STI College of Nursing

Sta. Cruz, Laguna

College of nursing

Submitted to:

Mrs. Aurea Celino, RN

Clinical Instructor

Submitted by:

GROUP III

Members:

Avanzado, leonel

Dawinan, Paullette Edilyn

Del Rosario, Jason

Mallari, Kim

Miras, Roxanne

Napiza, Charlene Diane

Salvador, Leomar

Valenzuela, Abrelaine

December 6, 2010

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TABLE OF CONTENTS

I. Introduction --------------------------------------------------------------------------------3

A. Objectives -------------------------------------------------------------------------------5

B. Background of the Study ------------------------------------------------------------5

C. Rationale for Choosing the Case -------------------------------------------------6

D. Significance of the Study -----------------------------------------------------------7

E. Scope and Limitations ---------------------------------------------------------------8

II. Clinical Study ------------------------------------------------------------------------------9

A. Demographic Data --------------------------------------------------------------------9

B. Physical Assessment -----------------------------------------------------------------10

C. System Affected -----------------------------------------------------------------------13

D. Laboratory and Diagnostic Exam -------------------------------------------------13

III. Clinical Discussion -----------------------------------------------------------------------16

A. Anatomy and Physiology -------------------------------------------------------------16

B. Pathophysiology ------------------------------------------------------------------------19

C. Nursing Care Plan ----------------------------------------------------------------------20

D. Drug Study -------------------------------------------------------------------------------26

E. Course in the Ward --------------------------------------------------------------------35

F. Discharge Plan --------------------------------------------------------------------------37

G. Evaluation --------------------------------------------------------------------------------38

H. Summary ---------------------------------------------------------------------------------38

I. Recommendation -----------------------------------------------------------------------39

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I. INTRODUCTION

CEREBROVASCULAR ACCIDENTA stroke, previously known medically as a cerebrovascular accident (CVA), is the

rapidly developing loss of brain function(s) due to disturbance in the blood supply to the

brain. This can be due to ischemia (lack of blood flow) caused by blockage

(thrombosis, arterial embolism), or a hemorrhage (leakage of blood). As a result, the affected

area of the brain is unable to function, leading to inability to move one or more limbs on one

side of the body, inability to understand or formulate speech, or an inability to see one side of

the visual field.

A stroke is a medical emergency and can cause permanent neurological damage,

complications, and even death. It is the leading cause of adult disability in the United States

and Europe and it is the number two cause of death worldwide.

The severity associated with cerebrovascular accident can best be demonstrated by the

following facts:

CVA is the leading cause of adult disability in the world.

Worldwide, one-quarter of all strokes are fatal.

Stroke is the third leading cause of death in the United States and the leading cause

of disability.

It is estimated that four of every five families in the United States will be affected by

stroke in their lifetime,

More than half a million people in the United States experience a new or recurrent

stroke each year.

Stroke kills about 150,000 Americans each year, or almost one out of three stroke

victims.

Three million Americans are currently permanently disabled from stroke.

In the United States, stroke costs about $43 billion per year in direct costs and loss of

productivity.

Two-thirds of strokes occur in people over the age of 65.

Strokes affect men more often than women, although women are more likely to die

from a stroke.

Strokes affect African Americans more often than Caucasians, and are more likely to

be fatal among African Americans.

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The incidence of strokes among people ages 30 to 60 is less than 1%. This figure

triples by the age of 80.

The rate of occurrence for strokes in the United States fell by 15.52% between 1988

and 1998. But the number of deaths from stroke actually rose by 5%.

According to the World Health Organization, one in ten of the 55 million deaths that

occur every year worldwide are due to stroke and two-thirds of which occur among

people living in developing countries). In the Philippines, stroke remains to be a

leading cause of disability, afflicting 400,000 Filipinos yearly

(Manila Bulletin, 13 September 2004). 

What Are the Risk Factors for Developing Stroke?

1) smoking

2) excessive alcohol intake

3) uncontrolled high blood pressure

4) high cholesterol 

5) overweight/unhealthy diet

6) illegal drugs/abuse of Rx drugs

7) known or unknown heart problems

8) diabetes

9) known or unknown vascular brain defects - aneurysm, etc.

10)family history of stroke

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A. OBJECTIVES

GENERAL OBJECTIVE

This study aims to:

Have a further study about cerebrovascular accident (CVA) or stroke.

Perform physical assessment to the patient with this kind of ailment.

Understand the pathophysiology of the disease, and how it affects our body

system.

Formulate nursing care plan for this patient with CVA.

Have further knowledge about the different medicines and treatment modalities

about this disease.

Give proper information through health teaching, rendering appropriate nursing

interventions to the patient about his present conditions are the main objectives of

this study.

B. BACK GROUND OF THE STUDY

MR. CVA is a 68 years old tricycle driver from Mabitac, Laguna. The patient was

rushed to the Emergency Room last November 25, 2010 at 12:30am with complaints of

chilling, chest pain, nausea and vomiting. The patient has been diagnosed with

cerebrovascular accident (CVA) or stroke and was admitted at the hospital.

We decided to present this case for the reason that we want to learn and explore

new knowledge and information about this type of condition. Our group wants to improve

our skill in rendering care with this kind of client.

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C. RATIONALE FOR CHOOSING THE CASE

Nurses in all settings perform a cruical role in assessing the patient, helping prevent

the occurence of possible complications and rendering supportive nursing care. Thus, it is

vital that we, as future nurses be enlighten with significant information that we may use, as

we render health encouraging services to our client.

This presentation has been chosen by the group under the following reasons:

1. Assess the patient’s family history and identify risk factors for developing the disease.

2. Apply a nursing process to the patient under the students care and resolve problem,

implement the plan and evaluate the progress of the plan.

3. Identify the appropriate nursing care interventions in managing the clinical signs and

symptoms that manifest in patient.

4. Utilize effective communication techniques for educating the client and the family.

5. Determine factors and conditions that may influence to the development of the disease.

Further enhance knowledge and understanding regarding the nature of the disease.

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D. SIGNIFICANCE OF THE STUDY

This would serve as an important source to the following sectors:

To the students:

This study discusses Cerebrovascular Accident, its definition, causes,

manifestation and proper treatment which will broaden our understading of the

disease.

This would also improve our knowledge in the anatomy and physiology of the

Nervous system and how its directly affected by the disease.

To the Family and Patient:

This study can also benefit the patient through better understanding of the

underlying causes of the diseases and to have knowledge on proper managament of

the illness.

This can also provide the patient on how to deal with the possible signs and

symptoms and other noticeable changes might observed.

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D. SCOPE AND LIMITATION

This research study primarily focused on the different nursing intervention and health

teaching that we students nurses can give/advice our patients to help alleviate pain and

discomfort. This study also focused on the nature and occurances of the diagnosis, as

well as the primary factors present in the environment that may worsen the situation.

We, as student nurses are limited in formulation of the best nursing care plan

for our patient. We also focused on the the different types of medication prescribed by the

physician,for us to know and understand its effect to our patient. Therapeutic nurse

patient interaction was also established to be able to render the best possible care.

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II. CLINICAL STUDY

DEMOGRAPHIC DATA

Patient Name : MR. CVA

Age : 68 years old

Sex : Male

Birth Date : April 15, 1942

Address : Mabitac, Laguna

Date of Admission : November 25, 2010

Time of Admission : 12:30am

Admitting Diagnosis: Cerebrovascular Accident

Source of Information

Secondary Source : Patient’s Relative

Chief Complaint: “nanginig, nagsuka at sumakit ang dibdib ng pinsan ko kaya namin sya

dinala sa hospital.” As verbalized by the patient’s relative.

History of Present Illness

Few days prior to admission according to his cousin MR. CVA was complaining of

experiencing dizziness, headache and mild chest pain. When MR. CVA was rushed to the

hospital he was having chills, nausea, vomiting, and mild chest pain. The Physician on duty

who have seen and examined MR. CVA decided to admit him in Medicine Ward.

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History of Past Illness

MR. CVA has suffered from stroke previously; he had his first stroke last 2000. His

cousin said that MR. CVA had recovered from the first accident without any permanent

damage or complication and then eight years after the first accident he had his second attack

on the year 2008. Fortunately MR. CVA recovered fully after hospitalization and treatment.

His third attack of stroke happened last November 25, 2010 and he was then admitted at the

Medicine ward.

Dietary History

Prior to the episode of his first stroke, MR. CVA was fond of eating fatty foods like pork

chop, meat viands and chicken skin. He loves to eat rice and fried foods. After suffering from

stroke MR. CVA began to regulate his diet. His relatives also prepared for him healthy foods

such as vegetables and fish and set a limit with their intake of meat and fried foods.

History of Elimination pattern

Output: 900 cc level of urine at urine bag for 24 hours. (Nov. 30, 2010)

400 cc level of urine at urine bag @ 12 noon.

Color: Amber Red.

B. PHYSICAL ASSESSMENT

Levels of consciousness: Glasgow coma scale

Faculty measured

Eye opening: 3

Motor response: 3

Verbal responses: 2

Total: 8

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General Appearance

- With flushes, dry skin

- Medium body built

- With IVF of @ right metacarpal vein

- With oxygen therapy regulated @ 10 LPM delivered by

face mask

- With NGT ( Nasogastric tube)

Head

- Normocephalic

- symmetrical in shape

- no masses, no lesions, no tenderness

Hair - evenly distributed over the scalp

- no dandruff

- Hair with few gray hairs.

Eyelids - with water eyelids

- no edema, and no discharges

Sclera - yellowish

Iris - symmetrical in size

- round and black

Pupils

- Symmetrical in size

- round and dark brown in color

- PERRLA (Pupils Equally Round And React To

Light and Accommodation)

Lower conjunctiva - Moist

Ears

- equal in size

- auricles are smooth and symmetrical

- pinna recoils after it is folded

Nose

- the external nose is symmetrical and straight

- color is the same with the entire face

- lesions and tenderness were both absent

- nasal septum is intact and in midline without

deviations

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- cilia present in internal nares

- absence of nasal discharge

- with oxygen mask

Mouth

- with cyanotic lips

- dry oral mucous membrane

- dentures are removed

Neck

- free from lumps and no tenderness

- at the center and midline

Thorax

- skin color was not evenly distributed

- no masses and tenderness upon palpation

- with wheezing sounds

- With irregular lub-dub sound * cannot be distinguished.

Breast

- round in shape, no lumps, no masses

- areola dark brown in color

- nipples round, equal in size

Abdomen

- skin color evenly distributed

- no lumps , masses and tenderness

Upper extremities

- skin uniform in color

- with IVF @ right metacarpal vein

- Left arm paralyzed ( limb ataxia)

- Capillary refill: 2-3 seconds

Lower extremities

- Skin uniform in color

- Left leg paralyzed

- Sole of the foot is pale

- No Deep tendon reflex

Genitalia

- With indwelling catheter

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C. SYSTEM AFFECTED

Cardiovascular system Increased BP

Nervous system Hemiplagia Limb ataxia Dysarthia Numbness

Respiratory system Increased RR

D. LABORATORY AND DIAGNOSTIC EXAM

HEMATOLOGY

COMPONENT RESULT NORMAL VALUES

SIGNIFICANCE INTERPRETATION

WBC (x109/L) 23.2 4.5 – 10.5 x 109 /L High Increased due to infection.

SEGMENTED NEUTROPHILS

87 45 – 65% High

MONOCYTES 18 2 – 10% High Increased in viral infections.

RBC (x1012/L) 4.16 5.5 – 6.5 x 1012/L Low Decreased in anemia.

MCH (pg) 22 27 – 32 pg Low Decreased in iron deficiency anemia.

MCHC (g/L) 24.4 32.0 – 36.0 g/L Low Decreased in iron deficiency anemia

Evaluation of Blood Smear: TROPONIN E – NEGATIVE

BLOOD ANALYSIS REPORT

COMPONENT RESULT NORMAL VALUES INTERPRETATION SIGNIFICANCE

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PH 7.51 7.35 – 7.45 High Indicates alkalosis.

PCO2 25 mm Hg 35 – 45 Low Indicates respiratory alkalosis (hyper or over ventilation).

PO2 90 mm Hg 80 – 100 Normal Normal

HCO3 20 mmol/L 22 – 26 Low Indicates metabolic acidosis.

TCO2 21 mmol/L 23 – 27 Low Indicates respiratory alkalosis

BE ecf -3 mmol/L (-2) – (+2) Low A negative base excess indicates metabolic acidosis (primary or secondary to respiratory alkalosis).

SO2 92% 95 – 100% Low Indicates that the hemoglobin is deoxygenated.

Readings: Uncompensated Respiratory alkalosis with unconnected oxygenation.

COMPONENT RESULT NORMAL VALUES INTERPRETATION SIGNIFICANCE

BUN kinetic UV (Blue)

9.8 mmo/L 2.5 – 6.4 High The BUN levelis significantlyabove thenormal limitswhich denotesan impairment in renal functions.

Creatinine Kinetic (2 *

133.7 umo/L 35.4 – 123.8 High The creatininelevel issignificantlyabove thenormal limitswhich is aresult of renalimpairmentrelated to theclient’s activerenal disease.

Direct HDL 0.214 mmo/L 0.700 – 2.200 Low Indicates heightened risk for heart disease.

ECG ANALYSIS RESULT

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819 Undefined Tachycardia

81 A Undefined Arrhythmia

303 High Voltage (Right Ventricular)

701 Poor R Progression

401 Short P-R Internal

618 Unspecified ST – T Abnormalities

III. CLINICAL DISCUSSION

A. ANATOMY AND PHYSIOLOGY

Circulatory

system

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NORMAL BLOOD CIRCULATION

BLOOD from the superior and inferior vena cava enters to the right atrium and

passed the tricuspid valve.

After the blood passed the tricuspid valve it flows to the right ventricle and

enters the pulmonary valve then flows to the pulmonary artery into the lungs.

The blood that enters the lungs will be oxygenated and by passing the

pulmonary vein it goes to left atrium.

And then it will passed the bicuspid valve to the left ventricle and pass the

aortic valve through aorta then the blood is ready for distributing and collecting

carbon dioxide to the tissues and organs.

Nervous system

FUNCTIONS OF THE NERVOUS SYSTEM

1. Sensory input- sensory receptors monitor numerous external and internal

stimuli that may be

interpreted as touch,

temperature, taste, smell,

sound, blood pressure and

body position. Action potential

from the sensory receptors

travel along nerves to the

spinal cord and brain, where

they are interpreted.

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STIMULUS

Sensory division conducts action potentials from the periphery to the

CNS

CNS processes and integrates information, initiates response, and

carries out mental activity

Motor division conducts action potentials to the periphery

2. Integration- the brain and the spinal cord are the major organs processing

sensory input and initiating responses. The input may produce an immediate

response, may be stored as memory, or may be ignored.

3. Homeostasis- the nervous system plays an important role in maintenance of

homeostasis. This function depends on the ability of the nervous system to

detect, interprets, and responds to the changes in the internal and external

conditions. In response, the nervous system can stimulate or inhibit the

activities of other system to help maintain a constant internal environment.

4. Mental activity- the brain is the center of the mental activity, including

consciousness, memory and thinking.

5. Control of muscles and glands- skeletal muscle normally contract only when

stimulated by the nervous system. Thus, through the control of skeletal muscle,

the nervous system controls the major movement of the body. The nervous

system participates also in controlling cardiac muscle, smooth muscle, and

many glands.

Organization of the nervous system

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PREDISPOSING FACTORAge: 68 yrs.old,

Sex: maleFamily history of hypertension 2 times Hx of stroke accident.

PRECIPITATING FACTORHypertension

Lifestyle: Lack of ExerciseDiet: Eating Foods Rich in Cholesterol

Deposition of fats in the artery of the brain or neck

Narrowing of the vein occurs

Occlusion of the artery in the brain or neck

Disruption of the blood flow

Ischemic cascade occurs * cellular metabolic events

Oxygen on the neurons (aerobic respiration of the neurons fails)

Switching of the mitochondria into anaerobic respirations

Production of the lactic acid

pH is changed

Acidosis occurs

Insufficiency in the production of ATP

Electrolyte ion imbalance occurs

Depolarization of the cells

Intracellular calcium increased Depolarization of the cell

Increased of glutamate

Cell membrane and protein breakdown, formation of free radicals, protein production

Cell injury and death occurs

Dizziness

Body temperature

B. PATHOPHYSIOLOGY OF CVA

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C. NURSING CARE PLAN

HYPERTHERMIA

ASSESSMENT NURSING DIAGNOSIS

PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: “Nilalagnat ang pinsan ko.” As verbalized by the patient’s relative.

Objective:

- Febrile- Warm to

touch- Flushed

skin- Temp: 37.7

0 C

Hyperthermia related to increased intracellular calcium as evidenced by elevated body temperature.

After 8 hours of nursing interventions the client body temperature will be decreased from 37.7 0C to the normal range.

1. Monitor vital signs.

2. Noted body temperature

3. Provide tepid sponge bat (if not contraindicated).

4. Promote ventilation ofskin by means of undressing or unclothing

1. Regular temperaturemonitoring will identifyadequatethermoregulation.

2. Noting the body temperature indicates and show the progress of the client’s condition

3. To promote cooling of body surface.

4. To maintain stablebody temperature of

After 8 hours of nursing interventions the clients body temperature remain 37.7 0 C. GOAL UNMET.

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(heat loss by radiation andconduction).

5. Administered medication (antipyretics) e.g paracetamol, as prescribed.

the clients

5. Medication such as antipyretics can decrease and normalized body temperature.

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IMPAIRED PHYSICAL MOBILITY

ASSESSMENT NURSING DIAGNOSIS

PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: “Hindi makagalaw ang lolo ko simula noong ma-stroke siya” as verbalized by the patient’s relative.

Objective:

(+) general body weakness

(+) Paralysis of left side of the body (hemiplagia)

(+) lethargy Functional

level scale: 0 (completely independent)

Inability to perform gross/fine motor skills

Impaired physical mobility related to disturbance of upper motor neuron in one part of the brain (neurovascular impairment) as evidenced by hemiplagia.

After 8 hours of nursing interventions the patient’s:

S/O will demonstrate techniques that will enable safe repositioning.

1. Determine diagnosis that contributes to immobility.

2. Assist or have S/O reposition client on a regular schedule by turning to side every 3 hours (as ordered by the physician).

3. Provide safety measure such as putting side rails up, or using pillows to support body part.

1. To identify causative/contributing factors.

2. To prevent complications like bedsore.

3. To provide safety.

After series of nursing intervention the patient relatives:

Relatives can demonstrated techniques that will enable safe repositioning.

GOAL MET.

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4. Involve S/O in care, assisting them to learn ways to managing problems of immobility.

5. Teach relatives to perform passive Range of Motion Exercises

4. To impart health teaching to the patient’s family.

5. To enhance blood circulation and prevent contractures

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IMPAIRED VERBAL COMMUNICATION

ASSESSMENT NURSING DIAGNOSIS

PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: “Hindi makapagsalita ng maayos ang lolo ko” as verbalized by the patient’s relative.

Objective:

Difficulty producing speech

Dysarthria Presence of

face mask

Impaired verbalcommunicationrelated to loss offacial or oral muscletone control as evidenced by difficulty speaking.

After 1 hr. of nursingintervention, thepatient will establishmethod ofcommunication inwhich needs can beexpressed

1. Provide alternativemethods ofcommunication, likepictures or visual cues,gestures ordemonstration and Hand gestures

2. Talk directly to patient.Speaking slowly anddirectly. Use yes or noquestion to begin with.

3. Speak in normal tones

1. Providecommunication needsor desires based onindividual situation orunderlying deficit.

2. It reduces confusionor anxiety and havingto process andrespond to largeamount ofinformation at onetime.

3. Patient is notnecessary hearing

After 1 hr. ofnursingintervention, thepatient was able toestablish method ofcommunication inwhich needs can beexpressed.

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and avoid talking too fast.Give patient ample timeto respond.

4. Encourage familymembers and visitors topersist efforts tocommunicate with thepatient.

impaired and raisingvoice may irritate oranger the patient

4. It is important forfamily members tocontinue talking tothe patient to reducepatients isolation,promoteestablishment ofeffectivecommunication andmaintain sense ofconnectedness orbonding with thefamily

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D. DRUG STUDY

GENERIC NAME

BRAND NAME

CLASSIFICATION

MECHANISM OF ACTION

INDICATION CONTRAINDICATION

ADVERSE REACTION

NURSING RESPONSIBLITY

Acetyl Salicylic Acid

Dosage: 80mg tabOnce a day

ASA, Aspergum, Aspercin

Pharmacologic Class: NSAIDs

Therapeutic Class:Non opioid Analgesic, Antipyretic, Anti platelet drug

Reduces pain and inflammation by inhibiting prostaglandin production. Fever reduction mechanism unknown; may be linked to decrease in endogenous pyrogens in hypothalamus resulting from prostaglandin inhibition. Exerts anti platelet effect by inhibiting synthesis of prostacyclin and thromboxane A2.

Mild pain or fever

Mild to moderate pain caused by inflammation

Acute rheumatic fever

To reduce the risk of transient ischemic attacks or cerebrovascular accident in men with a transient ischemic attack caused by emboli

To reduce the risk of myocardial infarction in patients with history of MI or unstable angina

Thromboembolic disorders.

Hypersensitivity to salicylates, other NSAIDs

Renal impairment

Severe hepatic impairment

Vitamin K deficiency caused by dehydration

Pregnancy or breastfeeding

Concurrent anticoagulant use

EENT: hearing loss

GI: nausea, vomiting

Hematologic:thrombocytopenia, leukopenia

Hepatic: hepatotoxicity

Respiratory: wheezing

Skin: rash, urticaria

Tell to relatives of the patient to report ototxicity symptoms, unusual bleeding and bruising

Instruct the relative of the patient to tell all prescribers he’s taking the drug because it may cause serious interactions with many common medicines

Tell patien’s relative not to take over the counter preparations containing aspirin

GENERIC NAME

BRAND NAME

CLASSIFICATION MECHANISM OF ACTION

INDICATION CONTRAINDICATION

ADVERSE REACTION

NURSING RESPONSIBLITY

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Isordil

Dosage: 5 tabletssublingual

Isosorbide Dinitrate

Pharmacologic Class:Nitrate

Therapeutic Class:Anti anginal

Promotes peripheral vasodilation and reduces preload and afterload, decreasing myocardial oxygen consumption and cardiac output. Also dilates coronary arteries, increasing blood flow and improving collateral circulation

Treatment and prophylaxis in situations likely to provoke acute angina pectoris.

Prophylaxis of angina pectoris.

Hypersensitivity to drug

Severe anemia

Acute myocardial infarction

CNS: dizziness,headache

CV: tachycardia, orthostatic hypotension

GI: nausea , vomiting

SKIN: flushing

Teach patient relative to give oral drug 30 mins. before or 1 to 2 hours after a meal

Inform patient relative that drug may cause headache.

Advise his relative to treat headache as usual and not to alter drug schedule.

GENERIC NAME

BRAND NAME

CLASSIFICATION MECHANISM OF ACTION

INDICATION CONTRAINDICATION ADVERSE REACTION

NURSING RESPONSIBLITY

Acetaminophen

DOSAGE:Ampule IV q4h

PARACETAMOL

Pharmacologic Class:Synthetic non opioid p- aminophenol derivative

Therapeutic class:analgesic, antipyretic

Unclear. Pain relief may result from inhibition of prostaglandin synthesis in cns, with subsequent blockage of pain impulses. Fever reduction may result from vasodilation

Mild to moderate caused byheadache, muscle ache, backache, mild arthritis, common cold, toothache, and fever.

Hypersensitivity to drug.

HEMATOLOGIC: thrombocytopenia, neutropenia, hemolytic anemia

HEPATIC: Jaundice, hepatotoxicity

SKIN: rash. urticaria

Tell patient, parents, or other caregivers not to use drug concurrently with other acetaminophen-containing products.

Advise patient , parents or other caregivers to contact prescriber

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and increased peripheral blood flow in hypothalamus, which dissipates heat and lowers body temperature.

METABOLIC: hypoglycemic coma

OTHERS: hypersensitivity reaction

if fever or other symptoms persist despite taking recommended amount of drug.

Inform patient with chronic alcoholism that drug may increase severe liver damage.

As appropriate, review all other significant and life threatening adverse effect and interactions and behaviors mentioned above.

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GENERIC NAME

BRAND NAME

CLASSIFICATION MECHANISM OF ACTION

INDICATION CONTRAINDICATION ADVERSE REACTION

NURSING RESPONSIBILITY

Berodual

Dosage:Nebule q6h

Ipratropium Bromide

Anti cholinergic drug, Anti asthmatic

It blocks the muscarinic cholinergic receptors in the smooth muscles of the bronchi in the lungs. This opens the bronchi, and provides relief in chronic obstructive pulmonary disease and acute asthma.

Prevention and treatment of symptoms in chronic obstructive airway disorders with reversible bronchospasm (eg bronchial asthma and chronic bronchitis.

Hypertrophic obstructive cardiomyopathy, tachyarrythmias. hypersensitivity to atropine like substance.

Nervousness. Restlessness, tachycardia, palpitations, dizziness, headache. dry mouth and cough.

Instructed the clients relative on how to use of inhaler, nebulizer.

Advised the patients relative to use dry cotton and tap the lips to avoid dryness.

Instructed the clients relative to do back tapping or vibration after the medication.

GENERIC NAME

BRAND NAME

CLASSIFICATION

MECHANISM OF ACTION

INDICATION CONTRAINDICATION ADVERSE EFFECTS

NURSING RESPOSIBILITY

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Digoxin

Dosage:20 g OD.

Lanoxin Antiarrythmic, inotropic

Increase force of and velocity of mayocardial contraction and prolongs refractory period of AV node by increasing calcium entry into myocardial cells. Slows conduction through sinoatrial and AV nodes and produces antiarrythmic effect.

Heart failure; tachyarrythmias; atrial fibrillation and flutter; paroxysmal atrial tachycardia.

Tab.20mg OD

Hypersensitivity to drugs

Uncontrolled ventricular arrhythmias

AV block

Idiopathic hypertropicsubaortic stenosis

Constrictive pericarditis

CNS: fatigue, headache, astheniaCV: bradycardia, ECG changes, arrhythmiasEENT: blurred or yellow visionGU: gynecomastiaGI: n/v, diarrhea

Check PR regularly, if it’s below 60 or above 110bpm/min, tell him to withhold dose and notify the prescriber.

Instruct patient relative not to take OTC drugs without prescribers approval

Teach patient relative on how to recognize and report signs and symptoms of digoxin toxicity

GENERIC NAME

BRAND NAME CLASSIFICATION

MECHANISM OF ACTION

INDICATION CONTRAINDICATION

ADVERSE EFFECTS

NURSING RESPOSIBILITY

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Mannitol

Dosage: 100 cc every q6 hours.

Osmitrol, resectisol

Diuretics Enhance water flow from various tissues and ultimately decrease intracranial and intraocular pressure. Also protects kidneys by preventing toxins from forming and blocking tubules.

To prevent acute renal failure during cardiovascular and other surgeries 50-100g I.V. infusion as 5%-25% solution.

To reduce intracranial pressure and brain mass. 0.5-2g/kg I.V infusion as 15-25% given over 30-60 mins.

To promote dieresis in drug toxicity 25g I.V. infusion as loading dose, followed by infusion of 5-25% solution given continuously to maintain high urine output.

Active intracranial bleeding

Anuria secondary to severe renal disease

Progressive heart failure, pulmonary congestion, renal damage or renal dysfunction after mannitol therapy begins

Severe dehydration

CNS: dizziness, headache, seizureCV: chest pain, hypotension, hypertension, tachycardia, thrombophlebitis, heart failure, vascular overloadEENT: blurred vision, rhinitisGI: n/v, diarrhea, dry mouthGU: polyuria, urinary retentionRespi: pulmonary congestionSkin: rash, urticaria

Teach patient relative about importance of monitoring exact urinary output.

Advise patient relative to report adverse reaction, such as increase shorthness of breath or back

Tell patient relative that drug may cause thirst or dry mouth.

GENERIC NAME

BRAND NAME CLASSIFICATION

MECHANISM OF ACTION

INDICATION CONTRAINDICATION

ADVERSE EFFECTS NURSING RESPOSIBILITY

Furosemide

Dosage: 20 mg IV

Furoside, lasix, novosemide

Diuretics, antihypertensive

Unclear. Thought to inhibit sodium and chloride reabsorption from ascending loop of Henle and distal renal tubules, promoting renal excretion of water, sodium, chloride,

Edema caused by heart failure, hepatic cirrhosis, or renal diseaseAdults: initially, 20-80 mg/day PO as a single dose; may increase 20-

Hypersensitivity to drug or other sulfonamides

Anuria

CNS: dizziness, headache, vertigo weakness, lethargy, restlessness, light headednessCV: hypotension, tachycardiaEENT: blurred vision, xanthopsia, hearing loss, tinnitus

Take the drug in the morning with foods to prevent nocturia.

Instruct S/O to report s/sx of ototoxicity.

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magnesium, hydrogen and calcium

40mg increments PO q 6-8 hrs until desired response occur.

GI: n/v, constipation, dyspepsia, cramping, anorexia, dry mouthGU: excessive and frequent urination, nocturia.Musculoskeletal: muscle pain and muscle cramps

Caution patient relative not to give any alcohol content beverages and herbs while taking this drug.

GENERIC NAME

BRAND NAME

CLASSIFICATION

MECHANISM OF ACTION

INDICATION CONTRAINDICATION

ADVERSE EFFECTS

NURSING RESPOSIBILITY

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Ceftazidime

Dosage:IV q8 hours

Ceptaz, portaz, tazidime

Anti-inffective

Interferes with bacterial cell wall synthesis and division by binding to cell wall, causing cell to die. Active against gram negative and gram positive bacteria, with expanded activity against gram negative bacteria. Exhibits immunosuppressant activity.

Skin infection, bone and joint infection urinary tract and gynaecologic infection; adults and children ages 12 and older: 500mg to 2 g. IV or IM q 8-12hrs. UTIs 500mg q 8-12hrs. IV or IM

Hypersensitivity to cephalosporins and penicillin

CNS: headache, lethargy, confusion, syncope seizuresCV: hypotension, palpitation, chest pain vasodilationEENT: hearing lossGI: n/v, abdominal crampingGU: vaginal candidiasisRespi: dyspneaSkin: urticaria, maculopapular rash

Instruct patient relative to report reduced urine output, persistent diarrhea, bruising and bleeding

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E. COURSE IN THE WARD

November 30, 2010

Received client on a bed lying down asleep with IVF of 200cc of 0.9

NaCl in SS level of 70cc of mannitol and with oxygen regulated at 10

LPM. IVF infusing well.

DATE TIME VITAL SIGNS NURSES OBSERVATION

November 30, 2010 8:00 am

12:00 noon

BP: 120/ 90 mmHg

PR: 62 bpmRR: 30 cpmTemp: 37.7 O C

BP: 120/ 90 mmHg

PR: 62 bpmRR: 30 cpmTemp: 37.7 O C

- Asleep

- Febrile

- With flushed skin

- Warm to touch

- With cyanotic lips

- DOB

- Lethargic

- Hemiplagia

- Limb ataxia

- Pale sole of the foot

- With indwelling

catheter

- Dysathria

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December 1, 2010

Received client on a bed lying down asleep with IVF of 275cc of 0.9

NaCl in SS level of 81cc of mannitol and with oxygen regulated at 10

LPM. IVF infusing well.

DATE TIME VITAL SIGNS NURSES OBSERVATION

December 1, 2010 8:00 am

12:00 noon

BP: 140/ 100 mmHg

PR: 71 bpmRR: 36 cpmTemp: 38.0 O C

BP: 140/ 100 mmHg

PR: 98 bpmRR: 41 cpmTemp: 38.8 O C

- Asleep

- Febrile

- With flushes skin

- Warm to touch

- With cyanotic lips

- DOB

- Lethargic

- Hemiplagia

- Limb ataxia

- Pale sole of the foot

- With indwelling

catheter

- Dysathria

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DISCHARGED PLAN

M-EDICATION

Patient has to take his medication on time.

E-XERCISEThe patient was advised to have complete bed rest until strength is regained. Have

turn side to side every 2 hours to prevent bed sores. Have ROM exercise on to enhance client's body function.

T-REATMENTInsist physical therapy for improving strength and walking. Undergo Occupational

therapy for regaining dexterity of the arms and hands. The client should go through speech therapy to learn talking and swallowing. Oxygen inhalation should be available if necessary.

H-EALTH TEACHINGTeach the client how to have a healthy lifestyle. Teach patient the foods to eat and

the foods to avoid. Teach the family members how to prepare low sodium and low fat diet.Encourage environmental modification to enhance safety and prevent injury.

O-UT PATIENT

The client was advised to have a follow-up check-up, as indicated by the physician.

D-IET

Patient was instructed to maintain the low salt and low fat diet. The low salt diet is

designed to induce a loss of sodium and water from the body or avoid sodium retention. A

2000 mg low sodium diet is sufficient to control blood pressure. A low fat diet help lose

weight to decrease risk of having CVA again.

S-SPIRITUAL ADVICE

The patient needs a spiritual advice by their relative to have faith in GOD that his

illness will lessen, and only GOD can cure his pain with the help of medicine.

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F. EVALUATION

The nursing process and procedure rendered to the patient is accordingly.

Health teaching and nursing interventions were done properly and effective. In order to

provide care our group applies the knowledge, skills and right attitude for caring for our

patient. In terms of rendering and giving independent intervention, we as student nurses

believe that we have done our best to be able to provide our outmost care. The client was

admitted in the hospital because he suffered from chills, dizziness, nausea and vomiting. The

Physicians diagnosis was Cerebral Vascular Accident (CVA) or stroke. He is confined in the

hospital for more than seven days. We assisted this patient and made some independent

nursing interventions to help alleviate his conditions and to be of assistance to the client’s

relatives.

G. SUMMARY

This study focused on Cerebral Vascular Accident (CVA). The condition is caused by

the interruption of the blood supply to the brain, usually because a blood vessel bursts or is

blocked by a clot. This cuts off the supply of oxygen and nutrients, causing damage to the

brain tissue.

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The most common symptom of a stroke is sudden weakness or numbness of the face, arm

or leg, most often on one side of the body. Other symptoms include: confusion, difficulty

speaking or understanding speech; difficulty seeing with one or both eyes; difficulty walking,

dizziness, loss of balance or coordination; severe headache with no known cause; fainting or

unconsciousness.

The effects of a stroke depend on which part of the brain is injured and how severely it

is affected. A very severe stroke can cause sudden death.

After choosing this case, we researched about CVA to know the cause, clinical

manifestation and nursing intervention that we are going to perform. After doing procedures

such as physical assessment and assessing the vital signs, along with our research, this

helped us to gain more knowledge and understanding about the disease.

H. RECOMMENDATION

As a student nurse we recommended the following:

To the patient:

1. Continue his medication with the help of the relatives

2. Eat healthy and nutritious foods avoid cholesterol that trigger his condition

3. Initiate physical therapy after discharged in the hospital

4. Teach the relatives how to monitors patients vital signs, frequently specially blood

pressure because patient is unstable in her condition.

5. The relatives should always pray for the fast recovery of their love ones.

6. Be patient in caring for his, who suffering from this kind of disease.

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