauma to the brain parenchyma often results in a loss of cognitive ability or even death.

Carotid Angioplasty. A minimally invasive procedure in which a very small hollow tube, or

catheter, is advanced from a blood vessel in the groin to the carotid arteries

Hemineglect. An unawareness or unresponsiveness to objects, people, and other stimuli

sometimes patients even ignore or disown their own left limbs in the left side of space.

Subarachnoid. Bleeding in the space that surrounds the brain. Most often, it occurs when a

weak area in a blood vessel (aneurysm) on the surface of the brain bursts and leaks.

Thalamic Stroke. Fall under the category of subcortical strokes or lacunar strokes, which affect

the deeper brain regions beneath the cerebral cortex, as opposed to the outer cortical region.

The Circle of Willis. An anatomical structure that provides an anastomotic connection between

the anterior and posterior circulations, providing collateral flow to affected brain regions in the

event of arterial incompetency.

Hemoglobin A1C(HbA1c) Test.A simple blood test that measures your average blood sugar
levels over the past 3 months. It's one of the commonly used tests to diagnose prediabetes and
diabetes, and is also the main test to help you and your health care team manage your diabetes.

Serum Glutamic Pyruvic Transaminase (SGPT)/Alanine Transaminase (ALT) Test.

Measures the level of alanine aminotransferase, also called ALT or SGPT. ALT is one of the
enzymes that help the liver convert food into energy.

Thyroid Stimulating Hormone Test (TSH). Is a blood test that measures this hormone. TSH
levels that aretoo high or too low may be a sign of a thyroid problem. The thyroid is a small,
butterfly-shaped gland in the front of your neck. Your thyroid makes hormones that control how
your body uses energy.

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 INTRODUCTION

This is a case study of a 42-year-old man who was diagnosed with Cerebrovascular Disease,
Infarct Thalamus.

Cerebrovascular disease is a condition affecting the blood vessels that supply blood to the
brain. This decreases the amount of oxygen that reaches the brain, causing damage.
Cerebrovascular diseases can affect both arteries and veins. The most commonly affected
cerebral blood vessels that supply blood to the brain include the carotid and vertebral arteries.
Deep in the center of the brain, there is a walnut-sized center called the thalamus.
Located right next to the brain stem, this tiny part of the brain is very important. Even though
this complex part of the brain is very small, having a stroke in the thalamus can have many
different health implications for the body.‌
In addition to having a stroke in the thalamus, it could also suffer from a thalamic infarct.
An infarct is when the stroke cuts off oxygen to the tissue to the degree that the tissue dies.
Depending on the severity and location within the thalamus, infarcts can present long-lasting and
serious consequences.
A thalamic stroke is a type of lacunar stroke, which refers to a stroke in a cerebral
complex of the brain. Thalamic strokes occur in the thalamus, a small but important part of the
brain. It’s involved in many crucial aspects of everyday life, including speech, memory, balance,
motivation, and sensations of physical touch and pain. Thalamic stroke symptoms vary
depending on the part of the thalamus that’s affected. However, some general symptoms of a
thalamic stroke include:
● pure motor hemiparesis, with face, arm, and leg equally affected
● pure hemisensory stroke
● clumsy hand-dysarthria
● ataxic hemiparesis

Stroke is the most common type of cerebrovascular disease. An abrupt interruption of

constant blood flow to the brain causes a loss of neurological function. A stroke in the left
middle cerebral artery (M.C.A.) causes symptoms on the right side of body and visa-versa.
Large-vessel strokes like M.C.A. strokes affect large areas of the brain. Sometimes, only a
branch of the M.C.A. is blocked, and the stroke is less severe. Blood clots that travel from the
heart or carotid artery cause M.C.A. strokes. Lack of sufficient blood flow (ischemia) affects
brain tissue and may cause a stroke. The interruption of blood flow can be caused by a blockage,
leading to the more common ischemic stroke, or by bleeding in the brain, leading to the more
deadly hemorrhagic stroke. Possible symptoms are slurred speech, right-sided weakness on the
upper extremities, tongue deviation, facial asymmetry, nonspecific ventricular conduction delay,

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left atrial abnormality, increased creatinine, hyperglycemia, increased cholesterol, decreased
R.B.C., decreased lymphocytes, and cardiomegaly.

Types of Stroke
Ischemic Stroke is by far the most common type of stroke, accounting for a large
majority of strokes. There are two types of ischemic stroke: thrombotic and embolic. A
thrombotic stroke occurs when a blood clot, called a thrombus, blocks an artery to the brain and
stops blood flow. An embolic stroke occurs when a piece of plaque or thrombus travels from its
original site and blocks an artery downstream. The material that has moved is called an embolus.
How much of the brain is damaged or affected depends on exactly how far downstream in the
artery the blockage occurs.
Hemorrhagic Stroke can be caused by hypertension, rupture of an aneurysm or vascular
malformation or as a complication of anticoagulation medications. An intracerebral hemorrhage
occurs when there is bleeding directly into the brain tissue, which often forms a clot within the
brain. A subarachnoid hemorrhage occurs when the bleeding fills the cerebrospinal fluid spaces
around the brain. Both conditions are very serious.
Transient Ischemic Attack is a temporary cerebrovascular event that leaves no
permanent damage. Most likely an artery to the brain is temporarily blocked, causing stroke-like
symptoms, but the blockage dislodges before any permanent damage occurs.
The provider can treat cerebrovascular disease with medications and surgery as ordered.
People of every sex, age, and race can have cerebrovascular disease. Certain uncontrollable
factors put some people at higher risk for cerebrovascular diseases, such as age or biological sex.
According to the American Stroke Association (A.S.A.), more than 2 in 3 Black Americans have
at least one of the following risk factors for stroke: high cholesterol, high blood pressure,
diabetes, more weight or obesity, sickle cell anemia, consuming too much salt, smoking, and
stress. The American Stroke Association suggests using the acronym F.A.S.T. to identify
symptoms: Face drooping, Arm weakness, Speech difficulty, and Time to call 911. Urgent
medical attention is essential if anyone shows signs of a cerebrovascular attack because it can
have long-term effects, such as cognitive impairment and paralysis.
In the Philippines, an estimated half million are affected annually by stroke. From 2009
to 2019, stroke remains the second leading cause of death and one of the top five leading causes
of disability in the Philippines.

Treatment
● A cerebrovascular event requires emergency treatment. Rapid assessment and treatment
are crucial because a person must receive stroke medications within a specific time from
the onset of symptoms.

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 ● In the case of an acute stroke, the emergency team may administer a medication
called tissue plasminogen activator (tPA)  that breaks up the blood clot.
● Catheter-directed mechanical thrombectomy is an emergency stroke treatment that is
becoming more widely available in dedicated stroke centers. This procedure involves a
doctor inserting a catheter into an artery. Then, the surgeon inserts a small clot-removing
device through the catheter to suck out the clot.
● A neurosurgeon must evaluate an individual who has a brain hemorrhage. They may
carry out surgery to reduce the increased pressure that a bleed causes. Doctors usually
perform surgical procedures, including carotid endarterectomy, carotid angioplasty, and
stenting, to prevent a person from having another stroke.
● A carotid endarterectomy making an incision in the carotid artery and removing the
plaque. This allows the blood to flow again. The surgeon then repairs the artery with
sutures or a graft.
● Some people may require carotid angioplasty and stenting, which involves a surgeon
inserting a balloon-tipped catheter into the artery. They will then inflate the balloon so
that it reopens the artery.
● Afterward, the surgeon fits a slender, metal mesh tube, or stent, inside the carotid artery
to improve blood flow in the previously blocked artery. The stent helps to prevent the
artery from collapsing or closing up after the procedure.
Rehabilitation
As a cerebrovascular event can cause permanent brain damage, people may experience
temporary or permanent disability following one. For this reason, they may require a range of
supportive and rehabilitative therapies so that they can retain as much function as possible.
These may include:
● Physical therapy: This aims to restore mobility, flexibility, and limb function.
● Speech therapy: This may help people communicate more clearly and regain speech
after a stroke or cerebrovascular attack.
● Occupational therapy: This can help a person access facilities that support a return to
work and daily life.
● Psychological therapy: Physical disability can create unexpected emotional demands
and require intensive readjustment. A person may benefit from visiting a psychiatrist,
psychologist, or counselor after a cerebrovascular event if they feel overwhelmed.

Diagnostic Tests

● A cerebral angiography: A doctor uses this to identify a vascular abnormality, such as a

blood clot or a blood vessel defect. It involves injecting dye into the arteries to reveal any
clots and display their size and shape on a computed axial tomography (CAT), CT,
or magnetic resonance imager (MRI) scan.
● An MRI scan: This can detect even early stage strokes.

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● A magnetic resonance angiogram (MRA): This procedure takes place in an MRI. The
MRA shows the blood vessels in the neck and brain. It may help to detect aneurysms and
blockages.
● A CAT scan: This can help a doctor diagnose and detect hemorrhagic strokes as it can
distinguish between blood, bone, and brain tissue. However, it does not always reveal
damage from an ischemic stroke, especially in the early stages.
● A CT angiography (CTA): This scan allows healthcare professionals to see blood
vessels in a person’s head and neck.
● An electrocardiogram (EKG or ECG): This can detect cardiac arrhythmia, which is a
risk factor for embolic strokes.
● A lumbar puncture (spinal tap): This may help detect bleeding caused by a cerebral
hemorrhage. This procedure involves removing cerebrospinal fluid with a needle.
● Glucose Screening Test: This measures the body's response to sugar (glucose).

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 NORMAL ANATOMY AND PHYSIOLOGY

BRAIN
The brain receives information through
our five senses: sight, smell, touch, taste, and hearing -
often many at one time. A complex organ that controls
thought, memory, emotion, communication, motor
skills, vision, breathing, temperature, hunger, and every
process that regulates our body. The brain and spinal
cord that extends from it make up the central nervous
system or CNS. When it comes to cardiovascular
illness, the brain's cerebrum and cerebellum are the areas that are affected.
● Cerebrum: It performs higher functions like interpreting touch, vision, and hearing, as
well as speech, reasoning, emotions, learning, and fine movement control.
● Cerebellum: is located under the cerebrum. Its function is to coordinate muscle
movements and maintain posture and balance.
Brain lobe affected by the stroke. Each area of the brain controls different functions, and
everyone’s brain is wired differently. Therefore, the effects of a stroke greatly vary from
person to person. This is why therapists and doctors frequently say, “Every stroke is
different, so every recovery will be different.”
● Frontal lobe: Almost one-third of the cerebrum comprises the frontal lobe. It should be
no surprise that the frontal lobe plays a role in many functions. Motor skills, executive
functioning, speech, language, and social skills are all controlled, in some parts, by the
frontal lobe. Effects of a frontal lobe stroke (a type of cortical stroke) include motor
impairments, problem-solving and judgement issues, behavioural changes, and difficulty
with speech (aphasia, dysarthria, or apraxia of speech), among others.
● Parietal lobe: It mainly affects sensory interpretation along with language skills and
spatial awareness. Some secondary effects of this cortical stroke include hemineglect,
difficulty writing (agraphia), difficulty reading (alexia), difficulty speaking (aphasia), and
more.
● Temporal lobe: Also, part of the cerebrum, is an area of the brain that controls language
comprehension, hearing, and other sensory processes. A stroke that affects the temporal
lobe can cause problems with hearing, seeing, and understanding speech, among other
things.
● Occipital lobe: The occipital lobe, the final type of cortical stroke, plays a significant
role in your vision. As a result, damage to the occipital lobe often results in vision
difficulties like central vision loss, cortical blindness, visual hallucinations, or other
secondary effects.

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 THALAMUS
The Thalamus is derived from the embryonic diencephalon and early in development
becomes divided into two progenitor domains, the caudal domain and the rostral domain.
The patterning of these domains is driven by the mid-diencephalic organiser (MDO),
which sets a gradient of transcription factors to form distinct thalamic regions.
Differential transcription of genes leads to neuronal differentiation. The caudal progenitor
domain leads to the development of excitatory glutamatergic neurons (those that
modulate glutamate and aspartate signalling), which contribute to the formation of the
functionally and spatially distinct groups of neurons known as the thalamic nuclei. The
rostral progenitor domain leads to the development of inhibitory gamma-aminobutyric
acid (GABA) neurons that form the thalamic reticular nucleus.

The thalamus is an area of the brain that helps process information from the senses and
transmit it to other parts of the brain. The thalamus is a paired grey matter structure of the
diencephalon located near the centre of the brain. It is above the midbrain or
mesencephalon, allowing for nerve fibre connections to the cerebral cortex in all
directions with each thalamus connected to the other via the interthalamic adhesion.

The five main functional components of the thalamus are:

● Arousal and pain regulation. This part of the thalamus is able to discern what object is
creating which brain patterns. Both through memory and the ability to synthesise
patterns, the thalamus can interpret sensory information.
● Sensory experiences. There are parts within the thalamus that regulate every type of
sensory information except for smell.

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● Motor language function. Speech and motor functioning are connected. Motor
functioning is essential in connecting the planning, expression, and execution of saying
an idea out loud.
● Cognitive function. The thalamus is integral for your overall cognitive functioning. Its
decline is directly associated with the natural decay of cognitive functioning while you
age. It affects memory, attention, and information processing.
● Mood and motivation. There are components within the thalamus that are connected to
parts of the brain that encompass mood and motivation.

Even though this complex part of the brain is very small, having a stroke in the thalamus
can have many different health implications for your body.‌ In addition to having a stroke
in the thalamus, you could also suffer from a thalamic infarct. An infarct is when the
stroke cuts off oxygen to your tissue to the degree that the tissue dies. Depending on the
severity and location within the thalamus, infarcts can present long-lasting and serious
consequences.

There are two different causes of Strokes:

● Ischemic strokes. A build-up of fatty deposits, blood clots, or other debris move
throughout your bloodstream in your body and finally lodge in and clog your
brain.
● Hemorrhagic stroke. Is due to bleeding into the brain by the rupture of a blood
vessel.

Thalamic strokes also present some unique post-stroke health implications.

These includes:

● Issues with speech and talking. Usually, this presents problems using the correct
lexical semantics but quickly goes away.
● Dejerine-Roussy. This is a rare disease that occurs after a thalamic stroke. It is at
first characterised by numbness, then tingling, then pain. This pain can become
severe and does not go away without treatment.
● Generalised spike-wave. This is a phenomenon in the brain that usually precedes
things like seizures or epilepsy.
● Fatal familial insomnia. A hereditary disease that slowly deteriorates the brain.
People with this disease get panic attacks, paranoia, and phobias. These symptoms
are eventually joined by a complete loss of sleep and hallucinations. Ultimately,
people with fatal familial insomnia bring dementia, mutism, and death.

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 Cranial Nerve: The brain communicates with the body through the spinal cord and twelve
pairs of cranial nerves.

• Cranial Nerve No. III: Oculomotor: Cranial nerve

III works with other cranial nerves to control eye
movements and support sensory functioning.
• Cranial Nerve No. VI: Abducens Nerve: Ability to
Move Your Eyes
• Cranial nerve No. VII: Facial nerve: facial
expressions or movements and sense of taste
• Cranial Nerve No. VIII: Vestibulocochlear: The
vestibulocochlear nerve is responsible for the sense
of hearing and balance (body position sense).

BLOOD VESSELS IN BRAIN

Blood vessels are channels that carry blood throughout the
body. It forms a closed loop that begins and ends at heart. Along
with the heart vessels, it includes the circulatory system. If
blood vessels supply the brain and become blocked or
"clogged," they impair flow to the heart of the brain. There are
three types of blood vessels:
● Arteries: They carry blood away from the heart. Bring the blood full of oxygen to the
capillaries, where the exchange of oxygen and carbon dioxide occurs.
● Veins: They carry blood back toward the heart.
● Capillaries: the smallest blood vessels, connect arteries and veins. Capillaries are the
tiniest blood vessels, connecting arteries, and veins. Deliver the wasterich blood to the
veins for transport back to the lungs and heart.

CIRCLE OF WILLIS
● The brain receives blood from two arteries known as the
carotid arteries. They lead to the Willis circle and run
along either side of the neck. An internal and an exterior
carotid artery branch off of each carotid artery. The
cerebral arteries are then split off from the internal carotid
artery. The circle of Willis can be filled with blood from
the two internal carotid arteries because of its
arrangement.
● The vertebral arteries supply the cerebellum, brainstem,
and underside of the cerebrum. After passing through the

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 skull, the right and left vertebral arteries join together to form the basilar artery. The
basilar artery and the internal carotid arteries "communicate" with each other at the base
of the brain, called the Circle of Willis. The communication between the internal carotid
and vertebral-basilar systems is an important safety feature of the brain. If one of the
major vessels becomes blocked, collateral blood flow can come across the Circle of
Willis and prevent brain damage.
● Those with a complete circle of Willis may be protected from stroke by its structure and
function. Even in obstructions or thinning veins, the entire process allows blood to flow
from one side of the brain to the other.

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 ASSESSMENT

A. VITAL INFORMATION

Name:  Mr. CB

Age: 42 years old

Gender: Male

Civil Status: Married

Birthdate: June 10, 1980

Address: Bangco, Matungao, Lanao Del Norte

Nationality: Filipino

Religion: Islam

Room: 298

Physician: DR. APM (Internal Medicine- Endocrinologist)

Date of Admission: April 24, 2023

Admitting Diagnosis: Peripheral Neuropathy

Final Diagnosis: Cerebrovascular Disease, Infarct Thalamus, Dyslipidemia

B. SOURCE OF INFORMATION

● Patient: 30%

● Wife: 20%

● Chart: 50%

C. CHIEF COMPLAINTS

● Right Upper Extremity Weakness

D. PHYSICAL ASSESSMENT

Vital Signs: April 25, 2023

BP- 130/80

Temperature- 36.3 

O2sat - 98%

PR - 78

RR - 20

Patient’s Appearance & Behavior

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   The patient is responsive, well-groomed and has good hygiene.

     General Appearance: The patient is conscious, coherent, and has weakness on
the right side of the upper extremity.

a.     Skin: Good skin turgor, without rashes

b.     HEENT: Pink palpebral conjunctiva, Moist lips, No

lymphadenopathy.

c.     NECK:  No bruits, No neck vein engorgement.

d.     CHEST/ LUNGS:  Equal chest expansion, Clear Breath sounds,

Negative Crackles.

e.     HEART: Distinct heart sound, No murmurs

f.    ABDOMEN: Soft, nontender, normal active bowel sounds.

g.     EXTREMITIES: Full and equal pulses, Left finger with a CRT <

2 seconds

E. HISTORY OF PRESENT ILLNESS

   At 4 pm in the afternoon on this day, the patient experienced recurrence of numbness on

the right side of the upper extremity.

This time, it was accompanied by weakness and mild headache which prompted consultation. At
the emergency room, the patient is comfortable, still with the right side of the upper extremity
and a blood pressure of 130/80 mmhg.

Four days prior to admission, the patient went to a physician and was given medications and
provided mild relief.

Five days prior to admission, onset of numbness on the right side of the upper extremity,
accompanied by blurring vision.

F. PAST MEDICAL HISTORY

Past Illness: 

The patient has no past illness.

G. FAMILY HISTORY

The patient has a family history of hypertension and diabetes mellitus.

H. ALLERGIES

 No unknown allergies to food and drugs.

I. PREVIOUS HOSPITALIZATION

Mercy Community Hospital, Inc. (unrecalled year)

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J. MEDICATION AND DRUG STUDY

 History of Past Medication:

Clopidogrel 75mg, Aspirin, Pregabalin 150 mg, Citidicholine 500mg.

History of Present Medication:

Pregabalin 75mg, Vitamin B complex, Atorvastatin 40mg, Clopidogrel 75mg, Aspirin
80mg.

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 MEDICATION

Name of Drug Dosage/ Mechanism of Action Indications Contraindications Adverse Effects Nursing Responsibilities
Frequency/Route
Generic Name: 75mg 1 tab, oral, Inhibits platelet ● Prophylaxis of ● Hypersensitivity CNS: Depression, ● Instruct patient that
Clopidogrel once a day aggregation by thromboembolic ● Pathologic fatigue, dizziness, medication can be taken
irreversibly inhibiting disorders bleeding headache with or without food.
Brand Name: the binding of ATP to ● To reduce ● Lactation EENT: Epistaxis ● Instruct patient to take
Plavix platelet receptors. It thromboembolic Respiratory: medication exactly as
decreases occurrence of events with Cough, Dyspnea directed. Take the missed
Classification: atherosclerotic events in atherosclerosis CV: Chest pain, dose as soon as you
Antiplatelet agent patients at risk. documented by edema, remember it unless almost
recent CVS, MI, hypertension time for next dose. Do not
or peripheral GI: GI bleeding, double dose.
arterial disease. abdominal pain, ● Use cautiously if patient
diarrhea is at risk for bleeding.
Skin: Rash, ● Advise patient to notify
itchiness, hives health care professional if
Hema: Bleeding, fever, chills, sore throat,
neutropenia or unusual bleeding or
Fever, bruising occurs
hypersensitivity ● Assess patient for
reactions symptoms of stroke.
Generic Name: 40 mg 1 tab, oral, Atorvastatin ● Reduction of risk ● Hypersensitivity ● Headache ● Tell patient to take drug
Atorvastatin once a day competitively inhibits of stroke and ● Active liver ● Flatulence at the same time each day
HMG-CoA reductase, heart attack in disease or ● Diarrhea to maintain its effects.
Brand Name: the enzyme that type 2 diabetes unexplained ● Nausea ● Instruct patient to take a
Lipitor catalyses the conversion patient without persistent ● Vomiting missed dose as soon as
of HMG-CoA to evidence of heart elevations of ● Anorexia possible. If it’s almost

15
Classification: mevalonic acid. This disease but with serum ● Angioedema time for his next dose, he
HMG-CoA results in the induction other CV risk transaminase ● Myalgia should skip the missed
Reductase of the LDL receptors, factors, and ● Porphyria ● Rash/pruritus dose.
Inhibitors, Lipid- leading to lowered revascularization ● Alopecia ● Monitor liver function
Lowering Agents LDL-cholesterol procedures in ● Allergy tests, including AST and
concentration. patients without ● Infection ALT, before initiating
evidence of ● Chest pain therapy.
coronary heart ● Instruct the patient to
disease (CHD) notify the healthcare
but with multiple professional if there are
risk factors other signs of unexplained
than diabetes. muscle pain, tenderness,
or weakness especially
accompanied by fever or
malaise.
Generic Name: 1 tab, oral, once a day A coenzyme that Used for Vitamin B Hypersensitive to CV: Peripheral ● Monitor vital signs
Vitamin B stimulates metabolic complex vitamin B12 or vascular ● Give the drug with meals
Complex function and is needed deficiencies: neuritis, cobalt thrombosis, heart ● Administer liquid
for cell replication, polyneuritis, diabetic failure preparations in water or
Brand Name: hematopoiesis, and neuritis, peripheral GI: Transient juice to mask the taste
Fortiplex nucleoprotein and neuro-paralysis, diarrhea and prevent staining of
myelin synthesis. arthralgia and Respiratory: teeth
Classification: myalgia. Pulmonary edema ● Monitor patient for
Vitamins and Skin: Itching, hypokalemia for first 48
minerals transitory hours, as anemia correct
exanthema, itself.
urticaria
Other:
Anaphylaxis,

16
 anaphylactoid
reactions with
parenteral
administration,
pain or burning at
injection site.
Generic Name: An analogue of gamma- Used to treat pain Contraindicated in ● Allergic ● Monitor for weight gain,
Pregabalin aminobutyric acid caused by nerve patients with known reactions peripheral edema and
(GABA). It is damage due to hypersensitivity to ● Suicidal signs and symptoms of
Brand Name: structurally related to diabetes or to pregabalin or aby of thoughts or heart failure such as
Lyrica gabapentin, but shows shingles (herpes its components. actions shortness of breath,
greater potency in pain zoster) infection. It Angioedema and ● Swelling of fatigue and weakness,
Classification: and seizure disorders. may also be used to hypersensitivity your hands, rapid or irregular
Anticonvulsant, treat nerve pain reactions have legs, and feet heartbeat, and wheezing.
analgesics caused by spinal occurred in patients ● Dizziness and ● Lab tests: Baseline and
cord injury. This receiving sleepiness periodic kidney function
medication is also pregabalin therapy. tests; periodic platelet
used to treat pain in counts: Creatinine
people with phosphokinase (CPK) if
fibromyaglia rhabdomyolysis is
suspected.
● Monitor diabetics for
increased incidences of
hypoglycemia.
● Hold drug and notify
physician if
rhabdomyolysis is
suspected.
● Instruct patient to report

17
 any of the following to a
health care provider:
changes in vision,
dizziness and
incoordination,
unexplained muscle pain,
weakness or tenderness;
weight gain and swelling
of the extremities.
Generic Name: 200mg cap, oral, Lipid-lowering agent, Adjunctive therapy Hepatic & renal ● Headache ● Perform regular
Fenofibrate once a day fenofibric acid primarily to diet for insufficiency. ● Vertigo monitoring of Liver
inhibits triglyceride hypertriglyceridemia Concomitant use w/ ● Fatigue Function Test (LFT)
Brand Name: synthesis, lowering (Fredrickson types another fibrate; ● Digestive, during therapy and
Zinof cholesterol and IV & V), primary HMG-CoA gastric or discontinue therapy if
triglycerides with hypercholesterolemia reductase inhibitors. intestinal enzymes levels persist >3
Classification: or mixed disorders times the normal limit.
Antihyperlipidem dyslipidemia (abdominal ● Instruct patient to take
ic drug (Fredrickson types pain, nausea, medication with food for
IIa, IIb) who are at vomiting, better absorption.
risk of pancreatitis & diarrhea,
who do not respond flatulence)
adequately to dietary ● Rashes,
effort. pruritus or
photosensitivity
reactions.

18
 PEROS (Physical Assessment and Review of Systems)

Areas Subjective Findings Objective Findings Problem Identified

Assessed
General “Nag numb ang right
Health side sa iyang braso og Inspection
Survey nag luya,” as Ineffective Cerebral
· Male Tissue Perfusion related
verbalized by SO.
to neurologic illness as
· Endomorph body type
“Nadugangan gyud evidence by altered
akong timbang, · Height: 162 cm speech/language
nanambok tungod sa
· Weight: 61.5 kg.
Ramadhan”, as
verbalized by pt. · Looking weak Impaired physical
mobility related to
· Anxious
decrease muscle control
· Slurring of speech (04- or strength.
25-23)

· GCS: 14 (E4, M6, V4)

Activity intolerance
· Problems in related to weakness in the
movements of the right
side of the upper upper right extremities.
extremities.

· With Intravenous fluid

via IV Pump (PNLSS 1L, Risk for decrease cardiac
20 cc/hr, keep vein open) output related to altered
afterload as evidence by
BP: 130/80
V/S during admission: 4-24-23
Situational Self-esteem
BP: 130/80 related to weight gain

HR: 78

RR: 20

02: 97%

T: 36.3

V/S During shift: 4-25-2023

(9AM)

BP: 120/70

HR: 84

RR: 20

19
02: 98%

T: 36.2

(1PM)

BP: 120/70

HR: 82

RR: 21

02: 98%

T: 36.4

(5PM)

BP: 130/70

HR: 84

RR: 21

02: 98%

T: 36.1

V/S: 4-26-2023 (9AM)

BP: 120/70

HR: 86

RR: 21

02: 98%

T: 36.1

(1PM)

BP: 130/70

HR: 78

RR: 20

02: 98%

T: 36.3

(5PM)

BP: 130/80

HR: 84

RR: 20

20
 02: 98%

T: 36.4

Integument “wala koy mga katol- Inspection No problems identified.

ary System katol sa lawas man,
wala sad mga rashes og · Warm to touch
lagom-lagom”, as
· Good skin turgor
verbalized by pt.
· No rashes and bruises
“syempre mag grabe
ang singot, kay init · Capillary refill time:
<2 sec. (Assessed on the
kayo ang panahon”, as
left hand)
verbalized by pt.
· Trimmed and clean
nails

· No presence of edema

· No pruritus noted

HEENT Head and face

a. Head “mga ilang araw, ayha 04-24-23 : reports of mild Acute Pain related to
and face ko na admit diri, headache disease process, as
b. Eyes medyo nag halap akong 04-25-23: (+) facial evidenced by headache
c. Ears
panan-aw, pero sa asymmetry
d. Nose
e. Oral karon wala naman,
Cavity okay na akong panan- Risk for injury/fall
aw”, as verbalized by Ears related to altered sensory
pt. No presence of discharges. reception as evidence by
blurring vision
Nose
Eyes ● No presence of
discharges
04-19-23: blurring of Disturbed sensory
● No signs for nasal
vision. perception (visual)
flaring.
Oral Cavitiy related to neurologic
04-25-23: no blurring
● No problems with deficit as evidence by
of vision reported.
swallowing ability and blurring of vision.
ability to determine
taste.

Neck Inspection
Student nurse: wala No problems identified

21
 kay nabatian na stiff
neck sir or sakit sa ● Normal head
liog? movement in all
Patient answered, “ directions.
wala ra man”.
Palpation

· No presence of lumps or
masses.

TSH Result: (04-25-23)

0.374 (0.250-5.800 uIU/mL)

Respiratory
System Student nurse: Risk-Prone Health
asthmatic ka sir? or nay · Equal chest expansion Behavior related to
kaliwat na naay inadequate understanding
· No crackles of health information as
asthma?
Patient answered, · Lips is dark brown in evidenced by long term
“wala”. color. use of cigarette smoking.

Vital signs: V/S During shift:

“wala sad ko gi ubo
4-25-2023 (9AM)
man,oo, dugay nako
nag sigarilyo, mga 30 RR: 20
years na.”, as
verbalized by the pt. 02sat: 98%

(1PM)

RR: 21

02sat: 98%

(5PM)

RR: 21

02sat: 98%

V/S: 4-26-2023

(9AM)

RR: 21

02sat: 98%

(1PM)

BP: 130/70

HR: 78

22
 RR: 20

02: 98%

T: 36.3

(5PM)

RR: 20

02sat: 98%

Cardio- Student: naa ba kay gi Inspection.

vascular bati na sakit sa imong ● Non-Jugular vein Risk for decrease cardiac
System dughan or paspas distended output related to altered
imong dughan sir? ● Non chest pain afterload as evidence by
BP: 130/80
Patient answered, Palpation
“wala”. Capillary refill time: < 2 sec.

V/S During shift: 4-25-2023

(9AM)

BP: 120/70

HR: 84

RR: 20

02: 98%

T: 36.2

(1PM)

BP: 120/70

HR: 82

RR: 21

02: 98%

T: 36.4

(5PM)

BP: 130/70

HR: 84

RR: 21

02: 98%

T: 36.1

23
 V/S: 4-26-2023 (9AM)

BP: 120/70

HR: 86

RR: 21

02: 98%

T: 36.1

(1PM)

BP: 130/70

HR: 78

RR: 20

02: 98%

T: 36.3

(5PM)

BP: 130/80

HR: 84

RR: 20

02: 98%

T: 36.4

Breast and NA NA No problems identified.

axilla
Gastro- Student nurse: walay No problems identified.
intestinal sakit sa imong tiyan Percussion
System and sir? Ang pagkaon, dili
No presence of distention on
the lisod i-tulon?
the abdomen.
abdomen Patient responded, “ah
wala may sakit akong Palpation
tiyan, usahay mag
hapdos lang pag dili No reports and signs of pain
kakaon, okay lang sad upon deep palpation, soft,
maka tulon kog tarong nontender.
sa pagkaon.”, as
verbalized by pt.

Bowel Movement: No bowel

movement during the student
“Okay lang, wala man
sad ko problema sa

24
 akong pag libang”, as
verbalized by pt. nurses’ shift.

SGPT Result: (04-25-23)

73.6 (N: 5-41 U/L)

Genito- Student nurse: ang pag Inspection No problems identified.

urinary / ihi sir okay ra? Dili
Reproducti sakit i-ihi? 4-25-2023
ve system
7AM - 3PM:
Patient answered,” oh
okay ra, walay sakit”. Total intake: 1450

Total output: 660

Yellowish urine, 2 times.

24hr intake: 2700

24hr output: 2060

4-26-2023

7AM - 3PM:

Total intake: 1150

Total output: 730

Yellowish urine, 4 times.

M “wala raman sakit sa Inspection

U akong likod”, as Decrease Physical
S verbalized by pt. (+) weakness and numbness of Mobility related to
C right hand and arm. neuromuscular problems,
U “kani ra may as evidenced by
Palpation decreased muscle
L deperensya sa ako,
O gahapon nag sugod og strength on the right hand
· No deformities on all
S binhod ni akong right and arm.
joints.
K na abaga”, as
E verbalized by pt. · No presence of any
L masses.
Activity Intolerance
E · No edema related to cerebrovascular
T “usahay ma wala ang impairment as evidenced
A binhod sa akong abaga, by weakness and
L pero kaning diri sa numbness of right hand
System akong kamot (referring and arm.
to fingers) dili gyud
diri mawala”, as

25
 verbalized by pt.

Neurologic -How would you ● Looking weak

System describe your mood? ● Anxious Anxiety related to muscle
● Dizziness weakness.
“Ay okay ra ako mood, ● GCS: 14 (E4, M6,V4)
Disturbed Sensory
happy raman pod ko ● Gag reflex: (+) patient
Perception related to
ron”, as verbalized by is responsive after
physiological condition
pt. obtaining an
as evidenced by GCS 14
assessment by using
“Oo, kani akong right the tongue depressor to
na kamot padulong diri touch the back of the
sa akong abaga, binhod pharynx and watching Risk for Fall related to
ni siya. Pero sa uban the elevation of the dizziness
lawas nako wala na palate.
okay ra dayun”, as Cerebellar, motor Ineffective Cerebral
verbalized by pt. Tissue Perfusion related
● Able to demonstrate to thalamic infarct as
pronation and evidenced by weakness
supination of both at the right arm
hands. But reported of extremities.
numbness on the right
Anxiety related to muscle
hand upon doing the
weakness.
assessment.

Strength Activity Intolerance

● Able to move arms, but related to body weakness
still reported of as evidence by poor
numbness on the right grasp strength.
arm upon doing the
assessment.

● Can slowly move

fingers up and down on
the right hand
● Grasp reflex: has
limitations when
grasping hand on the
right side.

Cranial nerves
I . Olfactory – Patient can
identify different scents.
II. Optic – reports of blurring
of vision
VII. Facial – able to make
faces, open eyes.
VIII. Acoustic – No problems
with hearing using the whisper

26
 test
IX. Glossopharyngeal and X.
Vagus – no problems with
identifying different taste.
XI – weakness & numbness of
the right upper extremities,
reports of slurring of speech on
04-25-23.

CT-SCAN Result:
Lacunar infarcts in the left
thalamus and left lentiform
nucleus.

Probable infarct in the right

superior cerebral peduncle.
Lymphatic Student nurse: wala ray
/ mga nabatian na sakit Inspection Ineffective Peripheral
Hematologi or na kapa na mga tissue perfusion related to
Skin is fair, no paleness or decrease red blood cells
c System bukol diri sa liog og
flushed appearance. and hematocrit. levels
mga dapit sa ilok sir?
No signs of bleeding in the Unstable blood glucose
Patient answered, “ah different areas of the body related to lack of
wala ra pod”. including the oral mucosa, understanding about
nose and rectal bleeding with glucose levels control as
stool color of brown. evidence by
hyperglycaemia.
Clinical Chemistry Test:
Risk for fatigue related
Hgt: 73.6
to decreased hemoglobin
HBAIC: 6.4 and diminished oxygen-
carrying capacity to the
blood.
CBC lab results: Activity intolerance
RBC- 4.69 (N: 5.2 – 5.4 related to the imbalance
M/mm^3) between oxygen supply
Hematocrit- 0.41 (N: 0.42- and demand
0.52)
Hemoglobin- 139 (N: 135-
180 g/L)
WBC- 8.45 (N: 4.0 – 10.5x
10^3 cells/mm^3)
Platelet Count- 313 (N: 150-
400x 10^3 cells/mm^3)

GORDON’S FUNCTIONAL HEALTH PATTERNS ASSESSMENT OF PATIENT 

27
   Before Hospitalization During Hospitalization

1. Health According to the patient, he believed The patient was complaining about
Perception and that he is not healthy in terms of his the weakness on his right arm and
Health age, and he doesn’t have any food there is numbness on his right
Management restrictions. He mentioned that he middle finger. According to the
Pattern smokes cigarettes for 30 years and patient, he eats what was being
doesn’t drink any alcohol beverages. served to him and takes his
Whenever he gets fever and cough medicine on time.
and other common viral infections,
he just takes over the counter
medications and have some rest at
home.

2. Nutritional / According to the patient, he has a According to the patient, he eats

Metabolic normal eating pattern, he eats three three times a day but the patient is
Pattern times a day. He likes eating meat under NPO since his blood needs to
such as chicken and beef and he be tested. After the blood test, he
seldom eats vegetables. He does not eats his meal and it was fully
eat pork since his religion is Islam, consumed. He consumed 1 liter of
but during Ramadan he eats a lot of bottled water everyday.
oily food. He drinks at least 6-8
glasses of water per day.

3. Elimination According to the patient, before he According to the patient that when
was hospitalized he usually defecated he was hospitalized, he only
 
1-2 times a day and has no difficulty defecates once during his 2-day

  and discomfort in urinating. The hospitalizations and still had no

patient has a normal bowel difficulty in urinating.
movement.
The patient was under NPO starting
2am on April 25, 2023 for fasting
blood sugar, and ends at 11:00 am.

4-25-2023

28
 3PM:
Total intake: 1450
Total output: 660
Yellowish urine

24hr intake: 2700

24hr output: 2060

4-26-2023
3PM:
Total intake: 1150
Total output: 730
Yellowish urine

4. Activity / According to the patient before he According to the patient now he

Exercise was hospitalized, he would do was hospitalized his activities were
walking and do household chores as limited only to the room, But he can
 
his daily exercise. move and raise his extremities. He

  was able to transfer without

assistance and it is a good exercise
  for him.

5. Cognitive / The patient has no problem in terms The patient is still alert, conversive
Perceptual of hearing, tasting, seeing(vision), and literate, can express his feelings
smelling and he can speak properly and still have a very
continuously. He is oriented to the positive perception in life. The
time and place. patient has no problem in terms of
hearing, tasting, seeing(vision),
smelling and he can speak
continuously. He is oriented to the
time and place, And can perform
his activity of daily living (ADL)
without assistance.

6. Sleep / Rest According to the patient before he According to the patient, he can get

29
   was hospitalized, he would sleep late better sleep during hospitalization
around 11 to 12 am, and could only since he can sleep 5 to 7 hours
sleep for 4 hours only since he would straight.
wake up at 5 am.

7. Self- The patients believe that everything The patient believes that admission
Perception / can be solved and have a positive will be helpful to alleviate the
Self-Esteem outlook on himself. occurrence of his condition. 

8. Role / According to the patient, he is a The patient verbalizes that he still

Relationship house husband and has a close has a close relationship with his
relationship with his family. family especially his wife, since she
 
is always by his side.

9. Sexuality The patient stated no difficulty with No noted abnormalities around the
sexual function. reproductive area.

10. Coping / The patient verbalized that before The patient verbalized that now that
Stress hospitalization he can cope with his he is hospitalized, he can cope up
stress by doing household chores and with his stress by sleeping. He still
 
walking. has a positive outlook in life,
especially that his family supports
him and love him so much, he does
not think about stress because he
always knows that his family got
his back no matter what happens.

11. Value / The patient's religion is Islam and he The patient’s relationship with God
Belief has a very strong faith in Allah. remains unchanged and he has
strong faith in Allah.

30
 DIAGNOSTIC TEST

DATE TEST RESU NORMAL INTERPRETA SIGNIFICANCE

LT RESULT TION

4-25- RBC 4.69 5.2-5.4 DECREASED ANEMIA

2023 HCT 0.41 M/mm^3 DECREASED ANEMIA

HGB 139.0 0.42-0.52 NORMAL

WBC 8.48 135-180 g/L NORMAL

PLT 313 4.0-10.5x10^3 NORMAL

150-400x10^3

4-25- CREATININE 84.08 62-120 umol/L NORMAL

2023 SGPT/ALT 73.6 5-41 U/L INCREASED LIVER DAMAGE

BLOOD URIC 284.49 208-428 NORMAL

ACID umol/L

HGT 148 INCREASED HYPERGLYCEMIA

70-110 mg/dL

4-25- POTASSIUM 4.06 3.5-5.3 NORMAL

2023 SODIUM 139.8 mmol/L NORMAL

135-148

mmol/L

4-25- CHOLESTEROL 5.87 3.5-5.2 INCREASED HYPERLIPIDEMIA

2023 TRIGLYCERIDES 6.36 mmol/L INCREASED HYPERTRIGLYCER

IDEMIA
HDL 0.91 0.68-1.88 NORMAL

LDL 2.07 mmol/L NORMAL

VLDL 2.89 0.77-1.83

mmol/L

2.08-4.94

mmol/L

4-25- FBS 5.66 3.89-5.84 NORMAL

2023 mmol/L

4-25- TSH 0.374 0.250-5.800 NORMAL

2023 uIU/ml

31
4-25- HBAIC 6.4 4.2-5.6% INCREASED INCREASED RISK

2023 OF DIABETES

CT-SCAN REPORT (4-25-2023)

FINDINGS IMPRESSION
BRAIN PARENCHYMA LACUNAR INFARCTS IN THE
There is subcentimeter hypodensity in the left thalamus LEFT THALAMUS AND LEFT
and left lentiform nucleus. Suspicious subtle LENTIFORM NUCLEUS.
hypodensity in the right superior cerebellar peduncle.
No other abnormal density changes are seen in the PROBABLE INFARCT IN THE
brain and brainstem parenchyma. RIGHT SUPERIOR CEREBRAL
PEDUNCLE. COMPLETION
VENTRICLES AND EXTRA-AXIAL CSF SPACES CONTRAST STUDY
No abnormal intra-axial nor extra-axial fluid collection. SUGGESTED.
The midline structures are not displaced.
Vascular structures. Unremarkable. ETHMOID AND MAXILLARY
SINUSITIS
SINUS AND MASTOIDS
Opacifications of the ethmoid and maxillary sinuses.
The calvarium and visualized facial bones are intact.

32
GENOGRAM

33
34
THALAMIC INFARCT

35
 NURSING CARE PLAN
ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Subjective Data: Ineffective Short term goal: Independent: Independent: Short Term Met:
“Oo, kani akong right na Cerebral Tissue After 2-3 hours of nursing 1. monitor vital signs 1. Irregularities in these After 2-3 hours of nursing
kamot padulong diri sa Perfusion related intervention, the patient will noting: are indications of intervention, the patient had
akong abaga, binhod ni to infarcts in the have adequate cerebral hypertension or problems/complications adequate cerebral perfusion
siya. Pero sa uban lawas left thalamus and perfusion as evidenced by hypotension, heart of the brain function. as evidenced by heart rate
nako wala na okay ra left lentiform heart rate less than 120 beats rate, pupillary 2. Reduces arterial less than 120 beats per minute
dayun”, as verbalized by nucleus of the per minute and blood reaction and pressure by promoting and blood pressure 120/70
pt. brain as pressure 120/70 mm Hg respirations. venous drainage and mm Hg immediately after
evidenced by immediately after position 2. Position the client may improve cerebral position change, normal skin
reports of change, normal skin color, with and in neutral circulation and color, dry skin, and absence
Objective Data: headache, dry skin, and absence of position. perfusion. of vertigo and syncope, with
● v/s: BP-120/70 blurring of vertigo and syncope, with 3. Promote active/ 3. Exercise prevents return of heart rate and blood
● weakness & vision, and return of heart rate and blood passive ROM venous stasis and pressure to resting levels
numbness of the weakness and pressure to resting levels exercise. further circulatory within 3 minute of position
right upper numbness of within 3 minute of position 4. Encourage position compromise. change.
extremities right hand and change. changes within the 4. Changes in position
arm. patient when the help adjust patient to
Long term goal: patient is preparing the upright position. Long Term Met:
● Patellar tendons Within 7 hours of rendering to move out of the After 7 hours of rendering
reflex: cannot therapeutic nursing care, the bed. therapeutic nursing care, the
fully grasp hand patient will have: patient :
on the right side. ● have improvements Collaborative: ● Had improvements in
● reports of in terms of 1. Administer Collaborative: terms of movement.
slurring of speech movement. medication as 1. To promote wellness. ● Had improve cerebral
● Have improve ordered tissue perfusion
cerebral tissue
perfusion

36
 ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS
Subjective Data Activity Short Term Goal : Independent: Independent: Short Term Met
“kani ra may deperensya Intolerance After 1-2 hours of rendering 1. Present a safe 1. These measures After 1-2 hours of rendering
sa ako, gahapon nag related to appropriate nursing environment: bed rails up, promote a safe, secure appropriate nursing
sugod og binhod ni akong weakness in the interventions the patient will bed in a down position, and environment and may reduce interventions the patient was
right na abaga”, as right upper be able to performs physical important items close by. the risk for falls. able to performs physical
verbalized by pt. extremities activity independently. activity independently.
2. Let the patient 2. Healthcare providers
Long Term Goal : accomplish tasks at his or and significant others are often Long Term Goal :
After 1 to 2 days of rendering her own pace. Do not hurry in a hurry and do more for After 1 to 2 days of rendering
Objective Data appropriate nursing the patient. Encourage patients than needed. Thereby appropriate nursing
● weakness of right interventions the patient will independent activity as able slowing the patient’s recovery interventions the patient will
hand and arm. be able to maintain activity and safe. and reducing his or her be able to maintain activity
● Limited Range of level within capabilities as 3. Provide the patient confidence. level within capabilities as
Motion evidenced by the absence of with rest periods in between 3. Rest periods are evidenced by the absence of
numbness and weakness of activities. Consider energy- essential in conserving energy. numbness and weakness of
right upper extremity. saving techniques. The patient must learn and right upper extremity.
4. Execute passive or accept his or her limitations.
active assistive ROM 4. Exercise enhances
exercises to all extremities. increased venous return,
prevents stiffness, and
Collaborative: maintains muscle strength and
1. Note treatment stamina. It also avoids
related factors, contraction deformation, which
such as side effects can build up quickly and could
interaction of hinder prosthesis usage.

37
 medication.
2. Provide referrals to Collaborative:
other discipline 1. To monitor the effect of the
such as exercise medications that were given.
physiologist, 2. To develop individually
physical therapist appropriate therapeutic
as indicated. regimens.

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective Data: Risk for injury Short term goal Independent: Independent: Short Term Met:
related to altered After 2 hours of nursing 1. Encourage to increase 1. To replace fluid loss After 2 hours of nursing
sensory perception intervention, the patient will fluid intake. and to prevent intervention, the patient:
as evidenced by be able to: 2. Monitor and record dehydration. ● Verbalize
Objective Data: vertigo ● Verbalize vital signs. 2. To have baseline data. understanding of
Vital signs: understanding of 3. Provide a safety 3. It ensures safety and individual factors
BP- 120/70 individual factors environment by reduces risk for falls. that contribute to
RR- that contribute to keeping bed rails up. 4. Sudden movements can possibility of
- Headache possibility of injury. 4. Sit or lie down right trigger dizziness. injury.
- Blurring of vision away when you feel 5. To determine the
- Dizziness dizzy. Keep your head causes of injury.
Long term goal: as still as possible and Long Term Met:
After 6 hours of nursing do not change position Collaborative: After 6 hours of nursing
intervention the patient will quickly. 1. Help to control/ intervention the patient:
be able to: 5. Assessed alleviate the symptoms.
environmental factors ● Demonstrate
● Demonstrate that may lead to injury. behaviors, lifestyle
behaviors, lifestyle changes to reduce
changes to reduce risk factors and
risk factors and Collaborative: protect self from
protect self from 1. Facilitation of oral injury.

38
 injury. medication.
● had free from
injury.
● Be free from injury.

ASSESSMENT NURSING PLANNING NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective Data: Disturbed sensory Short Term Goal Independent: Independent: Short Term Met
“mga ilang araw, perception (visual) After 2 hours of 1) Encourage the patient to see 1. Can monitor progressive After 2 hours of
ayha ko na admit related to neurologic rendering nursing an ophthalmologist at least visual loss or complications. rendering nursing
diri, medyo nag deficit as evidence by interventions the yearly. Decreases in visual acuity can interventions the
halap akong panan- blurring of vision patient will able to 2) Provide sufficient lighting for increase confusion in elderly patients. patient was able to
aw, pero sa karon verbalize the patient to carry out 2. Elderly patients need twice as verbalize
wala naman, okay ● awareness of activities. much light as younger people. ● awareness of
na akong sensory needs. 3) Provide lighting that avoids 3. Elderly patients’ eyes are sensory
pananaw”, as ● Identify/ glare on surfaces of walls, more sensitive to glare and cataracts needs.
verbalized by pt. modify factors reading materials, and so diffuse glare so the patient has more ● Identify/
that contribute forth. difficulty with vision. modify
to alterations 4) Provide night light for the 4. Patients’ eyes may require factors that
Objective Data: insensory. patient’s room and ensure longer accommodation time to contribute to
● blurring of ● Be free of lighting is adequate for the changes in lighting levels. The alterations
vision. injury. patient’s needs. provision of adequate lighting helps insensory.
5) Provide large print objects to prevent injury. ● Be free of
Long Term Goal and visual aids for teaching 5. Assists patient to see larger injury.
After 1 to 2 days of print and promotes a sense of
nursing intervention, Collaborative: . independence. Long Term Met
the client will be able to After 1 to 2 days of

39
 compensate for sensory Collaborative: nursing intervention,
impairments. 1) Administration of 1) These direct acting the client was be able
medications that help topical myotic drugs to compensate for
decrease intracranial cause pupillary sensory impairments.
pressure constriction,
facilitating the
outflow of aqueous
humor and decreasing
the intracranial
presssure

ASSESSMENT NURSING PLANNING NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective Data: Self-care deficit related Short term goal: Independent: Independent: Short Term Met:
to decreased strength in At the end of 1-2 hour 1. Encourage independence 1. An appropriate At the end of 1-2 hour of
the right upper of nursing intervention but intervene when level of assistive nursing intervention the client
extremities the client will be able patient cannot perform. care can prevent was able to verbalize the
Objective Data: to: 2. Provide patient with injury with importance of proper hygienic
- Patellar tendons appropriate utensils (e.g., activities without practices like bathing, proper
reflex: cannot - Verbalize proper drinking straw, food causing hand washing, nail cutting,
fully grasp hand hygienic practices. guard, nonskid place frustration. tooth brushing.
on the right side. mat) to aid in self- 2. These items
- Can slowly move feeding. increase Long Term Met
fingers up and - Identify alternative 3. Encourage use of opportunities for After 1-2 days of providing
down on the right action to perform clothing one size larger.  success. nursing interventions, the
hand. Activity of Daily 4. Keep call light within 3. This ensures patient was able to identify
living. reach and instruct patient easier dressing areas of weakness and identify
to call as early as and comfort. his significant other as his
possible. 4. This enables staff personal assistance.
Long term goal
5. Encourage patient to use members to have

40
 the stronger side (if time to assist
Within 1-2 days of appropriate) as best as with transfer to
effective nursing possible commode or
intervention the client toilet.
will be able to identify Collaborative: 5. Stroke patients
individual area of 1. Assured that consistency experience
weakness or needs and of diet is appropriate for weakness in their
identify personal patient’s ability to chew dominant side;
resources that can and swallow therefore, it will
provide assistance. be necessary for
them to develop
muscle strength
and coordination
on the stronger
side

Collaborative:
1. Mechanical
problems may
prohibit the
patient from
eating.

41
 HEALTH TEACHING
Eat Right

The best way to help lower your blood cholesterol level is to eat less saturated fat, avoid
cholesterol and control your weight. Here are some other nutrition tips:

● Eat a variety of fruits, and vegetables.

● Consume fat-free and low-fat dairy products, fish, beans, skinless poultry and lean meats.
● Limit foods high in saturated fats like oily foods such as fried foods.
● Eat less than 6 grams of salt a day.
Be Active

Physical activity is good for your entire body, especially your heart. While getting into a regular
exercise routine is great, there are a number of quick ways to easily add more physical activity
into your days:

● Take the stairs Get in the habit of taking the stairs. If you are going to a high floor, take the
elevator part of the way – either walk up a few flights and then catch the elevator, or get off early
and walk the rest of the way.
● Go for a walk Even a short walk around the block or through your office can help get your heart
rate up and invigorate your body.

Changes in daily living

Doing some everyday tasks may be hard after you’ve had a stroke. But you can learn new ways
to manage your daily activities. In fact, doing daily activities may help you to regain muscle
strength. This can also help your affected arm or leg work more normally. Be patient. Give
yourself time to adjust. And appreciate the progress you make.

Lifestyle changes

● Take your medicines exactly as directed. Don’t skip doses.

● Begin an exercise program. Ask your provider how to get started. Ask how much activity
you should try to get every day or week. You can benefit from simple activities such as
walking or gardening.
● Limit how much alcohol you drink.
● Control your cholesterol level.
● If you are a smoker, gradually stop smoking. Find something to do like playing scrabble
or any mind games.
● Learn stress management methods. These can help you deal with stress in your home.
Diet

Your healthcare provider will guide you on changes you may need to make to your diet. He or
she may advise that you see a registered dietitian for help with diet changes. The changes can
improve your cholesterol, blood pressure, and blood sugar. Changes may include:

● Reducing the amount of oily foods you eat

● Reducing the amount of salt (sodium) in your diet, especially if you have high blood
pressure
● Eating more fresh vegetables and fruits
● Eating more lean proteins, such as fish, poultry, and beans and peas (legumes)
● Eating less red meat, canned goods and instant foods
● Limiting vegetable oils and nut oils

42
 ● Limiting sweets and processed foods such as chips, cookies, and baked goods.

Follow-up care

● Keep your medical appointments. Close follow-up is important to stroke rehabilitation

and recovery.
● Some medicines require blood tests to check for progress or problems. Keep follow-up
appointments for any blood tests ordered by your providers.

Call Emergency Hotline

Call emergency hotline right away if you have any of the following symptoms of stroke:

● Weakness, tingling, or loss of feeling on one side of your face or body

● Sudden double vision or trouble seeing in one or both eyes
● Sudden trouble talking or slurred speech
● Trouble understanding others
● Sudden, severe headache
● Dizziness, loss of balance, or a sense of falling
● Blackouts or seizures

43
 PROGNOSIS

The patient's prognosis is favourable overall because there are no signs of facial asymmetry,

sudden confusion, difficulty speaking, or hearing problems. Despite continuing to complain

about weakness in his right upper extremities, the patient is able to sit, walk, and move around in

a moderate manner. He can speak and understand clearly as we perform our assessment, give

him medication, and keep an eye on his vital signs. He is at a significant risk of suffering or

experiencing serious consequences due to the fact that he has been diagnosed with

cerebrovascular illness with infarct thalamus. The patient's family history of stroke on both the

paternal and maternal sides is the triggering factor. Given that the patient previously had an

infarcted thalamus, this makes the patient's dyslipidemia a significant risk factor for the

development of his cerebrovascular disease and the progression into serious issues, even if he is

aware of and able to understand his current health situation and is willing to change his lifestyle.

It also suggests that, albeit gradually, the patient's daily regimen would change. providing the

patient with the proper health education on how to improve. For instance, setting up an exercise

routine, helping with diet, and enhancing communication are all examples of feasible goals that

may be set for the patient at home with the help of the patient, family, and the complete medical

team. Another example is improving mobility and preventing deformities. The prognosis for

cerebral vascular disease and infarct thalamus is influenced by the size, location, and severity of

the aneurysm, cerebrovascular malformation, or stenosis. Because brain damage brought on by

complications of cerebrovascular illness is irreversible, people with more severe symptoms

should seek emergency treatment right away. The overall recovery time can range from a few

days to several months.

44
 DISCHARGE PLAN

Name of Client: Mr. CB Age: 42 Gender: Male

Religion: Islam Diagnosis: Cerebrovascular Disease, Infarct Thalamus
Surgery if any: None
Hospital: Adventist Medical Center Iligan Room/Ward Bed No. 298
Attending Physician/s: Dr. APM
A. OBJECTIVES
At the end of an hour of health education the client will be able to:
1. Learn more about the disease process;
2. Understand therapeutic regimen to promote proper knowledge of long-term
management;
3. Promote self-care and family members engagement to the client’s treatment;
4. Demonstrate behaviors and techniques to improve condition; and
5. Modify lifestyle patterns to prevent or minimize complications.

B. METHODS
1. Medications
Name of Dosage Route Curative Side Effects Instructions
Drug Preparation Effects
(Generic Frequency
and Trade Duration
Name)
Clopidogrel 75mg 1 tab, oral Antiplatelet ● Fatigue ● Instruct
(Clovix) once a day agent ● Dizziness patient that
● Headache medication
can be
taken with
or without
food.
● Take the
medication
at 1 pm
Atorvastatin 20 mg 1 tab oral Lipid- ● Headache ● Tell patient
(Itorvaz) once a day Lowering ● Flatulence to take drug
Agents ● Diarrhea at the same
● Nausea time each
● Vomiting day to
maintain its
effects.
● Take the
medication
during
bedtime at 9
pm.

Vitamin B 1 cap once a oral Vitamins and ● Abdominal ● Give the

Complex day minerals Cramps medication
(Pronerv) ● Excessive during
Thirst breakfast at
● Nausea 8 am.
● Vomiting ● Administer
liquid
preparations

45
 in water or
juice to
mask the
taste and
prevent
staining of
teeth
Fenofibrate 200 mg I cap oral Antilipemic ● Loss of ● Should be
(Zinof) once a day agent appetite taken with a
● Nausea meal.
● Pains in ● Give the
stomach, medication
side, or during
abdomen, bedtime at 9
possibly pm.
radiating to
the back
● Vomiting.
Citicoline 500mg I tab oral Neurotropic ● Stomach ● Take it with
(Citifar) twice a day pain or after
● Back pain food with
● Blurred adequate
vision amount of
● Constipation water
● Headache. ● Take the
medication
twice a day
at 8 am and
8 pm..

2. Exercise/Activity and Home Environment

Types of activity that should not be allowed
● Heavy lifting
● Strenuous or difficult activities that requires great energy like running.

Type of Activity Allowed/To be continued:

● Encourage the patient to have physical activity, like walking outside or even
stretching that may include leg, arm, or combined arm-leg ergometry, at the
appropriate intensity.exercises.
Restrictions:
● Always do it at a slow-pace and avoid straining yourself.
● Stop the activity if you start feeling discomfort.

Home Environmental Hazards:

● Keep the floors dry to avoid or prevent any slipping.

3. Treatments/Therapies (e.g., Chest physiotherapy, warm compress, steam

inhalation, hydrotherapy, nebulization, etc)
● Physical therapy

4. Health Teaching/Education (e.g., asthma)

Health Prevention/Promotion
● Eat well-balanced diet
● Get plenty of sleep

46
 ● Avoid strenuous activities
● Eat more fresh vegetables and fruits
● Eat less red meat and canned goods
● Quit Smoking

5. OPD Visit
Clinic Appointment Schedule: follow-up after 1 month
Follow-up Diagnostic or Laboratory Exam:
Referrals:
6. Diet
a. Prescribed Diet: Low Salt Low Fat Diet, Low Cholesterol Low Sugar Diet

3- Day Sample Menu

Day 1 Day 2 Day 3
Breakfast Breakfast Scrambled eggs
Vegetable soup Steamed fish 1 cup of rice
1 cup of rice 1 cup of rice 1 glass of water
1 glass of water 1 glass of water
Lunch Lunch Lunch
Chicken tinola Fish stew with malunggay Fish tinola
1 slice of banana 1 cup of rice 1 cup of rice
1 glass of water 1 glass of water 1 slice of banana
1 apple 1 glass of water
Dinner Dinner Dinner
Monggo with malunggay Vegetable tapa Chicken pancit with
1 cup of rice 1 cup of rice vegetables
1 glass of water 1 glass of water 1 cup of rice
1 glass of water

b. Diet Restrictions:
● Reduce the amount of fat, cholesterol, and salt (sodium) in the patient's diet,
especially if they have high blood pressure.
● Eat less red meat and processed meats.
● Limit vegetable oils and nut oils, sweets, and processed foods such as chips,
cookies, and baked goods.

7. Spiritual Care and Psychological or Sexual Needs (Give special consideration to

religious and cultural practices)
Spiritual and Psychological Needs
( ) Spiritual Counseling
( ) Grief Work
( ) Anger Management
( ) Confession
( /) Family Therapy
( ) Reconciliation of Conflicted Relationships
( ) Supportive Counseling
( ) Join Church Organizations/Activities
(/ ) Prayer
(/ ) Meditation, Reflection, and Spiritual Devotion
(/ ) Religious Rituals
( ) Religious/Spiritual Materials

Sexual Needs

47
 ( ) Marriage Counseling
( ) Sex Therapy
( ) Sexual Violence
( ) Referral to Appropriate Agencies

C. DISCHARGE DETAILS
a. Date and Time of Discharge: N/A
b. Accompanied by: N/A
c. Mode of Transportation: N/A
d. General Condition upon Discharge: N/A

This discharge plan was explained to me by my student nurse and I have understood it.

___________________________
CLIENT/SIGNIFICANT OTHER
(Signature over Printed Name)

Instructed By: Approved By:

____________________________
________________________________
STUDENT NURSE CLINICAL INSTRUCTOR
(Signature over Printed Name) (Signature over Printed
Name)

48
 REFERENCE

● Ackley, BJ, Ladwig, GB, et al. (2020). Nursing diagnoses handbook: An evidence based-guide to

planning care. St. Louis, MO: Elsevier

● Carpenito, L. (2016). Handbook of Nursing Diagnosis (15th ed.)

● Doenges, ME, Moorhouse, MF, & Murr, AC (2019). Nurse's pocket guide: Diagnoses, prioritized

interventions, and rationales. Philadelphia: FA Davis

● American Association of Neurological Surgeons. (2022). Neurosurgical Conditions and Treatments

to Stroke. Retrieved November 9, 2022 from https://www.aans.org/Patients/Neurosurgical-

Conditions-and-Treatments/Stroke

● Heidi Moawad, M.D. — By Jill Seladi-Schulman, Ph.D. (April 20, 2020). What to Know About

Your Brain’s Frontal Lobe. Retrieved November 09, 2022 from

https://www.healthline.com/health/frontal-lobe#rehabilitation

● Tonya Hines, CMI, Mayfield Clinic, Cincinnati, Ohio. (May 2018). Anatomy of the Brain.

Retrieved November 09, 2022 from https://mayfieldclinic.com/pe-anatbrain.htm

● Johns Hopkins Medicine. (2022). Effects of Stroke. Retrieved November 09, 2022 from

https://www.hopkinsmedicine.org/health/conditions-and-diseases/stroke/effects-of-stroke

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