City of Manila

UNIVERSIDAD DE MANILA

(Formerly City College of Manila)

A. Villegas St. Mehan Garden, Ermita, Manila

In partial fulfillment of the requirement in

Related Learning Experience

Gat Andres Memorial Medical Hospital – Medicine Ward

A Case Study on

CEREBROVASCULAR ACCIDENT with BLEEDING

Submitted to:

Ms. Sandra Loberiano, RN(Clinical Instructor)

Submitted by:

Marie Joy AbelleraMel Acol

Mary Anne AmbolarioJohn Elison AmoresAlyssa Marie Andres

Mica Sheena BautistaRhodelyn Bonifacio

Melvin BufeteJonelyn Carlos

Jhon Calvin ClementeAbegail Conopio

Maria Andrissa Damiar

Group 1 of Nr-31

December 19, 2009

ACKNOWLEDGEMENT

The Researchers would like to acknowledge Gat Andres Bonifacio Memorial Medical

Center for granting us permission to conduct a case study.

To all doctors and staff nurses of medicine ward, for the openhanded assistance and

services they showed.

To the researcher’s loving parents for expressively and economically supporting the

career the researchers have been taking.

The researchers also greatly acknowledge Mr. Romeo R. Orcasitas’ significant other,

for cooperation and willingness she showed.

To the researchers’ Clinical Instructor, Ms. Sandra Loberiano, for sharing her

knowledge, observation and generous cooperation, for the suggestion she gave to secure

information that made a valuable involvement to our case study.

Above anything else, to Almighty God who has given the researchers the guidance and

knowledge to achieve this study.

The Researchers

TABLE OF CONTENTS

Objectives of the Study

Introduction

Nursing Health History

Biographical Data

Chief Complaint

Present Health History

Past Medical History

Family Medical History

Lifestyle

Social Data

Psychological Data

Patterns of Health Care

Physical Assessment

Review of System

Gordon’s Typology of Functions of Health Pattern

Anatomy and Physiology

Pathophysiology

Laboratory and Diagnostic Studies

Medication and Drug Study

Nursing Care Plan

Medical Record

Discharge Plan

Summary

Conclusion

OBJECTIVES OF THE STUDY

General Objective:

At the end of the case study, the Researchers would be able to develop and evaluate

clinical assessment to effectively manage the patient through determining significant signs and

symptoms, history and main etiology of the disease.

Specific Objectives:

To know the risk factors that would contribute to the causation of the disease.

To determine the physiologic changes undergone by the patient with regards to the

condition.

To recognize the health history of the patient as basis for evaluating the disease

condition.

To be familiar of the medical and surgical procedures being done to the patient.

To formulate appropriate nursing intervention and effective care plan in the course

study.

To acquire beneficial knowledge that may improve the researcher’s foundation in

relation to the disease.

INTRODUCTION

Cerebrovascular accidents are the problems that result from inadequate blood supply to

the brain. CVA or in Layman’s term, “stroke” is probably the first disorder that comes to the

mind in considering cerebrovascular disorders.

A cerebrovascular accident or stroke is infarction of a specific portion of the brain due to

insufficient blood supply. It can occur from an occlusion of one of the major vessels feeding the

brain, a partial or complete obstruction of a major intracranial vessel, or it can also be a

hemorrhage within the brain. The blood vessels affected determines the area and extent of

infarction.

The third most common cause of death in most countries is CVD disorders,

approximately 0.5 to 1.0 per 1000 people. The narrowing or complete closure of one of the

vessels supplying the brain is the most common cause of this accident. Furthermore,

thrombosis, embolism and hemorrhage are included. Thrombosis is the most common cause

of stroke and is usually due to atherosclerosis or the fat or lipid deposition in the major vessel

of the cranium. It may occur anywhere along carotid artery and its branches; a common site is

at bifurcation of the common carotid into the internal and external carotid arteries. Cerebral

embolism is the occlusion of the cerebral vessel by emboli and some fragments of clotted

blood, tumor, fats, bacteria and even air. Intracerebral hemorrhage results from rupture of a

cerebral vessel that causes the bleeding into brain tissue.

There are risk factors prior to the recurrence of CVA such as hypertension,

polycythemia, hypercholesterolemia, smoking, oral contraceptives use, emotional stress,

obesity, family history of stroke and age. This condition may alter the original circulation of

blood, then leads to stroke. In line with this, as we all know almost all of the illicit drugs, alcohol

and nicotine found in cigarettes are one of the potent vasoconstrictor.

Stroke depends primarily on the location of the lesion or infracted tissue. If the brain

stem is affected, blood pressure fluctuations altered respiratory patterns and cardiac

dysrythmias are all possible.

Coma can follow stroke from various causes; strokes due to occlusal disease

(thrombus, embolus) rarely caused sudden death. When sudden death thus occurs it is usually

due to heart failure. Respiratory infection and brain stem failure are two primary causes of

death with stroke.

In lieu of the forgoing study, the Researchers presented this case study to enhance the

level of competency not only for the health care providers and the health institution itself, but

also for the knowledge enhancement of ordinary people.

NURSING HEALTH HISTORY

A. Biographical Data

Name: Romeo R. Orcasitas

Age: 43 years old Sex: Male

Address: 809 La Suerte st. Binondo, Manila

Marital Status: Married

Occupation: Messenger (F & N International Freight Forwarder Corporation)

Religious Preference: Roman Catholic

Health Care Financing: Phil. Health, SSS

B. Chief Complaints

Mr. Orcasitas, a 42 year old male patient who was admitted on December 11,

2009 at Gat Andres Bonifacio Memorial Medical Hospital was complaining of left sided

weakness.

C. Present Health History

The patient is having Cerebrovascular Accident (CVA) or commonly known as

stroke. According to Mr. Orcasitas’s significant other which is his wife, the symptoms

started on December 11, 2009 (Friday). It was unexpected and the patient experienced

vomiting, watery sputum with presence of blood and also noticed urine with slightly dark

yellow in color. After a while, the patient had lost its consciousness. The patient also

experienced pain in his nape (left side) on the same day and this accident with signs

and symptoms occurred all of a sudden. The client was drinking alcoholic beverages

before the symptoms manifested. Factors that aggravate the problems are fatigue and

during alcohol drinking as stated by Mrs. Orcasitas.

D. Past Medical History

During his childhood the client had chicken pox, measles, and mumps. He also

had Immunizations like BCG, OPV, AMV, and DPT. The client has no allergy neither he

experienced any accidents or injuries. On December 11, 2009 the client experienced

loss of consciousness which is also a reason of his hospitalization.

E. Family Medical History

Cardiac problems, most pronounced is hypertension for his father side.

F. Lifestyle

Patient doesn’t smoke but he’s drinking alcohol beverages every after work. He

is workaholic at the same time. His hobbies are watching TV and listening to music of

Pepe Smith. He is fond of eating meat, vegetables, fish, and fatty foods and drinks 8

glasses a day. Furthermore, he has no usual food patterns although he eats frequently.

During the course of his condition, CVA, patient was ordered to have OF.

G. Social Data

He is a high school graduate and currently working at F & N International Freight

Forwarder Corporation as a messenger. With regards of his health care, he is regularly

paying for health insurance at Phil. Health. Mr. Orcasitas has three children; a 9 and 6

year old female and an 8 year old male. According to his significant other, he is the one

who handle when he is sick. In addition, health care service like health centers is

geographically accessible for him but not even visit then ever since.

H. Psychological Data

According to the wife of Mr. Orcasitas, the main stressors of the patient is stress

regarding his children, work and financial problems. During this time, the time when he

got stressed, he usually drinks alcoholic beverages as his way to cope to those

stressors. When he has problem, he usually don’t share it to others and he is a serious

person but he loves to share jokes with others.

I. Patterns of Health Care

Mr. Orcasitas has been hospitalized at the Gat Andres Bonifacio Memorial

Medical Center last December 11, 2009 because of diagnosed Cerebrovascular

Accident. His healthcare providers are his physician and nurses on duty. His primary

care provider is himself. According to his significant other, he was cared properly when

he was hospitalized and the health care provider did not neglect him in any way that it

can be.

PHYSICAL ASSESSMENT

General Survey:

Body build, height and weight in relation to the patient’s age is proportional; patient is

conscious and coherent; partially assisted during hospitalization.

Vital Signs:

Blood Pressure: 140/90 mmHg

Temperature: 37.1oC

Respiratory Rate: 21 resp/min

Pulse Rate: 70 bpm

Body Part Tools Normal Findings Interpretation

Skin and Nails Inspection,

Palpation

Varies from light to

deep brown;

uniform skin

temperature and

within normal range;

skin turgor; normal

nail texture; highly

vascular and pink

color of nails

Normal

Hair Inspection Evenly distributed

hair; thick and silky;

no infections or

infestations;

variable amount of

hair

Normal

Head Inspection,

palpation

Rounded; smooth

skull contour;

uniform

consistency;

symmetric facial

features and

movement

Normal

Eyes Inspection,

palpation

Penlight

Eyebrows

symmetrically

aligned; skin intact;

no discharge; no

discoloration;

transparent; shiny

and smooth cornea;

pupils are black in

color; round and

smooth; coordinated

ocular movements

and move in unison.

Normal

Ears

Inspection,

palpation

Symmetrical; auricle

aligned with outer

canthus of the eye,

firm, and not tender.

Normal

Nose

Inspection,

palpation

External nose is

symmetric and

straight; no

Normal

discharge; uniform

in color

Mouth

Inspection,

palpation

Lips are pink in

color; soft and

moist; gums is pink,

moist and pink in

texture.

Normal

Neck

Inspection Muscles equal in

size and head

centered;

coordinated and

smooth head

movements with no

discomfort; equal

muscle strength; not

palpable lymph

nodes.

Normal

Thorax and lungs

Stethoscope,

inspection and

palpations

Chest symmetric;

supine vertically

aligned, skin and

chest wall is intact;

full and symmetric

chest expansion;

costal angle is less

than 90 degrees.

Normal

Abdomen Inspection,

auscultation,

palpation,

percussion

Uniform in color; no

evidence of

enlargement of liver

or spleen;

symmetric

movements caused

by palpations;

audible bowel

sounds; no

Normal

tenderness in

abdomen; relaxed

with smooth and

consistent tension.

Male genitals and

inguinal areas

Palpation Penile skin intact;

foreskin is easily

retractable; penis is

smooth; semi firm

and slightly movable

over the underlying

structures; scrotal

skin is darker in

color; and appears

asymmetric;

inguinal area with

no swelling and

palpable bulges.

Normal

REVIEW OF SYSTEM

CVA is directly affecting the nervous system of the body which is composed of different

parts. This condition is manifested primarily by its level of consciousness. Based on the case

study, the patient experienced weakness at his left side, vomiting, and pain at his nape area.

GORDON’S TYPOLOGY OF FUNCTION OF HEALTH PATTERN

Pre

Hospitalization

During

Hospitalization

Post

Hospitalization

Eating Pattern

The patient is fond of

eating fatty and salty

foods.

The patient is now on

NGT taking osteorized

feeding at 1800 kcal

in 6 equal feedings in

24 hours.

During post

hospitalization the

patient is expected to

eat healthy foods like

vegetables and fruits

(diet modifications).

Drinking Pattern

He is fond of drinking

softdrinks and liquor

and less intake of

water.

Patient is in

osteorized feeding,

and water intake is

taken via nasogastric

tube.

During post

hospitalization the

patient is expected to

drink 8-10 glasses of

water and less intake

of alcoholic

beverages.

Elimination Pattern

His eliminating pattern

usually ranges from 1-

2 times a day.

Urine output

measured in urine bag

is approximately 250

ml per day and

bowel elimination is 2-

3 times a day.

The patient is

expected to have a

good elimination

pattern in connection

with diet and lifestyle

modification.

Sleeping PatternNot good sleeping

pattern, light sleeper.

During hospitalization,

sleeping pattern is

enhanced through

comfort provided by

nurse on duty.

The patient is

expected to have a

good sleeping pattern.

Activity/ Exercise The patient really

likes to watch

television and listen to

the music of Pepe

Smith

During hospitalization,

patient is in bed and

partially assisted by

significant others.

The patient is

expected to bring

back his usual daily

activity such as

watching television

and listening to music.

Furthermore, routine

exercise must be

promoted for good

tone of the body.

Coping Stress/ Tolerance Pattern

When the patient is

having problems, he

usually drinks liquor to

cope and eventually

forget his problems as

stated by his

significant other.

During hospitalization,

patient is always

praying for fast

recovery as his way to

manage the stress

brought by the

condition.

Patient is expected

during post

hospitalization to have

good stress

management skills.

Spiritual Pattern

The patient is a God-

fearing person and

attends the mass

every Sunday.

Patient always pray

for the fast recovery

and therefore more

time is allotted for the

spiritual pattern.

The patient is

expected to

established a more

stronger relationship

to God.

ANATOMY AND PHYSIOLOGY

(Nervous System)

The nervous system integrates and monitors the countless actions occurring

simultaneously throughout the entire human body. Therefore, every task, no matter how

menial, accomplished by a person is a direct result of the components of the nervous

system. These actions can be under voluntary control, like touching a computer key, or

can occur without your direct knowledge, like digesting food, releasing enzymes from

the pancreas, or other unconscious acts.

It is difficult to understand all the complexities of the nervous system because the

field of neuroscience has rapidly evolved over the past 20 years. Moreover, answers to

new questions are being found almost daily. However, a thorough knowledge of the

individual components of the nervous system and their functions will lead to a better

understanding of how the human body works and facilitate the acquisition of knowledge

in the future.

The nervous system consists of two parts; the central nervous system (CNS)

consists of the brain and spinal cord and the peripheral nervous system (PNS) consists

of nerve outside the CNS.

Nerves of the PNS are classified in three ways. First, PNS nerves are classified

by how they are connected to the CNS. Cranial nerves originate from or terminate in the

brain, while spinal nerves originate from or terminate at the spinal cord. Second, nerves

of the PNS are classified by the direction of nerve propagation. Sensory (afferent)

neurons transmit impulses from skin and other sensory organs or from various places

within the body to the CNS. Motor (efferent) neurons transmit impulses from the CNS to

effectors (muscles or glands). Third, motor neurons are further classified according to

the effectors they target. The somatic nervous system (SNS) directs the contraction of

skeletal muscles. The autonomic nervous system (ANS) controls the activities of

organs, glands, and various involuntary muscles, such as cardiac and smooth muscles.

The autonomic nervous system has two divisions; the sympathetic nervous

system is involved in the stimulation of activities that prepare the body for action, such

as increasing the heart rate, increasing the release of sugar from the liver into the blood,

and other activities generally considered as fight-or-flight responses (responses that

serve to fight off or retreat from danger) and the parasympathetic nervous system

activates tranquil functions, such as stimulating the secretion of saliva or digestive

enzymes into the stomach and small intestine.

Generally, both sympathetic and parasympathetic systems target the same

organs, but often work antagonistically. For example, the sympathetic system

accelerates the heartbeat, while the parasympathetic slows the heartbeat. Each system

is stimulated as is appropriate to maintain

homeostasis.

The brain is an organ located in the skull.

It weighs about 3 pounds. The senses

(taste, smell, sight, hearing, and touch),

emotions, thoughts, and movement are

controlled by the brain. The right side of

the brain controls the left side of the body and the left side of the brain controls

the right side of the body.

There are three main part of the brain: the cerebrum, the cerebellum, and the

brain stem. Cerebrum controls higher brain functions and has four lobes, each with

different functions:

Frontal lobe: executive function, decisions, personality, language, planning, movement

Parietal lobe: intelligence, reasoning, sensation, reading

Occipital lobe: vision

Temporal lobe: language, behavior, hearing, vision, emotions, memory

Cerebellum controls balance, coordination, and fine muscle control.

The Spinal cord starts at the brain stem and goes to the tail bone. It is about as

wide as your little finger and extends the length of your back. Messages are carried

from the spinal cord to and from the brain to the rest of the body. Nerves extend from

the spinal cord on each side and go to the parts of the body. The brain and spinal cord

are protected by bony structures: the skull and the spinal column.

Meninges are membranes that cover and protect the brain and spinal cord.

There are three layers of meninges: Dura mater (closest to the bone), Arachnoid loosely

around the brain, Pia mater is closely attached to the brain and spinal cord surface.

Cerebrospinal Fluid (CSF) cushions the brain and spinal cord. It is a clear, water-

like fluid, also called spinal fluid, found between the arachnoid and pia mater. It is made

within the four ventricles of the brain. The area in the lateral ventricles that makes spinal

fluid is called the choroid plexus. About 20cc of spinal fluid is made but not absorbed

each hour. There is about 140 cc (about ½ can of soda) of spinal fluid that surrounds

the brain and spine. The brain and spinal cord are bathed and cushioned by this spinal

fluid, which flows and circulates around the brain and spine.

PATHOPHYSIOLOGY

Risk Factors: Sedentary Lifestyle Substance Abuse Increased lipid and fats in food Increased sugar and carbohydrate intake Obesity Lack of Exercise

HypertensionArterioschlerosis

HyperlipidemiaDiabetes Mellitus

Thrombi Formation

Atheroschlerosis

Dislodged Thrombus from Sire of Attachment(Emboli)

Emboli Obstruction in Cerebral Blood Vessel

Increased Pressure in Cerebral Blood Vessel

Transient Ischemic Attack

Cerebral Blood Vessel Leakage

Cerebral Blood Vessel Leakage

Spasm of Adjacent Vessel

Brain Tissue Compression

Cerebrovascular Accident with Bleeding(Neurologic Deficits)

LABORATORY AND DIAGNOSTIC STUDIES

Electrolytes Result Form

Constituent Result Normal Values Interpretation

Sodium 134.2 mmol/L 135-145 Indicates water excess.

Potassium 4.30 mmol/L 3.4-4.0 Indicates decreased kidney functioning.

Chloride 92-102

Calcium 2.02-2.6

Rationale:

Serum electrolytes are taken in order to know whether the patient has electrolyte

imbalance (excess or deficit in the plasma level of a specific ion). It is important to keep a

balance of electrolytes in the body, because they affect the amount of water in our body, blood

acidity (pH), muscle action, and other important processes.

Clinical Chemistry

Conventional S.I. Unit

Constituent ResultNormal Value

ResultNormal Value

Interpretation

Alkaline Phosphatase

(ALP)____ U/L 35-129 ____ U/L 35-129

ALT/SGPT 27.6 U/L 10-50 27.6 U/L 10-50Indicates normal liver functioning.

AST/SGOT 25.8 U/L 0-38 25.8 U/L 0-38Indicates normal liver functioning.

Cholesterol 206.5 mg/dl

0-200 5.4 mmol/L

0-52 Indicates risk for heart attack and

stroke.

Creatinine 0.93 mg/dl

0.5-1.2 82.2 mmol/L

44-106 Indicates decreased kidney

functioning.

Glucose (FBS) ___ g/dl 74-106 ___ g/L 4.11-5.9

Total Protein ___ g/dl 6.4-8.3 ___ g/L 64-83

Albumin ___ g/dl 3.4-4.8 ___ g/L 34-48

Globulin ___ g/dl 3.0-3.5 30-35

A/G Ratio 1.1-1.8 1.3 mmol/L

1.1-1.8

Triglycerides 117 mg/dl

0-200 0.30 mmol/L

0-2.26 Has normal level of triglycerides to be used as energy of

the body.

Uric Acid (BUA) 5.0 mg/dl 2.4-7.0 7.6 mmol/L

0.14-0.41 Indicates that the body is handling the breakdown of

purines well.

Urea Nitrogen (BUN)

14.7 mg/dl

6-20 5.2 mmol/L

2.1-7.1 Indicates normal kidney excretion.

Sodium 137.2 mg/dl

135-145 137.2 mmol/L

135-145 Indicator of normal water balance.

Potassium 3.80 mg/dl

3.4-4.0 3.80 mmol/L

3.4-4.0 Indicates normal kidney functioning.

Chloride __ mg/dl 92-102 mmol/L 92-102

Rationale:

This test helps provide information about the body's metabolism. It gives health care

providers the information about how the patient’s kidneys and liver are working, and can be

used to evaluate cholesterol, and calcium levels, among other things.

Urinalysis – Clinical Urinalysis

Physical Characteristics Interpretation

COLOR Light yellow Indicates normal urine color.

TRANSPARENCY Slightly hazy Normal transparency.

REACTION 6.5

SPECIFIC GRAVITY 1.020 Kidneys are able to concentrate urine.

Chemical Chemistry

Albumin (+++)

Sugar negative

Occult blood

Bilirubin

HCG Titer

Cells:

RBC 10-20/hpf

Pus cell 0-3/hpf

Squamous cells (+)

Yeast cells

Renal cells

Bacteria

Mucous Threads (++)

Crystals

Amorphous Urate (+)

Uric Acid

Ca Oxalate

Amorphous PO4

Triple PO4

Rationale:

The urinalysis is used as a screening and/or diagnostic tool because it can help detect

substances or cellular material in the urine associated with different metabolic and kidney

disorders. It is also used to detect urinary tract infections (UTI) and other disorders of the

urinary tract.

Clinical Chemistry

Conventional S.I. Unit

Constituent ResultNormal Value

ResultNormal Values

Interpretation

Alkaline Phosphatase

(ALP)____ U/L 35-129 ____ U/L 35-129

ALT/SGPT 27.6 U/L 10-50 27.6 U/L 10-50Indicates normal liver

functioning.

AST/SGOT 25.8 U/L 0-38 25.8 U/L 0-38Indicates normal liver

functioning.

Cholesterol 206.5 mg/dl

0-200 5.4 mmol/L

0-52 Indicates risk for heart attack and

stroke.

Creatinine1.22 mg/dl

0.5-1.2107.8

mmol/L44-106

Indicates decreased kidney functioning.

Glucose (FBS) ___ g/dl 74-106 ___ g/L 4.11-5.9

Total Protein ___ g/dl 6.4-8.3 ___ g/L 64-83

Albumin ___ g/dl 3.4-4.8 ___ g/L 34-48

Globulin ___ g/dl 3.0-3.5 30-35

A/G Ratio 1.1-1.81.3

mmol/L1.1-1.8

Triglycerides117

mg/dl0-200

0.30 mmol/L

0-2.26

Has normal level of triglycerides to be used as energy of

the body.

Uric Acid (BUA) 5.0 mg/dl 2.4-7.07.6

mmol/L0.14-0.41

Indicates that the body is handling the

breakdown of purines well.

Urea Nitrogen (BUN)

21.3 mg/dl

6-20 mmol/L 2.1-7.1Indicates normal kidney excretion.

Sodium __ mg/dl 135-145 mmol/L 135-145

Potassium __ mg/dl 3.4-4.0 mmol/L 3.4-4.0

Chloride __ mg/dl 92-102 mmol/L 92-102

Rationale:

This test helps provide information about the body's metabolism. It gives health care

providers the information about how the patient’s kidneys and liver are working, and can be

used to evaluate cholesterol, and calcium levels, among other things.

Hematology

Result Normal Range Interpretation

Hemoglobin 133 gm/l 120-180Has normal oxygen

carrying capacity of the blood.

Hct .435 0.370-0.540Has normal pack of

RBC/ blood viscosity.

Electrolyte count x109/L 4.0-6.0

Leucocyte count 18.1 x109/L 4.6-10.0Indicates acute

infection/ inflammatory response.

Differential Count

Neutrophils Bands 0-0.05

Segmenter .92 0.60-0.70

Lymphocytes .08 0.20-0.40Indicates increased

WBC capacity.

Monocytes 0-0.07

Eosinophils 0-0.08

Basophils 0-0.1

Cell Indices

MCV 820-920

MCHC 27.0-31.0

Platelet count 340-360

Reticulocyte count 385 x109/L 150-450

Coagulation time x10-5 5-15

Hemoglobin 133 gm/l 120-180Has normal oxygen

carrying capacity of the blood.

Hct .435 0.370-0.540Has normal pack of

RBC/ blood viscosity.

Rationale:

Hematology is the study of blood and its disorders. Hematology tests can help diagnose

anemia, hemophilia, blood-clotting disorders, and leukemia. It is actually a panel of tests that

examines different parts of the blood. It also helps to determine the general health status of the

patient.

Medications and Drug Study

Generic

NameClassification Indication Contraindication

Dosages and

RouteSide Effects

Nursing

Responsibilities

Mannitol Diuretic Reduction of

intracranial

pressure and

brain mass.

Active intracranial

bleeding,

hypersensitivity,

anuria, severe

pulmonary

congestion,

edema, severe

dehydration,

progressive heart

failure and renal

failure.

Oliguria,

prevention

Adult: IV 50

– 100g 5% -

25% sol

Renal failure

Adult: IV 50

– 200 g/24

hr, adjusted

to maintain

output of

30-50 mg/hr

Pulmonary

congestion, fluid

and electrolyte

imbalance,

electrolyte loss,

dryness of mouth,

thirst, marked

diuresis, urinary

retention, edema,

headache, blurred

vision,

convulsions,

nausea, vomiting,

rhinitis, arm pain,

skin necrosis,

chills, dizziness,

Monitor blood

pressure.

Check for

hypervolemia,

urinary tract

obstruction

and signs of

fluid

imbalance.

dehydration,

hypotension,

tachycardia, fever

and angina-like

chest pains.

Amlodipine Calcium-

channel

Blockers

Treat high blood

pressure or

chest pain.

Sick sinus

syndrome, 2nd- or

3rd-degree heart

block,

hypertension less

than 90 mm Hg

systolic,

hypersensitivity

Angina

Adult: PO 5

– 10 mg

q.d.

Hypertension

Adult: PO

5mg q.d.

initially, may

increase up

to 10mg/day

Headache and

edema (swelling)

of the lower

extremities,

dizziness,

flushing, fatigue,

nausea, and

palpitations

Assess cardiac

status: B/P,

pulse,

respiration,

ECG

Teach pt. do

not break,

open, crush, or

chew sust rel

caps

Nimodipine Cardiovascular

drugs

Improvement of

neurologic

deficits after

No known

contraindications

Adult: 60

mg PO q4

for 21 days.

Headache,

psychic

disturbances,

Use cautiously

for pt with

hepatic failure

subarachnoid

hemorrhage

from ruptured

congenital

aneurysm

Begin

therapy

within 96

hours after

subarachnoi

d

hemorrhage

decreased blood

pressure,

flushing, edema,

tachycardia

Monitor blood

pressure and

heart rate

Clarithromycin Semi-synthetic

macrolide

antibiotic

Treatment of

mild to

moderate

infections

caused by

susceptible

strains of the

designated

microorganisms

Hypersensitivity

to this drug or

macrolide

antibiotics

Adult: PO

250-500 mg

bid for 7 –

14 days:

500mg bid

continues

for M. avium

(mac)

Diarrhea, nausea,

abnormal taste,

dyspepsia,

abdominal

pain/discomfort,

and headache.

Assess I & O

ratio: report

hematuria,

oliguria in renal

disease

Assess skin

eruptions,

itching

Administer

adequate

intake of fluids

(2 L)

Adult: PO Monitor blood

Losartan Anti-

hypertensive

Hypertension,

alone or in

combination

Hypersensitivity 50mg q.d.

alone or 25

mg qd when

used in

combination

Dizziness,

insomnia, anxiety,

confusion,

abnormal dreams,

migraine, tremor,

vertigo

pressure.

Assess

edema in feet,

legs q.d.

Skin tugor,

dryness of

mucous

membrane for

hydration

status

Cefuroxime Broad-

spectrum

antibiotic

Serious lower

respiratory tract,

urinary tract,

skin, bone joint,

gonococcal

infection;

septicemia,

meningitis

Hypersensitivity

to

cephalosporins,

infants <1 mo

Adult &

child: PO

250mg q

12h; may

increase to

500mg q

12h in

serious

infections

Adult: IM/IV

750mg-1.5g

Headache,

dizziness,

weakness,

paresthesia,

fever, chills

Assess bowel

pattern q.d.; if

severe

diarrhea

occurs, drug

should be

discontinued;

may indicate

pseudomemb

ranous colitis

Assess for

q8h for 5-10

days

allergic

reactions

NURSING CARE PLAN

Assessment Diagnosis Rationale Planning Intervention Rationale evaluation

S: "balisa sya sa tingin ko"  as stated by the significant other

O: pt. is consciousshowed slow reaction the pt. eyes is shallow and dark spot around the orbital area

V/SB/P: 160/100RR: 23PR: 94T: 36.6

Altered sleeping pattern related to present condition as evidenced by slowed reaction and irritability.

Due to present condition the sleep pattern was altered that makes the pt. irritable and refuse to cooperate.

After a series of nursing intervention the pt. will be able to adjust sleeping pattern as usual.

1. established rapport

2. offer back massage

3. recommend divertional activities

4. provide calm quiet environment

5. position client comfortably in bed

to established trust and cooperation

for relaxation and comfort

to reduce irritation and to relax

to  enhance sleep

For comfort and relaxation.

After a series of nursing intervention the patient was able to adjust sleeping pattern as usual.

Assessment Diagnosis Rationale Planning Intervention Rationale Evaluation

S: "masakit ang batok nya kapag nagagalaw ko sya patagilid" as verbalized by the significant others

O: consciuos impaired ability to move side to sidefacial grimace of L7 out of L10

VSBP:140/100RR:24PR:94T:36.0

impaired mobility due to present illness

Due to decreased muscle strength related to his present illness the patient have impaired mobility.

After a series of Nursing Intervention the pt. will be able to increased muscle strength as seen in his initiative to move and was able to move from complete assistance to partially assist.

1. established rapport

2. maintained proper hygiene

3. give body massage

4. ROM exercise was doneturn the client every 2hr

elicited trust and cooperation

for relaxation and comfort

to stimulate blood flow

to increase muscle strength and prevent muscle atrophyto prevent pressure sore

After a series of nursing intervention the pt has gained muscle strength that enables him to improve his mobility as evidence by his initiative to do independently.Facial grimace was lessening as evidence by L4 from L7 facial grimace scale.

Assessment Diagnosis Rationale Planning Intervention Rationale Evaluation

S:”nahihirapan na siyang magsalita, puro ungol na lang.” s verbalized by the significant other

O:conscioussocial behavior is altered due to NGT insertiondysfunctional interaction with others

VSBP:160/100RR:23PR:94T:36.6

impaired social interaction due to communication barriers cause by neurological condition as evidence by inability to communicate that altered his social behavior

due to present neurological condition the client has an altered communication process that cause his impaired social interaction

 pt.  elicited and expressed desire in achieving positive changes in social behaviors and interpersonal relationship

1. established rapport

2. established therapeutic relationship to the pt

3. divertional activity was introducedposition the client

to gain trust and cooperation

to alleviate  the level of discomfort and increased social interaction

to encourage pt to involve such activityfor comfort and relaxation

After as series of nursing intervention the client is able to increase his social behavior as evidence by his initiative to cooperate and communicate well.

MEDICAL RECORD

Room No. 617

Patient’s Name: Orcasitas, Romeo

Age: 43 years old

Sex: Male

Address: 809 La Suerte St. Binondo, Manila

Diagnosis: CVA with Bleeding

December 11, 2009

6:00 am

11:00 am

received patient lying in bed conscious and coherent with

significant other

with IV fluid PNSS 1L x 12o at 600 ml level intact, NGT,

and foley catheter intact

morning care performed

comfort provided by changing lines

vitals signs taken and recorded as follows:

BP = 140/100 mmHg

HR = 71 bpm

RR = 20 resp/min

Temp = 37.1 oC

due meds taken at 9:30 am

vitals signs taken and recorded as follows:

11:30 am

12:00 am

BP = 140/90 mmHg

HR = 70 bpm

RR = 22 resp/min

Temp = 36.7 oC

seen and examined by Dra. Dela Cruz with orders made

health teachings rendered are as follows:

mannitol 100 ml TIV given

endorsed patient with IV fluid PNSS 1L x 8o at 400 ml level

Jhon Calvin V. Clemente

UDM, SN

DISCHARGE PLAN

Medications - home meds should be taken as prescribed on exact dosage, time,

and frequency via NGT.

- Cefuroxime 750mg/OD q8

- Clarithromycin 500mg/tab BID

- Amlodepine 10g/tab OD

- Losartan 50g/tab OD

- Simvastatin 1 tab OD HS

- Citicholine 500g TID q6

Exercise - prefer PROM exercise due to left sided weakness. It should be done at

least every morning.

Treatment - continue take home medications

- TCB after one week OPD at medicine department, 1pm

Health Teachings - render health teachings to the SO regarding:

- proper PROM

- positioning q2 to avoid decubitus ulcer

- good oral care

- bed bath at least OD

- hand washing before and after NGT feeding.

Out-Patient Department - TCB after 1 week for follow-up check-up to ensure the

continuing management and treatment.

Diet - continue OF as ordered.

- eat healthy foods and drink plenty of water

Spiritual - always pray to almighty god for spiritual support

SUMMARY

The study focused on the condition how stroke occurs and the damage causes to

the patient. A stroke can occur anywhere in the brain or just outside it in cases of

subdural or subarachnoid. The symptoms that the patient experienced are due to his

right hemisphere of the cerebrum damage, the result is the weakness on his left side of

the body. It interfere the patient ability to walk, talk, eat and perform other self care

tasks in the later stage of the condition. Brain stem strokes are the most devastating

and life threatening because they can disrupt the involuntary functions, essential to life.

In line with this topic, the Researchers made a case presentation focusing to

stroke. The name of the patient is Mr. Romeo R. Orcasitas, a 43 year old male and

working as a messenger in F&N INT’L. FREIGHT FORWARDER CO. currently. Aside

from the biographical data, the researchers also collected the patient’s diet and lifestyle,

habits, social data, psychological data, family background and health history and any

information that can be used to enhance the study. Mr. Orcasitas is an alcohol drinker,

since then until the time he was admitted, but he never tries to be a smoker. With

regards to his diet, he eats anything he wants like meat, vegetables, and fish but most

often he eats fatty or oily foods. Mr. Orcasitas is separated and currently living with his

children. His role as a guardian and provider is sufficiently met. According to him, his

major stressors in his life were family matters, work, and financial problems; he copes

with these problems by talking to his neighbors and preparing for a drinking session.

The researchers also inquired the patient history of present illness. Mr. Orcasitas

is having a cerebrovascular accident (CVA) bleed or commonly known as stroke.

According to Mr. Orcasitas significant others, signs and symptoms manifested at a

sudden. They observed that Mr. Orcasitas vomited and experienced loss of

consciousness. They conclude that this disease exists due to too much work and too

much abused of his body. The condition was diagnosed that moment when he was

admitted to the hospital, Friday, December 11, 2009. They also noticed that there was

sputum expelled by the patient which at first was in a watery form with blood but

eventually becomes viscous with white phlegm. The discharge which is urine was

slightly dark yellow in color. Mr. Romeo Orcasitas took an alcohol beverage before he

was admitted. The factors that cause the problem are too much intake of alcohol drinks,

too much intake of salty and fatty foods, and too much work and too much abused of his

body.

From the relevant information gathered by the researchers from Mr. Orcasitas,

they were able to identify the possible cause of the disease and predisposing factors

that contributed to the patient’s condition. This knowledge aided in rendering proper

management and in providing quality nursing care plan.

CONCLUSION

In summary content and analysis of the study, the researchers were able to drive

the following conclusions. The patient’s sedentary lifestyle greatly affects and

aggravates the conditions itself. With the diet of high in fats and salty foods, this can

cause hypertension and lipid deposition in the major vessel of the brain. On the latter

part of this fat and lipid deposition is atherosclerosis. With the lifestyle of alcohol

drinking and cigarette smoking, the patient’s susceptibility to this condition is increased.

Alcohol and nicotine found in cigarettes are potent vasoconstrictor.

As part of the nursing duties and responsibilities, health teachings like diet and

lifestyle modification must be rendered to promote health. Certain restrictions should be

emphasized and the threats of these if not followed.