UNIVERSITY OF SOUTHERN PHILIPPINES-FOUNDATION

COLLEGE OF NURSING
SALINAS DRIVE, LAHUG

A case study

on

HEMORRHAGIC CEREBROVASCULAR DISORDER

Submitted by:

Villano, Charles Dominic Y.

BSN 4 – D
 CLIENT IN CONTEXT
Name : M.C.
Age : 78 years old
Sex : Female
Status : Widow
Address : 88-E Tangcaan, Cebu City
Name of Hospital : Cebu City Medical Center
Date of Admission : July 19, 2010
Ward and Bed number : Female Medical Ward
Case number : 367737
Chief complaints : Body malaise
Medical Diagnosis : Hemorrhagic Cerebrovascular Disorder

Cerebrovascular disease is a group of brain dysfunctions related to disease of the

blood vessels supplying the brain. Hypertension is the most important cause; it damages
the blood vessel lining, endothelium, exposing the underlying collagen where platelets
aggregate to initiate a repairing process which is not always complete and perfect.
Sustained hypertension permanently changes the architecture of the blood vessels
making them narrow, stiff, deformed, uneven and more vulnerable to fluctuations in
blood pressure

Hemorrhagic strokes result in tissue injury by causing compression of tissue from an

expanding hematoma or hematomas. This can distort and injure tissue. In addition, the
pressure may lead to a loss of blood supply to affected tissue with resulting infarction,
and the blood released by brain hemorrhage appears to have direct toxic effects on
brain tissue and vasculature.
DEVELOPMENTAL TASK

Patient’s Developmental
Theories Developmental task
Task
Erik Erikson’s Eight Late Adulthood (45 years Patient verbalizes that she is
Stages of Development old and above) “Integrity contented with her situation in
vs. Despair“ life before her hospitalization.
Even though she was not able to
pursue her secondary education,
she was pleased with what her
life’s journey was about. Patient
also verbalized feelings of
accomplishment in providing
care for her family until they
were able to provide the needs
for themselves. Although being
financially inadequate, she was
still diligent in her job as a
laundrywoman. Based on the
assessment, the patient is
pleased with her way of living.

Havighurst’s Age Period Late Maturity Patient is still working as a

and Developmental laundrywoman to add some
Tasks income for her family. She is
staying with her 4th daughter
and she would like to help in
uplifting their financial status.
She is part of a group of elderly
who prays in the chapel every
novena and Sundays. She has
accepted the fact that she has a
degenerative state of health.
HEALTH ASSESSMENT
A. History of Past Illness
Client has suffered from common illnesses such as cough, colds and fever
alongside her development from childhood to adult. She experienced chickenpox during
her early elementary years. She goes to a clinic for a check-up when she is not feeling
well. She has no history of having major hospitalizations.

B. History of Present Illness

One week prior to admission, patient had onset of left-sided weakness. No
consult was done, no medications were taken and her condition was tolerated.
Five days prior to admission, patient had onset of fever and was given
Paracetamol which relieved the fever.
Two days prior to admission, onset of constipation and fever compels the patient
to seek consult thus resulting to admission. Upon admission, patient was diagnosed with
Hemorrhagic Cerebrovascular Disorder Infarct Right Middle Cerebral Artery alongside
with two other probable diagnoses.
C. Family History
Patient’s family has a history of Hypertension and Heart Problems on both sides
of the family. She and her brothers are exhibiting signs of Hypertension.
Genogram:

Legends:
 - Male - Patient
- Female
- with Heart Problems
- with Hypertension
- Deceased

D. Obstetrical History
The patient had her menarche at 11 years of age. She stated that she had a
regular cycle and that she has dysmenorrheal during her menstruation. She has 9
children and had her prenatal check-ups at their local health center. Her menopause
started when she was 45 years of age.

GORDON’S HEALTH PATTERN

A. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN

Before her admission, patient viewed her general health a 7 out of 10 because she
has not being practicing healthy living. The client viewed her present health a 5 out of
10, 10 being the highest, because she has not been well and has experienced
discomfort and pain during her stay at the hospital. Her goal is to be able to recover
from her illness and to be free from pain.

B. NUTRITIONAL AND METABOLIC PATTERN

Before her admission, patient consumes a lot of food containing protein,
carbohydrates, cholesterol and salt. She eats foods that are easily found in a sari-sari
store. She drank 4-5 glasses of water per day. She does not take any vitamin
supplements. The following is an example of her dietary menu in 24-hours
Breakfast:one (1) cup of rice, fried eggs (2), salted fish, water
Lunch: one (1) cup of rice, salted fish, vegetables, soup, water
Dinner: one (1) cup of rice, vegetables, meat, soup, water
During her admission, patient was on blenderized feeding with 1500kcal/day with
sips of water in six divided feedings.
 Last August 9, 2010, patient was advised to be on soft diet if able to tolerate in a
sitting position while eating or drinking.

C. ELIMINATION PATTERN
Before her admission, she defecates twice in a week with semi-solid feces and
urinates 3-4 times in a day with light yellow colored urine.
During her admission, she has experienced constipation and has not been able to
defecate during assessment. Her urination pattern has not changed.

D. ACTIVITY-EXERCISE PATTERN
She stated that she works as a laundrywoman the entire day. She wakes up early in
the morning for a morning stroll around the house. She then goes out to do her job and
returns late in the afternoon. Her daughter said that her mother usually overdo her job,
comes home late at night and arrives very tired.

E. SLEEP-REST PATTERNS
She sleeps early in evening at around 9 o’clock after watching television. She has
uninterrupted sleep for 7 hours as she wakes up at around 4 o’clock. She has no
prescribed sleeping medication or any sleeping devices. She does not sleep during the
afternoon because her work takes the time.
During her admission, she has difficulty sleeping because of the environment, the
pain and discomfort she has been experiencing. She stated that she has interrupted
sleep, experiencing short episodes of waking up at dawn.

F. COGNITIVE AND PERCEPTUAL PATTERNS

The patient is able to read and write. Upon assessment, her sensory organs are still
functioning well.

G. SELF PERCEPTIONS AND SELF CONCEPT PATTERNS

The patient views herself as a burden to her family. Because she is in a hospital, she
thinks that she is just making more expenses for the family.
H. ROLE RELATIONSHIP PATTERNS
She has a good relationship with her children. She has been visited by her children
who are worried about her health.

I. SEXUALLY-REPRODUCTIVE PATTERNS
The patient is sexually hypoactive since she is a widow for several years already. She
stated that she has no problems regarding her reproductive health.

J. COPING STRESS PATTERNS

Her family spends time with the patient and never leaves her side. She always has
his grandson to assist her in everything she needs.

K. VALUES-BELIEF PATTERNS
She has strong faith in God. She goes to church every Sunday to hear mass and
joins novenas at their local chapel.

PHYSICAL EXAMINATION
Date assessed: August 2, 2010
General survey: examined patient lying on bed in a Sims Lateral position, awake,
conscious and coherent, with intravenous fluid # 4 Plain Normal Saline Solution 1L at
30gtts/min infusing well on right hand, with a patent nasogastric tube, with oxygen of 2-
4L via nasal cannula with the following baseline vital signs: T-37.1°C, P- 89bpm, R-
26cpm and BP-100/40mmHg. Patient appears to be appropriate with chronological age
but is also generally weak. Patient has difficulty in saying the words loudly and properly.
 PART
INSPECTION PALPATION PERCUSSION AUSCULTATION
EXAMINED
brown skin
color, dry and
wrinkled skin,
no lesions,
black spots on
the cheeks
and nose,
presence of senile skin
SKIN N/A N/A
decubitus turgor,
ulcers on the
sacral area
(Stage4), left
anterior calf
and both
calcaneal area
(Stage1).

CRT : <2
pale, dirty,
NAILS secs, dry N/A N/A
short,

HAIR white hair with N/A N/A N/A

thin strands,
equally
distributed on
the head, no
hair on the
armpit and
genital area,
(-) dandruff
 and lice, dry
scalp
smooth and
hard contour,
no lesions, no
discharges,
HEAD normocephalic no masses, N/A N/A
no nodules,
no
depressions

brown-colored
iris, pupils
equally round,
reactive to
light and
accommodatio No masses,
EYES n, anicteric lesions N/A N/A
sclerae, pale present
conjunctiva,
cloudy cornea
at bottom
part,

EARS color same no lesions or N/A N/A

with the face, nodules
symmetrical,
few hair, can
hear ticking of
clock on both
ear, few
cerumen
present,
 wrinkly
earlobe, pinna
aligned to the
outer canthus
of the eyes
color same
with the face,
symmetrical,
(-) nasal
no nodules,
flaring, no
NOSE lesions or N/A N/A
unusual
masses
discharges,
some dry
mucus, few
hair
(-)
transluminatio
n test, no
SINUS N/A tenderness N/A N/A
upon
palpation

MOUTH symmetrical, no lesions, no N/A N/A

dark pink, dry discharges
and intact lips,
(+) prosthesis,
slightly
opened and
closed with
difficulty, (-)
tonsillitis. (+)
halitosis,
tongue in
 midline
trachea in
midline,
nonpalpable
neck color
lymph node,
NECK AND same with the
cervical pulse N/A N/A
LYMPH NODES face, wrinkly
easily
skin,
palpable, no
neck vein
distention
CHEST/ fair skin color, No masses, N/A (+) harsh sounds
THORAX no nodules, no lesions and heard
lesions, no nodules
masses, ECE, present
(+) equal
chest
expansion, (-)
barrel chest,
(-) chest
indrawing,
shoulder are
of the same
height with
the spine
vertically
aligned, both
breasts are
non-tender to
touch, sagging
and wrinkly,
axillary area
was dry
without hair,
 posterior
expansion was
symmetrical
upon
inhalation
(+) pulsation
above the
distinct sound at
sternum,
HEART N/A N/A the tricuspid and
strong
bicuspid valve
peripheral
pulses
(-) fractures,
weakness
noted,
weakness in
moving all
extremities, no
MUSCULO presence of
joint swelling, N/A N/A
SKELETAL edema (+1)
cannot sit up
because of
ulceration on
sacral area,
less muscle
mass
ABDOMEN bloated, (-) presence of no abdominal hypoactive bowel
umbilical mass on the tenderness sounds of 4 cycles
protrusion, no hypogastric per minute
wounds, no area, bladder
lesions, no palpable and
discharges, (-) hard
ascites,
no rash on
skin, round
 abdominal
contour,
urinates about
400cc per shift
in her diapers,
no defecation
noted in a 24-
hour period

NEUROLOGICAL:
CRANIAL NERVE ASSESSMENT

Nerve Name Function Result

Can identify smell when
I Olfactory Smell
introduce to both nostrils
Can identify the things asked
II Optic Visual Acuity
to name
Pupil constrict when light is
III Oculomotor Pupillary Reaction
introduced
Can follow the finger without
IV Trochlear Eye Movement
moving the head
Facial Sensation Can feel when face is pinched
V Trigeminal
Motor Function Can open her mouth
VI Abducens Motor Function Can move eyes laterally

Can smile, frown, puff her

Motor Function
cheeks
VII Facial
Can identify taste correctly and
Sensory
can feel touch appropriately

Can hear the ticking of clock at

VIII Acoustic Hearing
both ears

IX Glossopharyngeal Swallowing and Voice Can swallow and say “aah”

X Vagus Gag Reflex Positive gag reflex

 Weakly shrugs shoulders
XI Spinal Accessory Neck motion
against resistance

Tongue Movement Can move tongue up, down

XII Hypoglossal
and Strength and to the sides

DIAGNOSTIC and LABORATORY FINDINGS

A. Complete Blood Count
Date taken: July 19, 2010 and August 7, 2010
Results
Results
(as of
(as of Normal
Indicators August Interpretation Significance
July 19, Range
7,
2010)
2010)
The patient is
4.5- It is shown that it experiencing sepsis
White Blood
10.7 15.0 11.0x10 3  is higher in the due to her Stage4
Cell
/mm 3 second result. decubitus ulcer on
her sacral area.
Because the
A decrease in patient is of old
12.0 -
Hemoglobin 6.0 11.3 hemoglobin age, there is poor
15.0
signifies anemia reabsorption of
iron in the body
The patient was on
Increase of
folic acid
hematocrit level
Hematocrit .18 .34 .36 - .44 supplement thus
in comparison
the increase of
with the first test.
hematocrit level.
Adequa Adequa 100,000 to
Platelet Normal None
te te 450,000
Lymphocyte 0.16-0.46
.06 .13 Decrease
s fraction of
 white
blood cells
0.04-0.11
fraction of
Monocytes .01 .01 Decrease
white
blood cells
B. Electrolytes
Date taken: July 19, 2010 and August 3, 2010
Results Results
Normal
Indicators (as of July (as of August Interpretation Significance
Range
19, 2010) 3, 2010)
The patient
has sodium
There is a
bicarbonate
135 - 147 significant rise
Sodium 122.0 146.0 that helped
mEq/L between the
increase
two results.
her sodium
levels.
Contributes
3.5 - 5.2 Potassium is to patients
Potassium none 2.57
mEq/L decreased. muscle
weakness

C. Blood Chemistry
Date taken: July 20, 2010
Results
Indicators (as of July 20, Normal Range Interpretation Significance
2010)
Within normal
Creatinine 1.26 0.5 - 1.4mg/dL none
range
The obtained
result is higher No
SGPT 37 <35 IU/L
than the interpretation
normal range.
D. Urinalysis
Date taken: July 17, 2010

Normal
Indicators Results Interpretation Significance
Findings
Color Dark yellow Yellow Normal None
Turbidity Clear Clear Normal None
Pus 0.1 None Normal None
Bacteria Few rare Normal None
pH 6.0 5-7 Normal None
Specific gravity 1.025 1.001-1.035 normal None
Protein Negative negative-trace Normal None
Glucose Negative negative Normal None

E. Arterial Blood Gas

Date taken: August 11, 2010
Normal
Indicators Results Interpretation Significance
Findings
A manifestation of
pH 7.497 7.35-7.45 Blood pH is alkaline
the patient’s illness
Because there is low
oxygen level, the
 Low
normal response of
PaCO2 (respiratory
pCO2 28.5 35-45mmHg the body is to
alkalosis) hyper- or
increase ventilation
over ventilation.
to increase oxygen
supply.
In patients with
A low O2 indicates
stroke, there is
that the patient is
obstruction in the
pO2 67.2 80–100mmHg not respiring
circulation causing
properly, and is
deprivation of
hypoxemic.
oxygen.
19 – 26
HCO3 21.5 Normal None
mmol/ml
 Hypoxia can be
In a patient with low
caused by any event
pO2, there is a
that severely
decrease in the O2
SO2 94 95-98% interferes with the
saturation in which
brain's ability to
they are directly
receive or process
proportional
oxygen.
Creatinine 1.4 0.6-1.5mg/dL Normal None

SUMMARY OF SIGNIFICANT FINDINGS

GORDON’S HEALTH
HEALTH ASSESSMENT LABORATORY FINDINGS
PATTERN

Nutrition-Metabolic: eats Skin: presence of decubitus Complete Blood Count

mostly cholesterol and ulcers (stage4) on sacral  WBC
salt containing foods area  Hct
 Hgb
Activity-Exercise: Mouth: slightly  Lymphocytes
overworks, fatigue opened and closed with  Monocytes
Sleep-Rest: does not get difficulty
any rest in between work Blood chemistry
Abdomen: presence of  SGPT
mass on hypogastric area,
palpable bladder, Electrolytes
constipation  Sodium
 Potassium
Musculoskeletal: general
weakness Arterial Blood Gas
 pH
Chest: RR – 26cpm  pCO2
 pO2
  SO2

ANATOMY AND PHYSIOLOGY

Circulatory System
The circulatory system is extremely important in sustaining life. It’s proper
functioning is responsible for the delivery of oxygen and nutrients to all cells, as well as
the removal of carbon dioxide, waste products, maintenance of optimum pH, and the
mobility of the elements, proteins and cells, of the immune system. In developed
countries, the two leading causes of death, myocardial infarction and stroke are each
direct results of an arterial system that has been slowly and progressively compromised
by years of deterioration.
Arteries
Arteries are muscular blood vessels that carry blood away from the heart, oxygenated
and deoxygenated blood. The pulmonary arteries will carry deoxygenated blood to the
lungs and the systemic arteries will carry oxygenated blood to the rest of the body.
Arteries have a thick wall that consists of three layers. The inside layer is called the
endothelium, the middle layer is mostly smooth muscle and the outside layer is
connective tissue. The artery walls are thick so that when blood enters under pressure
the walls can expand.
Arterioles
An arteriole is a small artery that extends and leads to capillaries. Arterioles have thick
smooth muscular walls. These smooth muscles are able to contract (causing vessel
constriction) and relax (causing vessel dilation). This contracting and relaxing affects
blood pressure; the higher number of vessels dilated, the lower blood pressure will be.
Arterioles are just visible to the naked eye.

Capillaries
The "capillary bed" is the network of capillaries present throughout the body. These
beds are able to be “opened” and “closed” at any given time, according to need. This
process is called autoregulation and capillary beds usually carry no more than 25% of
the amount of blood it could hold at any time. The more metabolically active the cells,
the more capillaries it will require to supply nutrients.
Veins
Veins carry blood to the heart. The pulmonary veins will carry oxygenated blood to the
heart awhile the systemic veins will carry deoxygenated to the heart. Veins have low
blood pressure compared to arteries and need the help of skeletal muscles to bring
blood back to the heart. They also have a thick collagen outer layer, which helps
maintain blood pressure and stop blood pooling. If a person is standing still for long
periods or is bedridden, blood can accumulates in veins and can cause varicose veins.
The hollow internal cavity in which the blood flows is called the lumen. A muscular layer
allows veins to contract, which puts more blood into circulation.

Venules
A venule is a small vein that allows deoxygenated blood to return from the capillary
beds to the larger blood veins, except in the pulmonary circuit were the blood is
oxygenated. Venules have three layers; they have the same makeup as arteries with
less smooth muscle, making them thinner
Cerebrovascular system

Physiologic significance
The arrangement of the brain's arteries into the Circle of Willis creates redundancies in
the cerebral circulation. If one part of the circle becomes blocked or narrowed
(stenosed) or one of the arteries supplying the circle is blocked or narrowed, blood flow
from the other blood vessels can often preserve the cerebral perfusion well enough to
avoid the symptoms of ischemia.
Anatomic variation
In one common variation the proximal part of the posterior cerebral artery is narrow and
its ipsilateral posterior communicating artery is large, so the internal carotid
artery supplies the posterior cerebrum. In another variation the anterior communicating
artery is a large vessel, such that a single internal carotid supplies both anterior cerebral
arteries.
The left and right internal carotid arteries arise from the right and left common carotid
arteries.
The posterior communicating artery is given off as a branch of the internal carotid artery
just before it divides into its terminal branches - the anterior and middle cerebral
arteries. The anterior cerebral artery forms the anterolateral portion of the Circle of
Willis, while the middle cerebral artery does not contribute to the circle.
The right and left posterior cerebral arteries arise from the basilar artery, which is
formed by the left and right vertebral arteries. The vertebral arteries arise from
the subclavian arteries.
The anterior communicating artery connects the two anterior cerebral arteries and could
be said to arise from either the left or right side.
All arteries involved give off cortical and central branches. The central branches supply
the interior of the Circle of Willis, more specifically, the Interpeduncular fossa. The
cortical branches are named for the area they supply. Since they do not directly affect
the Circle of Willis, they are not dealt with here.

PATHOPHYSIOLOGY

Precipitating Factors:
Predisposing factors:
Hypertension
Age other heart diseases
Hereditary undesirable levels of cholesterol
Socioeconomic status poor diet

Atherosclerosis

Formation of plaque deposits

Thrombosis

Hypertension
Occlusion of major vessel

Lysed or moved thrombus from then vessel

Vascular wall becomes fragile and weakened

Leaking of blood from the fragile vessel wall

 Cerebral hemorrhage Cerebral Hypoperfusion

Blood seeps into the ventricles Mass of blood forms and grows
Impaired distribution of oxygen and glucose

Vasospasm of tissues and arteries

Tissue hypoxia and cellular starvation
Obstruction of CSF passageway

Accumulation of CSF in the ventricles

Formation of small and large clots

Lodges unto other cerebral arteries Cerebral Ischemia

Unrelieved obstruction Initiation of Ischemic cascade

Compression of tissue Cerebral edema

Vascular congestion

Increased intracranial pressure

Impaired perfusion and function

Anterior cerebral
Posterior
artery
cerebral
Internal
artery
carotid
Middle
artery
cerebral
Vertebrobasilar
artery Antero
system Postero inferior cerebellar
inferior cerebellar

Sx:
 Patient’s
Book-based Interpretation
manifestation
Patient has a mild case of the disorder therefore
Headache x
there is no increase in ICP
Change in Patient has a mild case of the disorder therefore
x
alertness there is no increase in ICP
Changes in Due to the patient’s old age, her hearing
√
hearing capabilities are degenerating
Changes in
x Patient’s cranial nerve’s are still intact
taste
Patient has a mild case of the disorder therefore
Confusion x
there is no increase in ICP
Loss of Patient has a mild case of the disorder therefore
x
memory there is no increase in ICP
Difficulty
x Patient’s cranial nerve’s are still intact
swallowing
Difficulty
√ Patient has general body weakness
writing
Patient has a mild case of the disorder therefore
Vertigo x
there is no increase in ICP
Lack of control
over the Due to old age, patient has weak or minimal
√
bladder or bladder and bowel control
bowels
Loss of balance x Patient only has mild attack without complications
Loss of
x Patient only has mild attack without complications
coordination
Muscle
√ Due to patient’s old age and prolonged bed rest.
weakness
Paresthesia x Patient only has mild attack without complications
Mood changes x Patient only has mild attack without complications
Changes in
x Patient’s sensory perception is still intact
sensation
Dysphasia x Patient is able to say words without difficulty
Nausea x Patient has a mild case of the disorder therefore
 there is no increase in ICP
Patient has a mild case of the disorder therefore
Vomiting x
there is no increase in ICP
Dysphagia x Patient’s cranial nerve’s are still intact
Paralysis x Patient only has mild attack without complications
Due to the patient’s old age, her visual capabilities
Visual changes √
are degenerating
MEDICAL MANAGEMENT
A. Pharmacologic Management
 Citicoline
 Lactulose 30cc HS
 Paracetamol 250mg prn pain

B. IV Therapy
 Plain Normal Saline Solution
Normal saline solution is a solution of common salt in distilled water, with strength of
0.9 per cent. It is called normal saline because the percentage of salt resembles that of
the crystalloids in the blood plasma. Another way of stating this is to say that normal
saline is isotonic. Sodium chloride is the major extracellular cation. It is important in
electrolyte and fluid balance, osmotic pressure control and water distribution as it
restores sodium ions. It is used as a source of electrolytes and water for hydration,
treatment of metabolic acidosis, priming solution in hemodialysis and treatment of
hyperosmolar diabetes. It is also used as diluents for infusion of compatible drug
additives.
C. Other treatment
 Oxygen therapy via nasal prong 2L/min
Oxygen therapy is the administration of oxygen as a medical intervention, which can be

for a variety of purposes in both chronic and acute patient care. High blood and tissue

levels of oxygen can be helpful or damaging, depending on circumstances and oxygen

therapy should be used to benefit the patient by increasing the supply of oxygen to

the lungs and thereby increasing the availability of oxygen to the body tissues,

especially when the patient is suffering from hypoxia and/or hypoxemia.

 SURGICAL MANAGEMENT

There was no surgical management done to the patient.

DISCHARGE PLAN

Medications
 Instruct patient to take all the prescribed medications as ordered by the
physician in charge.
Environment
 Advise patient to keep surroundings clean, dust-free, safe and hazard-
free.
Treatment
 Instruct patient to have follow-up check-up after one week (August 18,
2010) at the Out-Patient Department to monitor health status.
Health Teachings
 Advise patient to religiously take her medications.
 Encourage patient to have regular exercise.
 Advise patient to increase oral fluid intake.
 Advise patient to practice proper hand washing.
 Encourage patient to have adequate rest periods.
 Advise patient to maintain a good physical hygiene.
Observable Signs and Symptoms
 Advise patient to seek medical attention when the following signs and
symptoms reoccur:
 Difficulty in breathing
 Severe headache
 Chest pain
 Fever
 Chills
 Loss of ability to move or swallow
  Loss of consciousness
 Seizures
 Sudden loss of sensations
 Sudden change in mental state

Diet
 Encourage patient to have a well-balanced diet
 Teach patient to avoid salty foods, and foods with high cholesterol
content.
 Advise patient to increase oral fluid intake and avoid products containing
caffeine.
Spirituality
 Encourage patient to strengthen her faith in God during her times of
happiness and hardships.
 BIBLIOGRAPHY

A. Books
(2008). Nursing Drug Handbook. 28th ed.
Ackley and Ladwig(2006). Nursing Diagnosis Handbook. 7th ed. Singapore: Mosby
Elsevier.
Bullock and Henze(2006). Focus on Pathophysiology. 6th ed.
Brunner and Suddarth(2008). Medical-Surgical Nursing. 10th ed. pp.

B. Internet
cerebrovascular diseases(www.merck.com)
drug study.(www.mims.com)
cerebrovascular diseases(www.wikipedia.com)
cerebrovascular disease(www.disabled-world.com)
cerebrovascular disorder(www.scribd.com)
nursing care plans(www1.us.elsevierhealth.com)
 APPROVAL SHEET

Prepared by: Checked by:

Charles Dominic Y. Villano Mrs. Carmela S. Malaza, RN

Recommending Approval:

Mrs. Merlyn Ouano, RN, MAN Mrs. Norma A. Hinoguin, RN MN

RLE Coordinator Dean