ICU CVD GroupCaseStudy

A Case Study On Cerebrovascular Disease, Hemorrhagic

I.INTRODUCTION

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.

A fall in blood pressure during sleep can then lead to a marked reduction in blood

flow in the narrowed blood vessels causing hemorrhagic stroke in the morning.

Conversely, a sudden rise in blood pressure due to excitation during the daytime can

cause tearing of the blood vessels resulting in intracranial hemorrhage. Cerebrovascular

disease primarily affects people who are elderly or have a history of diabetes, smoking,

or ischemic heart disease. The results of cerebrovascular disease can include a stroke,

or occasionally a hemorrhagic. Ischemia or other blood vessel dysfunctions can affect

the person during a cerebrovascular accident.

Hemorrhagic stroke is a condition that occurs mainly due to a rupture of a blood

vessel in the brain. The blood vessel bursts and releases blood into the brain. Research

shows that nearly 20 percent of the strokes that occur overall are hemorrhagic in nature.

A systematic review of stroke incidence worldwide found that between 1970 and 2008,

stroke incidence decreased 42% in high-income countries and increased more than

100% in low- to middle-income nations; between 2000 and 2008, the overall stroke

incidence in low- to middle-income countries was 20% higher. (emedicine.com)

Once the arteries rupture they are incapable of carrying blood and oxygen to the

brain and it causes the cells to die. Another reason for hemorrhagic stroke is the blood

that flows into the brain due to the rupture forms a clot inside the brain and damages the

brain tissue. This could severely damage the brain functioning.

A hemorrhagic stroke is the least common. However, it is more frequently fatal

when compared to an ischemic stroke overall. Hemorrhagic stroke is of two types. Each

one is named after the part of the brain that is affected by the bleeding.

The subarachnoid hemorrhage is a condition that refers to the bleeding that takes

place in the gap between the top of the brain and the skull. The most common cause of

a subarachnoid hemorrhagic stroke is aneurysm. It is characterized by an abnormal

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swelling of a blood vessel within the brain followed by rupturing of that swollen blood

vessel.

We chose this case because we think that patients having Cerebrovascular disease

needs full attention as to prevention of complications, which we think is our primordial

responsibility as student nurses. Our concern is not only on the physical aspect but also

on the emotions and feelings of our patient having this disease condition who may not

be able to do the usual activities they used to deal on brought about by the condition.

Hence we wanted to widen our knowledge on how to take good care of these particular

patients so that we will be able to provide quality care and satisfaction to our future

patients having the same disease condition.

General Objective:

This case presentation seeks to enhance the students’ knowledge with regards

to the patient’s general health and disease condition, its pathophysiology, possible

complications, treatment plan and medical regimen. This also seeks to assimilate the

student’s skills through application of several nursing interventions and medical

management. Furthermore, this case presentation intends to improve the students’

attitude by conveying open-mindedness and utilizing therapeutic communication all

throughout the activity.

Scope and Limitation:

The scope of this study is within the context of the patient's condition based on the

assessment of the patient's present health condition and other precipitating and

predisposing factors that influenced the course of the disease, the anatomy and

physiology of the involved body systems, pathophysiology of the condition, patient’s

diagnosis and diagnostic exams, nursing and medical management, drug study,

discharge plan, prognosis and recommendation of the case study. The data presented

in this case was primarily obtained from student nurse- patient interaction as well as

with the significant other who partly served as informant. Further information is based

on the patient’s chart.

The case study is limited to the available resources during the making of this

study such as book sources, internet sources, and patient’s chart, information coming

from the family and as well the observation of the patient’s during the span of duty.

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Furthermore, this case study will only show the changes of the patient’s condition from

August 22, 2011 until August 24, 2011.

II.CLIENT’S PROFILE

This is a case of a 73 years old female Filipino, a resident of Poblacion 3,

Villaneuva Misamis Oriental. Patient X was born on December 8, 1938. She is married

and has 9 children all are in good health. Patient X was a high school graduate. She is a

housewife. Patient X was admitted on August 20, 2011; 5:55pm at Capitol University

Medical City – Intensive Care Unit.

A.VITAL SIGNS

Upon assessment, the following data was obtained from Patient X: BP:

162/68mmHg, HR: 112 bpm, RR: 25 cpm, Temp.36.9c. Patient X weighs 40 kg and is

5’1 in height.

B.CHIEF COMPLAINT

Patient X has a chief complaint of altered level of consciousness.

C. Family Health –Illness History

According to the significant others that the patient has known genetic disease

that runs in the family which is hypertension. Patient is non-compliant with her

medications.

D.HISTORY OF PRESENT ILLNESS

2 days prior to admission patient had 2 episodes of LBM watery, non-mucoid,

non-bloody stools associated with generalized body weakness. Sought consult at

Tagoloan Polymedic General Hospital managed as a case of AGE however, noted

change in sensorium, CT scan was done revealing acute hemorrhage involving the right

frontal lobe extending to corpus callosum and partly to left side frontal lobe

approximately 64ml, minimal subarachnoid hemorrhage.

Started meds and referred for further management. With positive cough,

masks yellowish phlegm.

E.HISTORY OF PAST ILLNESS

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According to the significant others the patient had several health conditions such

as fever, common cough and cold but haven’t sought any medical consultation.

F.STATEMENT OF THE PATIENTS GENERAL APPERANCE

Patient X looked pale, weak, drowsy and responsive to verbal stimuli but seen to

be inconsistent with her answers.

G. NUTRITIONAL AND METABOLIC PATTERN

Pre-hospitalization: Patient X eats three times daily. She consumed 1/ 2 share of

served food with good appetite. She drinks 8-10 glasses of water a day.

During hospitalization: Patient X is in osteorized feeding of 166cc every

8am/12nn; 4pm/8pm; 12mn/4am.

She was hooked to an Intravenous Fluid of IL PNSS regulated @ 20gtts/min

infusing well on the left arm.

H.ELIMINATION

Pre –hospitalization: Patient X defecates once a day, with yellowish to brownish

stool and soft in consistency and no discomfort felt during defecation. She urinates

three times daily with dark yellow colored urine in variable amount.

During hospitalization: Patient X do not have a bowel movement for 2 days, she

was inserted with Foley catheter attached to urobag draining with yellowish colored

urine.

I.ACTIVITY AND EXERCISE PATTERN

Patient X doesn’t any particular exercise regimen but she usually do brisk walking every morning

at the seashore.

ACTIVITIES OF DAILY LIVING

Feeding 4 total dependence

Bathing 4 total dependence

DRESSING 4 total dependence

Grooming 4 total dependence

Meal preparation 4 total dependence

Cleaning 4 total dependence

Laundry 4 total dependence

Toileting 4 total dependence

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Bed mobility 4 total dependence

Chair/toilet transfer 4 total dependence

Ambulation 4 total dependence

R.O.M 2 assist with person

J.COGNITIVE AND PERCEPTUAL PATTERN

Patient X speaks Cebuano and able to respond to some questions but she is

inconsistent with her answers.

K.SLEEP REST PATTERN

Pre- hospitalization: Patient X sleeps 8 hours a day.

During hospitalization: Patient X still sleeps 8 hours a day.

L.SEXUALITY-REPRODUCTIVE PATTERN

Patient X is already menopause since 60 years old. G9, P9 (9009)

.

PHYSICAL ASSESSMENT

Together with medical history, the physical examination aids in determining the correct

diagnoses and devising the treatment plan. This part of the study will present the normal

and regressed health function of Patient X pointing out the salient, manifestations of the

disease.

I. Neurologic Assessment

Level of consciousness Drowsy

Orientation Confused

Emotional state Calm

Appropriate behavior Cooperative, responsive

Glassgow Coma Scale 12 (E-3;V-4;M-5)

PHYSICAL ASSESSMENT

Component August 21, 2011 August 23, 2011

Head: Her head is normocephalic

with symmetrical facial

movements. Fontanels are

Her head is normocephalic

with symmetrical facial

movements. Fontanels are

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closed. Hair is dry with

normal/even distribution.

Scalp is clean.

closed. Hair is dry with

normal/even distribution.

Scalp is clean.

Eyes: Eyelids are symmetrical.

Conjunctiva is pale.

Bilateral Pupil size is 2mm

(constricted) with sluggish

reaction to light.

Eyelids are symmetrical.

Conjunctiva is pale. Pupils’

size is 2mm with sluggish

reaction to light.

Ears: The external pinnae are

normoset and there is no

presence of any form of

discharge from the external

canal.

The external pinnae are

normoset and there is no

presence of any form of

discharge from the external

canal.

Nose: There is no presence of alar

flaring. Septum is midline,

mucusa is pinkish and both

are patent.

There is no presence of alar

flaring. Septum is midline,

mucusa is pinkish and both

are patent.

Mouth: Her lips are pale in color

and slightly dry and crack.

Gums and mucosa are light

pink in color. Tongue is

located at midline. Has

dentures.

Her lips are pale in color

and slightly dry and crack.

Gums and mucosa are light

pink in color. Tongue is

located at midline. Has

dentures.

Pharynx: Uvula is midline. No

presence of deviation and is

pinkish in color. Tonsils are

not inflamed nor the

posterior pharynx.

Uvula is midline. No presence

of deviation and is pinkish in

color. Tonsils are not inflamed

nor the posterior pharynx.

Neck: Trachea is midline, no

deviations present and the

thyroids are non-palpable.

Trachea is midline, no

deviations present and the

thyroids are non-palpable.

Skin: Skin is pale, senile turgor.

Nails are convex in shape

with a capillary refill

> 4 seconds. Nail beds are

pale in color.

Skin is pale, senile turgor.

Nails are convex in shape

with a capillary refill >4

seconds. Nail beds are pale

in color.

Abdomen: The general contour of her The general contour of her

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abdomen is flat. Abdominal

skin is fair. Masses are not

observed. Presence of

superficial veins, striae. With

symmetrical configuration

and bowel sounds appear to

be hypoactive

(3clicks/min). It was

tympanitic upon percussion

with no muscle guarding,

direct tenderness, rebound

tenderness, or bladder

distention.

abdomen is flat. Abdominal

skin is fair. Masses are not

observed. Presence of

superficial veins, striae. With

symmetrical configuration and

bowel sounds appear to be

hypoactive (3clicks/min). It

was tympanitic upon

percussion with no muscle

guarding, direct tenderness,

rebound tenderness, or

bladder distention.

Cardiovascular: Her ECG tracing shows

Sick Sinus Syndrome.

Point of maximum impulse is

located at the left

midclavicular line 5th

intercostals space. Her rate

is 112 beats per minute

with bounding peripheral

pulse. She has a BP of

162/68 mmHg.

Her ECG tracing shows

Sick Sinus Syndrome. Point

of maximum impulse is

located at the midclavicular

line 5th intercostals space.

Her rate is 89 beats per

minute with bounding

peripheral pulse.

She has a BP of 120/80

mmHg.

Respiration: She has irregular

breathing pattern and

observed difficulty in

breathing. She has

abnormal respiratory rate

of 25 cpm. Lung expansion

was symmetrical, has

crackles noted upon

auscultation particularly at

the right lung. No

tenderness or masses in the

She has regular breathing

pattern with no observed

difficulty in breathing. She has

normal respiratory rate of 20

cpm. Lung expansion was

symmetrical, has crackles

noted upon auscultation

particularly at the right

lung. No tenderness or

masses in the chest is noted.

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chest is noted.

Back and extremities Patient has limited range

of motion with decreased

in the upper and lower

extremities. Capillary refill

>4sec.

Patient has limited range of

motion with decreased in

the upper and lower

extremities. Capillary refill

>4sec.

Review of Systems

EENT:[X] impaired vision [] blind[ ] pain [ ] reddened [] drainage[] gums [] hard of hearing [] deaf[] burning [] edema [] lesion [X] teethAssess eyes, ears, nose,throat for abnormality [] No problemRESP:[] asymmetric [X] tachypnea[] apnea [x] crackles [ X ] cough [] barrel chest[] bradypnea [] shallow [] rhonchi[] sputum [] diminished [X] dyspnea[] orthopnea [] labored [] wheezing[] pain [] cyanoticAssess resp. rate, rhythm, depth, pattern,breath sounds, comfort [] no problemCARDIOVASCULAR:[X] arrhythmia [X] tachycardia [] numbness[] diminished pulses [] edema [] fatigue[X] irregular [] bradycardia [] murmur[] tingling [] absent pulses [] painAssess heart sounds, rate rhythm, pulse, bloodPressure, circ., fluid retention, comfort[] no problemGASTROINTESTINAL TRACT:[] obese [] distention [] mass[X] dysphagia [] rigidty [] painAssess abdomen, bowel habits[X], swallowing,Bowel sounds[X], comfort [] no problemGENITO – URINARY AND GYNE:[] pain [X] urine color(yellowish) [] vaginal bleeding[] hematuria [] discharge [] nocturiaAssess urine freq., control, color, odor,

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With IVF of 1L PNSS regulated @ 20 gtts/min infusing well at the left arm.

With O2 inhalation regulated @ 3LPM; with Naso Gastric tube in placed.


Comfort / Gyn-bleeding, discharge[ X ] No problemNEURO:[] paresis [] stuporous [] unsteady[X] drowsy [] lethargic [] comatose [] vertigo[] tremors [X] confused [X] vision [] gripAssess motor function, sensation, LOC, strengthGrip, gait[], coordination, orientation, speech[] no problemMUSCULOSKELETAL and SKIN:[] appliance [] stiffness [] itching [] petechie[] hot [] drainage [] prosthesis [] swelling[] lesion [] poor turgor [X] cool [] deformity[] wound [] rash [X] skin color [pallor] flushed[] atrophy [] pain [] ecchymosis[] diaphoretic [] Moist [X] skin turgorAssess mobility, motion gait, alignment, joint function/Skin color, texture, integrity [] no problem

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With foley catheter attached to urobag darining well with yellowish colored urine


Muscle

Strength

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3/53/5 3/53/5

2/52/5 2/52/5


DEVELOPMENTAL DATA

Erikson's psychosocial development

Care: Generativity vs. Stagnation (Middle Adulthood, 45 to 65 years)

Generativity is the concern of establishing and guiding the next generation. Socially-

valued work and disciplines are expressions of generativity. Simply having or wanting

children does not in and of itself achieve generativity. Patient X has fulfilled this stage of

development for she was able to have a family of her own, has her own grand children

and worked for the society.

Freud psychosexual developmental theory

Genital stage

The fifth stage of psychosexual development is the genital stage that spans puberty and

adult life, and thus occupies most of the life of a man and of a woman; its purpose is the

psychologic detachment and independence from the parents. The genital stage affords

the person the ability to confront and resolve his or her remaining psychosexual

childhood conflicts. As in the phallic stage, the genital stage is centered upon the

genitalia, but the sexuality is consensual and adult, rather than solitary and infantile.

The psychological difference between the phallic and genital stages is that the ego is

established in the latter; the person’s concern shifts from primary-drive gratification

(instinct) to applying secondary process-thinking to gratify desire symbolically and

intellectually by means of friendships, a love relationship, family and adult

responsibilities. Patient X belongs to this stage; he has this now what we call

responsibility to fulfill for his family.

Robert Havighurst (middle adulthood, 30-60 years old)

The fifth stage of developmental task by Havighurst which composed of fulfilling civic &

social responsibilities, maintenance of an economic standard of living, assist

adolescent children to become responsible, happy adults, relate one’s partner, adjust to

physiological changes, adjust to aging parents. Patient X belong to this developmental

task wherein she was able to fulfill, she was able to provide a living to his family as well

as he is still adjusting to the physical changes he has having her husband as a partner

in terms of adjusting to the condition she has now.

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III.ANATOMY AND PHYSIOLOGY

The human nervous system consists of the central nervous system (CNS) and

peripheral nervous system (PNS). The former consists of the brain and spinal cord,

while the latter composes the nerves extending to and from the brain and spinal cord.

The primary functions of the nervous system are to monitor, integrate (process) and

respond to information inside and outside the body. The brain consists of soft, delicate,

non-replaceable neural tissue. It is supported and protected by the surrounding skin,

skull, meninges and cerebrospinal fluid.

The CNS consists of the brain which serves many important functions. It gives

meaning to things that happen in the world surrounding us. Through the five senses of

sight, smell, hearing, touch and taste, the brain receives messages, often many at the

same time. The brain controls thoughts, memory and speech, arm and leg movements,

and the function of many organs within the body. It also determines how people respond

to stressful situations (i.e. writing of an exam, loss of a job, birth of a child, illness, etc.)

by regulating heart and breathing rates. The brain is an organized structure, divided into

many components that serve specific and important functions.

The weight of the brain changes from birth through adulthood. At birth, the

average brain weighs about one pound, and grows to about two pounds during

childhood. The average weight of an adult female brain is about 2.7 pounds, while the

brain of an adult male weighs about three pounds and which is located in the dorsal

body cavity. The brain is surrounded by the cranium; the brain is continuous with the

spinal cord at the foramen magnum. In addition to bone, the CNS is surrounded by

connective tissue

membranes, called

meninges, and by

cerebrospinal fluid. The brain

is divided into the cerebrum,

diencephalons, brain stem,

and cerebellum.

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Meninges

The meninges (Figure 2–3) are three connective

tissue membranes enclosing the brain and the spinal

cord. Their functions are to protect the CNS and blood

vessels, enclose the venous sinuses, retain the

cerebrospinal fluid, and form partitions within the skull.

Theoutermost meninx is the dura mater, which

encloses the arachnoid mater and the innermost pia

mater.

Frontal Lobe

The frontal lobes are one of the four main lobes

or regions of the cerebral cortex. They are

positioned at the front most region of the

cerebral cortex and are involved in movement,

decision-making, problem solving, and planning.

There are three main divisions of the frontal

lobes. They are the prefrontal cortex, the

premotor area and the motor area. The

prefrontal cortex is responsible for personality

expression and the planning of complex cognitive behaviors. The premotor and motor

areas of the frontal lobes contain nerves that control the execution of

voluntary muscle movement.

Function:

The frontal lobes are involved in several functions of the body including:

Motor Functions

Higher Order Functions

Planning

Reasoning

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http://biology.about.com/od/anatomy/a/aa032505a.htm




Judgement

Impulse Control

Memory

Corpus Callosum

The corpus callosum is a thick band of nerve fibers that

divides the cerebrum into left and right hemispheres. It

connects the left and right sides of the brain allowing for

communication between both hemispheres. The corpus

callosum transfers motor, sensory, and cognitive

information between the brain hemispheres.

Function:

The corpus callosum is involved in several functions of the body including:

Communication Between Brain Hemispheres

Eye Movement

Maintaining the Balance of Arousal and Attention

Tactile Localization

Location:

Directionally, the corpus callosum is located underneath the cerebrum at the center of

the brain.

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http://biology.about.com/od/humananatomybiology/a/anatomybrain.htm

http://biology.about.com/od/anatomy/p/cerebrum.htm



IV. PATHOPHYSIOLOGY

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V. Diagnostic Procedure and Laboratory Result

REASON WHY DIAGNOSTIC and LABORATORY PROCEDURE WAS DONE

Complete Blood Count

A complete blood count (CBC), also known as full blood count (FBC) or full blood

exam (FBE) or blood panel, is a test requested by a doctor or other medical

professional that gives information about the cells in a patient's blood. A lab technician

(diploma holder) or technologist (bachelor holder) performs the requested testing and

provides the requesting Medical Professional with the results of the CBC. A CBC is also

known as a "hemogram".

Blood Chemistry Test

Blood Chemistry is needed to assess a wide range of conditions and the function

of organs. It also a test to check electrolytes, the minerals that help keep the body’s fluid

level in balance, and are necessary to help the muscles, heart, and other organs work

properly. This also helps assess kidney function and blood sugar, and other substances

in the blood.

Urinalysis A urinalysis is a group of manual and/or automated qualitative and semi-

quantitative tests performed on a urine sample. A routine urinalysis usually includes the following tests: color, transparency, specific gravity, pH, protein, glucose, ketones, blood, bilirubin, nitrite, urobilinogen, and leukocyte esterase. Some laboratories include a microscopic examination of urinary sediment with all routine urinalysis tests. If not, it is

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customary to perform the microscopic exam, if transparency, glucose, protein, blood, nitrite, or leukocyte esterase is abnormal.

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Hematology Report August 20, 2011

TEST RESULT UNIT REFERENCE INDICATION INTERPRETATION

WBC 12,800 10^3/µL 5,000-10,000

Determines any inflammation and infection.

Result is above normal range which indicates infection due to the presence of necrotic tissue.

RBC 4.87 10^6/µL 4.2-5.4

Determines the

oxygen carrying

capacity of the blood.

A normal number of RBC

may indicate normal

hemoglobin

concentration in the

blood.

Hemoglobin 14.3 g/dL 12.0-16.0

Usually done to a pt. with renal disease to determine if the kidney’s ability to release erythropoietin factor is already affected

Result is within normal level, thus indicating enough oxygen carrying capacity of the blood.

Hematocrit 43.0 % 37.0-47.0

Used to measure RBC number and volume. It is an integral part of the evaluation of anemic patients.

Result is within the normal range thus, normal hemoconcentration.

Differential Count

Lymphocyte 50.0 % 17.4-48.2

Determines any chronic bacterial infection or viral infection.

Result is within normal level. Showing presence of infection

Neutrophil 81.2 % 43.4-76.2

Determines any acute bacterial infection.

Value is above normal range. This shows positive bacterial infection.

Basophils 1.5 % 0.0-2.0

Used to help evaluate allergic, blood, neoplastic and infections caused by parasites.

Result is within normal range.

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Platelet 221,000 10^3/µL 200-400

To diagnose and/or monitor bleeding and clotting disorders.

Result is within normal level.

August 23, 2011

TEST RESULT UNIT REFERENCE INDICATION INTERPRETATION

WBC 11,20010^3/

µL5.0-10.0

Determines any inflammation and infection.

Increased and may indicate presence of infection.

RBC 4.5710^6/

µL4.2-5.4

Determines the

oxygen carrying

capacity of the blood.

RBC is within normal

level.

Hemoglobin 14.0 g/dL 12.0-16.0

Usually done to a pt. with renal disease to determine if the kidney’s ability to release erythropoietin factor is already affected

Result is within the normal level, thus indicating enough oxygen carrying capacity of the blood

Hematocrit 44.1 % 37.0-47.0

Used to measure RBC number and volume. It is an integral part of the evaluation of anemic patients.

Result is within the normal range.

Differential Count

Lymphocyte 68.9 % 17.4-48.2

Determines any chronic bacterial infection or viral infection.

Result is above normal level. Showing presence of infection

Monocyte 14.6 % 4.5-10.5Determines any acute bacterial infection.

Result is above normal. Indicating presence of bacterial infection.

Eosinophils 1.5 % 1.0-3.0To determine any allergic reaction of the body.


Basophils 1.9 % 0.0-2.0

Used to help evaluate allergic, blood, neoplastic and infections caused by parasites.

Result is above normal range which indicates presence of infections.

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Platelet 320,00010^3/

µL200-400

To diagnose and/or monitor bleeding and clotting disorders.


Clinical Chemistry August 8, 2011

Diagnostic/ Laboratory Procedure

Indication Result UNITNormal Values

used by the hospital

Interpretation

Creatinine

This test was ordered in order to evaluate renal function.

0.59 mg/dL 0.59-1.21

Result is within the normal level indicating adequate renal function. The kidney can excrete nitrogenous waste product of protein leading to its accumulation in the blood.

Na+

To evaluate if sodium is properly excreted by the kidneys.

125.50 mmol/L 135-148

Result is below normal which means that sodium is excessively excreted by the kidneys.

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K+

To evaluate if Potassium is properly excreted by the kidneys.

2.45 mEq/dl 3.5-5.3 Result is below normal, which indicates potassium is excessively excreted through the urine.

BLOOD CHEMISTRY August 21, 2011

Test Result Unit Reference Interpretation

HDL 20.1 mg/dL 29-71 A decreased result may indicate altered transport of LDL to the liver causing high

risk of developing cardiovascular disease.

LDL 190 mg/dL 66-178 A high result may indicate risk for developing cardiovascular disease.

X-ray Report August 18,

2011

X-ray AP

Hazed densities are seen in the right lower lung

Heart is magnified in this view

Aorta is tortuous and calcified

Diaphragm and both costophrenia sulci are intact

The rest of the visualized chest structures are unremarkable.

Impression:

Pneumonia, Right Lung

CT scan Report

Multiple sequential axial tomographic sections of the head from the skull base to the

vertex which contrast reveals the following findings.

- Irregular in homogeneous hyperdense collection seen at the right frontal lobe

with involvement of the corpus callosum genu extending partly into the left side

frontal lobe. It measures around 5.0x4.5x5.3 cm with volume of approximately

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64ml. there is surrounding edema with compression of the frontal horn of the

lateral ventricles.

- Ventricles are mildly dilated. Minimal layering hyperdensities within the

dependent portion of the lateral ventricles posterior horns demonstrating fluid

level.

- Minimal subarachnoid hemorrhage seen. Patchy hypodensities involving both

frontal parietal lateral periventricular white matter and subcortical white matter.

- Cerebellum and pons are intact.

- Included petromastoid and paranasal sinuses and orbits are intact.

Impression:

Acute hemorrhage involving the right frontal lobe extending to corpus callosum

and partly to left side frontal lobe approximately 64ml, minimal subarachnoid

hemorrhage.

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VI. Nursing Care Plan

Problem # 1

ASSESSMENT DATA

Objective: Crackles noted upon auscultation at right lung. Non-productive cough noted with whitish sputum. RR: 25 cpm

NURSING DIAGNOSIS Ineffective airway clearance related to retained secretions on the bronchial

airway secondary to pneumonia.

GOALS AND OBJECTIVES

At the end of 15 minutes of nursing care and intervention, patient will be able to: Maintain patent airway. Demonstrate absence /reduction of congestion with breath sounds clear and

normal respiratory rate from 25cpm to 20 cpm.

NURSING INTERVENTIONS

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Independent Place client in semi-fowlers position.

®-To promote maximum lung expansion. Change position of the client every 2 hours and as needed.

®-To take advantage of gravity decreasing pressure on the diaphragm and enhancing ventilation to different lung segments. Chest physiotherapy done.

®- to mobilize bronchial secretion to larger airways. Suction secretions as needed.

®- to remove secretions in the bronchial airway to promote proper breathing. Keep bedside clean and allergen free.

®-to reduce irritant on airway. Adjust activities within clients tolerance

®- to avoid overexertion.

Dependent

Administer Salbutamol 1 neb as prescribed.

®-aids in reduction of bronchospam and mobilization of secretions.

Collaborative Humidified with oxygen via nasal cannula at 3L/min.

®-aid in mobilization of secretions.

EVALUATION Goals Met: Patient maintained patent airway and demonstrated reduction of

congestion with breath sounds clear and normal respiratory rate of 20 cpm.

Problem # 2

ASSESSMENT DATAObjective:

Sick Sinus Syndrome (ECG result) Pallor Prolonged capillary refill (>4seconds) Increased Heart rate( 112 bpm) Elevated BP: 162/68mmHg

NURSING DIAGNOSIS

Decrease cardiac output related to alterations in rate, rhythm and electrical conduction of the heart as evidenced by ECG result.


Display hemodynamic stability with a normal heart rate from 122 bpm to 89 bpm and a normal blood pressure from 162/68 mmHg to 120/70 mmHg.

Participate in activities that require decrease workload of the heart.

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Independent: Assess potential for/ type of developing shock states: hematogenic, septicimic,

cardiogenic, vasogenic, and psychogenic

®- to identify possible causative factors. Monitored vital signs every hour

®- to have baseline for comparison to follow trends and evaluate response to interventions. Keep client on bed rest in positions of comfort.

®- to decrease metabolic demand. Provided good ventilation in the environment

®- to prevent fatigue and good breathing pattern.

Dependent: Administer Amlodipine 25mg as prescribed

®-to lower down blood pressure.

EVALUATION

Goals Met: Patient displayed hemodynamic stability with a heart rate of 89bpm and a blood pressure of 120/80 mmHg.

Problem # 3

ASSESSMENT DATA

Objective:

GCS= 12 (E-3;V-4;M-5) Constricted pupils, 2mm in size with sluggish reaction to light. LOC: confused Orientation: drowsy

NURSING DIAGNOSIS

Ineffective cerebral tissue perfusion related to hemorrhage secondary to CVA.


At the end of 8 hours of nursing interventions patient will be able to: Maintain usual/improved LOC, cognition and motor/sensory function. Demonstrate stable vital sign and absence of signs of increase ICP. Display no further deterioration /recurrence of deficits.

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Independent: Assess neuro vital signs hourly.

®- to closely monitor change in LOC. Position with head elevated and in neutral position.

®- to reduce arterial pressure by promoting venous drainage and may improve cerebral circulation/perfusion. Maintain bed rest, provide quiet environment, provide rest periods between care

activities, and limit duration of procedures.

®-Continual stimulation/activity can increase ICP, absolute rest and quiet environment may be needed to prevent bleeding. Prevent straining at stool or holding breath.

®-Valsalva maneuver increases ICP potentiates risk for rebleeding. Assess for nuchal rigidity, twitching, increase restlessness, irritability, onset of

seizure activity.

®- Indicative of meningeal irritation, especially in hemorrhagic disorders. Seizures may reflect increase ICP.

Dependent: Administer peripheral vasodilators of Amlodipine 5mg.

®- to protect brain by interrupting the destructive cascade of biochemical events.

Collaborative: Administer O2 inhalation via nasal cannula @ 3LPM.

®- reduces hypoxemia which can cause cerebral vasodilation and increase pressure/edema formation.

EVALUATION: Goal’s met. Patient was able to maintain usual LOC, cognition and motor/sensory

function, demonstrate stable vital sign and absence of signs of increase ICP and display no further deterioration.

Problem # 4

ASSESSMENT DATAObjective:

NURSING DIAGNOSIS

Impaired verbal communication related to impaired cerebral circulation secondary to CVA.


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Impaired articulation, soft speech Inability to modulate speech Inability to comprehend spoken language, wernicks aphasia.



Independent: Provide alternative methods of communication

®-provide for communication of needs/desire based on individual situation. Anticipate and provide for clients needs.

®-helpful in decreasing frustration when dependent on others and unable to communicate desires. Talk directly to client, speaking slowly and distinctly. Use yes/no questions to

begin with progressing in complexity as client responds.

®-reduces confusion/anxiety to give time to process and respond on the information given. Speak with normal volume of voice and avoid talking too fast. Give client ample

of time to respond. Talk without pressuring for a response.

®-Rising of voice may cause irritation or anger on the client’s side. Dependent:

Administer Citicholine 1gm IVTT as prescribed.

®-To enhance interneuronal function.

EVALUATION: Goals not met: Patient wasn’t able to indicate an understanding of the

communication problems and established method of communication in which her need can be expressed.

Problem # 5

ASSESSMENT DATAObjective

Limited range of motion Decrease muscle strength and control Generalized body weakness

NURSING DIAGNOSIS Impaired physical mobility related to neuromuscular impairment secondary to

cerebrovascular disease.


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At the end of 8 hours of nursing intervention patient will be able to: Indicate an understanding of the communication problems. Established method in which needs can be expressed.


Perfom passive range of motion.


Independent

®-to develop individual exercise/ mobility program and identify appropriate adjunctive device.

EVALUATION:

Problem # 6

ASSESSMENT DATA

Objective Hypoactive bowel sounds 3clicks/min Decrease physical mobility 2 days of absent bowel movement Serum potassium level: 2.45 mEq/dl

NURSING DIAGNOSIS Constipation related to insufficient physical mobility secondary to CVA.

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At the end of 16 hours of nursing intervention patient will be able to :Long term:

Maintain or increase strength and function of affected or compensatory body parts.

Maintain skin integrity. Maintain optimal position of function AEB absence of contractures or foot

drop.

At the end of 4 hours of nursing intervention patient will be able to:Short term:

Assist client reposition client reposition self on regular schedule as dictated by individual situation

®-to promote optimal level of functioning and prevent complications. Schedule activities with adequate rest periods .Provide client with ample time

to perform mobility related task.

®-to reduce fatigue Assisted patient in doing passive range of motion.

®-to promote circulation and prevent contractures. Encourage adequate intake of fluids/nutritious foods.

®-promotes well-being and maximizes energy.

Dependent Consult with physical/ occupational therapist as indicated.

Long term: Goals met: Patient maintained strength and function of affected and compensatory body parts, maintained skin integrity and maintained optimal position of function AEB absence of contractures or foot drop.

Short term: Goals met: Participated in doing passive range motion.


GOALS AND OBJECTIVESAt the end of 16 hours of nursing intervention patient will be able to:Long term:

Establish normal pattern of bowel functioning. Participate in bowel program as indicated.


Independent Auscultate abdomen for presence, location, characteristics of bowel sounds

®-to determine bowel movements Turn to sides every 2 hours

®-to promote peristaltic movement Placed patient into comfortable positions

®-to prevent fatigue Perform passive range of motion

®- to promote bowel functions. Provide safety by assisting client during feeding by elevating head of the bed

®-to prevent injury and aspiration.

Dependent Administer Senna concentrate 25mg as ordered.

®-to promote bowel movement.

EVALUATION Goal’s not met. Patient wasn’t able to established normal pattern of bowel

functioning and participated in bowel program.

Problem # 7

ASSESSMENT DATA

Risk Factors Immobility Friction Senile skin turgor

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NURSING DIAGNOSIS

Risk for Impaired skin integrity


At the end of 16 hours of nursing intervention patient will be able to:Long term:

Participate /demonstrate behavior/techniques to prevent skin breakdown such as regular change of bed position and passive range of motion.

NURSING INTERVENTION

Independent

Change position in bed in a regular schedule such as turning to sides every 2 hours. Encourage participation with passive range of motion exercise

®-To prevent skin breakdown Massage bony prominences gently and avoid friction when moving client

®-To improve circulation to the area and prevent skin breakdown Keep bed clothes dry and keep bed free of wrinkles.

®-To prevent vasoconstriction and shearing Encourage /provide adequate nutritional/fluid intake

®-to maintain general good health and skin turgor. Provide information to client about the importance of regular observation and

effective skin care in preventing problems

®-to promote wellness.

EVALUATION

Goals met: Patient participated /demonstrated behavior/techniques to prevent skin breakdown such as regular change of bed position and passive range of motion.

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VII. DRUG STUDY


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Drug Order Mechanism Of Action

Indication Contraindication Adverse Effects of the Drugs

Nursing Responsibility/Precautions

Generic name: amlodipine

Brand name: Norvasc

Classification: Calcium channel blockers

Dosage: 25 mg

Route: NGT

Frequency : o.d

Inhibits the transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of subsequent contraction

Management of hype

rtension

Hypersensitivity

Blood pressure <90mmhg

CNS: headache, dizziness, fatigue

CV: hypotension

Be alert for adverse reactions.

Monitor vital signs closely especially the blood pressure.

Monitor intake and output ratios and daily weight.

Caution patient in changes in position slowly to prevent orthostatic hypotension.

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Generic name: levofloxacin

Brand name: Levaquin

Classification: anti-ineffective

Dosage: 500mg

Route: IV

Frequency : o.d

Inhibit bacterial DNA synthesis by inhibiting DNA gyrase.

Treatment for Community acquired Pneumonia

Hypersensitivity

CNS: dizziness,headache,insomnia

GI: diarrhea,nausea and abdominal pain

Be alert for adverse reaction

Maintain a fluid intake of 1500-2000ml/day to prevent crystalluria.

May cause dizziness and drowsiness, advise client avoid activities.

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Generic name: mannitol

Brand name: Osmitrol

Classification: Osmotic diuretic

Dosage: 100 cc

Route: IVTT

Frequency : q6

Increase osmotic pressure of glomerular filtrate, inhibiting reabsorption of water and electrolytes. This elevates blood osmolality, enhancing water and sodium to flow into extracellular fluid. Increase water excretion, decreases intracranial pressure.

To reduce ICP

hypersensitivity to the drug or any of its component, and those with anuria, severe pulmonary congestion, severe heart dehydration, metabolic edema, progressive renal disease or dysfunction

CNS: dizziness,headache,insomnia

GI: diarrhea,nausea and abdominal pain

Assess patients condition before therapy and regularly thereafter to monitor the drug effectiveness.

Be alert of adverse reaction and drug interaction.

Monitor urine output.

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Generic name: potassium chloride

Brand name: Kalium durule

Classification: potassium supplement, mineral

Dosage: 1tab

Route: NGT

Frequency : t.i.d.

Aids in transmitting nerve impulses, contracting cardiac and skeletal muscles, maintaining intracellular toxicity, cellular metabolism, acid-base balance and normal renal function

Use an electrolyte replenishes in the treatment of hypokalemia

Contraindicated with untreated Addison disease, adrenocotical insufficiency.

Flaccid paralysis, metal confusion, weakness, paresthasia of the limbs.

Arrhythmias, cardiac arrest, ECG changes

Abdominal pain, diarrhea, Nausea, vomiting

Be alert of adverse reaction and drug interactions.

During therapy, monitor ECG, renal function, fluid intake and output, serum potassium level.

Give potassium with or after meals with full glass of water for GI distress

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Generic name: Captopril

Brand name: captopril

Classification: Antihypertensives

Dosage: 25 mg, 1 tab

Route: P.O./NGT

Frequency : q 6

Inhibits ACE, preventing convertion of angiotensin I to angiotensin II, a potent vasoconstrictor. Reduced formation of angiotensin II decreases peripheral arterial resistance, thus decreasing aldosterone secretion. This reduces sodium and water retention and lowers blood pressure.

Hypertension Use cautiously in patients with impaired renal functions or serious auto-immune disease (particularly systemic lupus erythematous) or in patients who have been exposed to other drugs known to affect WBC counts or immune response.

CNS: dizziness, fainting

CV: tachycardia, hypotension, angina pectoris

CHF: pericarditis.

GI: anorexia, dysgeusia

GU: proteinuria, nephritic syndrome, membranous glomerulopathy, renal failure.

Monitor the patient’s blood pressure and pulse rate frequently.

Monitor the patient’s WBC and differential counts before starting treatment, every 2 weeks for the first 3 months of therapy, and periodically thereafter.

Elderly patients may be more sensitive to the drug’s hypotensive effects.

Instruct patients to take this medication 1 hour before meals, food in the GI may reduce absorption.

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Generic name: Citicholine

Brand name: Somazine amp

Classification: Neuroenhanccer

Dosage: 1000 g

Route: IVTT

Frequency : q 12h

Citicoline is aninterneuronalcommunicationenhancer. Itincreases theneurotransmissionlevels because itfavors thesynthesis andproduction speed ofdopamine in thestriatum, actingthen as adopaminergicagonist thru theinhibition oftyrosine-hydroxylase.

CVD in acute &recovery phase,symptoms &signs of cerebralinsufficiency(dizziness,memory loss,poorconcentration,disorientation,recent cranialtrauma & theirsequelae.)

Contraindicated in patients with Parasympathetic hypertonia

GI: dyspepsia, abdominal pain, nausea, constipation, diarrhea.

Somazine must not beadministered along withmedicaments containingmeclophenoxate

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Generic name: Simvastatin

Brand name: Lipex

Classification: Antihyperlipidemic

Dosage: 20 mg

Route: NGT

Frequency : hs

Inhibits HMG-CoA reductase. This enzymes is early (and rate-limiting) step in synthetic pathway of cholesterol

Lowers LDL and Total cholesterol level

To reduce total cholesterol and LDL levels in patients with homozygous familial hypercholesterolemia

Hypersensitive to the drug or any of its components

CNS: asthenia, headache

GI: abdominal pain, constipation, diarrhea, flatulence, nausea

Hepatic: hepatitis, cirrhosis

Musculoskeletal: Myalgia

Obtain liver function test result before starting therapy.

Be alert for adverse reaction and drug interaction.

Assess patient’s dietary fat intake

Assess patien’s and family’s knowledge

Give drug with evening meal for enhanced effectiveness

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Generic name: Ipatropium bromide

Brand name: Atrovent

Classification: Bronchodilator

Dosage: 1 neb

Route: inhalation

Frequency : q 8h

Inhibits vagally mediated reflexes by antagonizing acetylcholine

Relieves bronchospasms and symptoms of seasonal allergic rhinitis

Bronchospasm Hypersensitive to the drug or any of its components

CNS: dizziness, headache, nervousness

CV: chest pain, palpitations

EENT: blurred vision, burning eyes, epistaxis

GI: constipation, dry mouth, GI distress, nausea

Respiratory: bronchitis, cough, upper respiratory tract infection

Skin: rash

Be alert for adverse reaction and drug interaction

Assess patient’s and family’s knowledge

Give drug on time to ensure maximal effect

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VIII. DISCHARGE PLAN

MEDICATIONS

Explain to the patient and family members the importance of taking medicines.

Discuss to the patient and family the dosage, frequency, and adverse effects of

the drugs.

The patient will be able to take medications as what had been prescribed by the

physician religiously and be able to follow directions as instructed by the nurse.

ECONOMIC STATUS

Explain to significant others that the rehabilitation may be prolonged to be able

for the family to prepare financial needs.

Have occupational therapist to help re- learn everyday activities or ADL.

Inform the patient to avail to some government programs such as philhealth.

TREATMENT

Physical Therapy

Rehabilitation can be explained as the planned withdrawal of support in

order to enable the patient to become as independent as possible. This is

achieved by an interdisciplinary team of professionals, one member of which is

the physical therapist. Physical therapists work with patients to help them regain

motor control, strength, physical conditioning, and mobility and to help them

return to independent living.

Occupational Therapy

Occupational therapists specialize in retraining patients to perform activities

of daily living. They teach and develop strategies for the patient and rehabilitation

team to enhance patient success in independence. This may include the use of

adaptive equipment or compensatory strategies or the redevelopment of skills

that were lost because of motor function, perception, and cognitive deficits.

HEALTH TEACHINGS

Inform client and instruct Deep Breathing Exercise to promote mobilization of

secretion.

Safety precaution should be maintained to prevent injury.

Encouraged in active range of motion exercises to promote circulation.

Importance of proper hygiene for comfort and decrease susceptibility to

infection.

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Adjustment of activities to avoid over exertion and fatigue, allow rest periods.

OUT-PATIENT

The patient could avail her medication from government hospitals in which she

could get some benefits.

She will also be able to avail the services offered by the barangay health center

and and at the “Botikang barangay”.

Instruct patient to seek regular medical check-up

DIET

Eat five or more servings of vegetables and fruit daily. Increase bulk in the diet to

allow defecation.

Intake of fluids 8-10 glasses a day to avoid constipation and to maintain skin

turgor.

Instruct patient to eat low sodium intake with zero transatrated fat that will help

the preventing the worsening of her condition as ordered by the physician.

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IX.PROGNOSIS

The outcome varies with the extent of disease and brain damage at the time of

treatment and other chronic underlying medical complications. The individual who was

healthy and had no neurologic symptoms before suffering a mild stroke may completely

recover and lead a normal life after following the prescribed treatment. The individual

who has suffered a massive stroke may be permanently paralyzed on one side of the

body and no longer be able to speak. The individual who has suffered more than one

stroke may be completely paralyzed and may have his or her life shortened

considerably. Recovery of any movement may be very limited. If carotid endarterectomy

is performed, the individual may avoid a stroke. Recovery from this surgery should be

complete within 6 weeks, and the individual may be able to return to his or her normal

activities, including work. Disability affects 75% of stroke survivors enough to decrease

their employability. Dysfunctions correspond to areas in the brain that have been

damaged. Some of the physical disabilities that can result from stroke include paralysis,

numbness, pressure sores, pneumonia, incontinence, apraxia (inability to perform

learned movements), and difficulties carrying out daily activities, appetite loss, speech

loss, vision loss, and pain. If the stroke is severe enough, or in a certain location such

as parts of the brainstem, coma or death can result.

30 to 50% of stroke survivors suffer post stroke depression, which is

characterized by lethargy, irritability, sleep disturbances, lowered self esteem, and

withdrawal. Depression can reduce motivation and worsen outcome, but can be treated

with antidepressants.

Cognitive deficits resulting from stroke include perceptual disorders, speech

problems, dementia, and problems with attention and memory. A stroke sufferer may be

unaware of his or her own disabilities, a condition called anosognosia. In a condition

called hemispatial neglect, a patient is unable to attend to anything on the side of space

opposite to the damaged hemisphere.

Patient X still has not loss her ability to speak although patient didn’t recognize

her condition and was unaware of it. As a family provider patient may suffer an

emotional problems. In General Patient X still has not manifested the worst course of

the disease process, hence patient X may still be classified as having good prognosis.

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X.LEARNING EXPERIENCE

Our experiences speak of what we have learned. It had improved us as an

individual. Likewise just as we are unique, we also have unique experiences

individually. Having our duty at CUMC ICU is quite a great experience for us. We've

encountered different people and learn to deal with them, to attend to their different

needs and most especially to the emotions that they have. We've learned to be more

passionate in the profession that we have chosen,

We’ve learned to be patient in dealing towards our patients especially with the

kind of conditions that they have. To manage our time effectively and to work efficiently

with the help of everyone (our group mates) and most especially the guidance of our

C.I. We’ve learned to be more helpful towards our group mates, to be respectful to

everyone and to be more careful in everything that we do.

It was quite frustrating because we only had 3 days of duty in the ICU, we were

expecting more challenges from the area in this rotation but because of some instances

we have to accept the fact that we will not totally experience everything what the area

(ICU) could offer.

Hence in this point, we will never be as effective as we are right now if without

our ever loving C.I Mr. Dennis Medalle who had helped us in becoming one of the

effective and efficient future nurses. For being a great disciplinarian and for being

understanding, bound with skills and knowledge and the heart to teach. For being a role

model of how an ideal nurse should be. Attending all our questions and enhancing our

skills in the care of these clients. To the members of group 3 for being very helpful and

very jolly to be with, there is a lot of learning from each of you, for the mistakes that we

have committed and for the remarkable things they have done for their patients. They’ve

been so cooperative and are always willing to help.

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XI.REFERENCE

Books

Black,Joyce(2010).Medical Surgical Nursing

Deglin,Judith(2010).Drug guide for nurses

Doenges, Marilyn (2004).Nurses Pocket Guide

Moorehouse, Mary Frances (2004). Nurses Pocket Guide

Internet Sources

http://emedicine.com

http://wikipedia.com

http://www.google.com

http://www.righthealth.com

http://www.yahoo.com

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http://www.yahoo.com/

http://www.righthealth.com/

http://www.google.com/

http://wikipedia.com/

http://emedicine.com/

Documents

ICU CVD GroupCaseStudy