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Liceo de Cagayan University
Rodolfo Neri Pelaez BoulevardCarmen, Cagayan de Oro City
In Partial Fulfillment of the Requirement in NCM501204 Related Nursing Experience
Submitted By:
NCM501205 Cluster 1 – Group A5
Respectfully submitted to:
Mrs. Franelee A. Zulueta, RN, MN
Clinical Instructor
November 26, 2010TABLE OF CONTENTS
PAGES
I. Introduction 1-3a. Overview of the caseb. Objective of the studyc. Scope and Limitation of the study
II. Database 3-5a. Profile of patientb. Family and Past personal health history c. Chief Complaintd. Health history of Present Illness
III. Developmental Data 5
IV. Medical Managementa. Medical Orders and Rationale 6-9b. Diagnostic Exams 9-11c. Drug Study 12-20
V. Anatomy & Physiology 21-26
VI. Pathophysiology 27-28
VII. Nursing Assessment 28-31
VIII. Nursing Managementa. Ideal Nursing Management 32-35b. Actual Nursing Management 36-40
IX. Health Teachings 41-42
X. Evaluation/Conclusion 42-43XI. Bibliography 43
I. INTRODUCTION
A. Overview of the CaseCerebrovascular 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. (Einbach, Medical-Surgical Nursing, 2009)
Cerebrovascular disease primarily affects people who are elderly or have a
history of diabetes, smoking, or ischemic heart disease. Cigarette smoking is the most
important modifiable risk factor of CVD. Risk factors include advanced age, male
gender, hypertension (high blood pressure), high cholesterol, atrial fibrillation. The
results of cerebrovascular disease can include a stroke, or occasionally a hemorrhagic
stroke or the thrombotic stroke. (Einbach, Medical-Surgical Nursing, 2009)
People with hypertension have a risk for stroke that is four to six times higher
than the risk for those without hypertension. Forty to 90 percent of stroke patients have
high blood pressure before their stroke event. (http://www.holistic-online.com/remedies/Heart/stroke_risk_mod_hypertension.htm)
Restrictions in blood flow may occur from vessel narrowing or stenosis, clot
formation or thrombosis, blockage or embolism, or blood vessel rupture or hemorrhage. (Einbach, Medical-Surgical Nursing, 2009)
The most common forms of cerebrovascular disease are cerebral thrombosis
(40% of cases) and cerebral embolism (30%), followed by cerebral hemorrhage (20%).
Stroke is the third leading cause of death in the United States. Of the more than
700,000 people affected every year, about 500,000 of these are first attacks, and
200,000 are recurrent. About 25 percent of people who recover from their first stroke
will have another stroke within five years. Each year, an estimated 30,000 people in the
United States experience a ruptured cerebral aneurysm and as many as 6 percent may
have an unruptured aneurysm. (http://en.wikipedia.org/wiki/Stroke)
1
According to the Philippine Nurses Association, the top 5 of the clinical disease
entities frequently studied were cerebrovascular disease, infectious disease,
neuromuscular diseases, epilepsy and demyelinating disease. For the past 10 years,
there has been an increasing trend in the number of studies dealing with
cerebrovascular disease. (http://nursingcrib.com/tag/brain-stroke)
B. Objective of the StudyThe patient’s case was chosen by the group to be a case study, to be able to
provide nursing intervention that would alleviate the condition of the patient. In same
way the group will be able to learn and enhance our knowledge and skills in caring
patients in such cases.
Specific objectives of the study are to:
Perform assessment of patient and her condition.
Identify possible problems that may rise from patient’s condition.
Determine the cause, predisposing factor, precipitating factors that constitute the
health condition.
Provide appropriate nursing intervention for client’s care.
Impart the important information as health teachings that would be useful to
patient’s understanding of care regimen and nature of her health condition.
Enhance skills & knowledge as health care provider in the clinical setting.
B. Scope and Limitation of the StudyThe study includes the information gathering specifically to the patient’s health
condition. It also includes the assessment of the physiological and psychological status,
adequacy of support systems and care given by the family as well as other health care
providers. The scope of this study would include:
a. The collection of data is via assessment, interviews with family members.
b. Actual problems for 24 hours including appropriate nursing intervention that
would be applied within her stay in the hospital.
c. Developing plan of care that will reduce identified predicaments and
complications.
2
d. Applying interventions within the plan of care to assist the client to reach
maximum functional health.
An array of factors influencing the limitations of this study includes:
a. Collected data is limited only to assessment and interview to the family
members.
b. The dealings, assessment and care were only limited to a total of 24 hours
with actual nursing intervention done.
II. DATABASE
A. Patient’s ProfileName of Patient : TG
Sex : Female
Age : 59 years old
Birthday : September 25, 1951
Birthplace : Cagayan de Oro city
Religion : Roman Catholic
Civil Status : Married
Husband : AG
Occupation : Farmer
Income : P 30,000-45,000 per 4 months
Nationality : Filipino
Date Admitted : November 18, 2010
Time : 3:20 AM
Informant : TG (pt herself)
Temperature : 36.4 0C
Pulse Rate : 64 bpm
Respiration : 15 cpm
BP : 190/100 mmHg
Height : 5’1’’
Weight : 51 kgs
3
B. Family and Past personal health history
The patient was born via Normal Spontaneous Vaginal Delivery at their home in
Gusa, CDO assisted by hilot. The patient had not received blood in the past 6 months
before admission.
The patient's heredo-familial disease is hypertension. During her teenager, mid-
adult years (mid 40’s) and the recent years, she had been eating many fatty foods such
as fried chicken, fried fish and humba and cholesterol rich foods such as fried egg. She
also loves to eat salty foods.
She has no previous illness for the past six months. She did not recall having
been admitted in a hospital in her life. She hasn’t experienced any surgery. She also
hasn’t experienced a blood transfusion. Patient had no known food and drug allergies.
She was also a herbalist, believing in the effectiveness of herbs as a health
treatment when having minor illness at home.
She had been pregnant trice and delivered her child in normal spontaneous
vaginal delivery at home by a trained hilot.
She claimed that she didn’t smoke. She admitted she drank alcohol occasionally
during her teenager years until her mid-30s.
C. Chief complaintRight sided body weakness with dizziness.
D. History of Present IllnessThis was the patient first admission in a hospital in her entire life as she can
remember.
Prior to admission patient complaint of a left sided body weakness, fatigue,
dizziness. 22 hours prior to admission at around 6:00 pm on November 17, 2010,
patient while washing clothes sitting, experienced a sudden acute body weakness on
left arms and legs without falling to the floor. She then called her daughter while patient
is having dizziness and headache. Her daughter placed her on bed in a high fowler’s
position. She called her sister, which is their neighbor and brought Neobloc to the
4
patient. The patient had taken the medication and relieved of her dizziness. She had a
sound sleep that night. The morning after, patient still experienced dizziness and
headache. At around 12:00 noon, she was visited by their parish priest. The priest gave
her 800 pesos and advised her to be admitted to a hospital since he said that it would
be better to take the medication that is prescribed by the physician, because the
Neobloc medicine that was taken by the patient was unprescribed and had only been
recommended by her daughter since her daughter is also hypertensive. Hence patient
was admitted at 3:20 PM.
III. DEVELOPMENTAL DATA
THEORIES IMPLICATIONS
Erikson’s Stages of Psychosocial Development Theory
Stage: Adulthood
Age: 25-65 y/o
Central Task: Generativity vs stagnation
(+) Resolution: Creativity, productivity,
concern for others.
(-) Resolution: Self-indulgence, self-
concern, lack of interests & commitments.
From our patient’s condition, we
can say that she’s halfway between
stagnation and generatively. Due to
poverty, she cannot generate
enough income to share with other
relatives, however, their work was
just enough for their own living.
Havighurst’s Developmental Stage and Tasks
- adjust to physiological changes &
alterations in health status
- adjust to retirement & altered income
Our patient was not able to adjust
completely to physiological
changes and alterations in her
health status, that’s why she has
been hospitalized because of her
disease condition. If she was able
to adjust, she would religiously
5
- develop affiliation with one’s age group consider maintaining a diabetic diet
as prescribed. The patient also had
low income which hinders her to
have routine check-ups yearly.
IV. MEDICAL MANAGEMENT
A. Medical Orders and Rationale
DOCTOR’S ORDER RATIONALE
11-18-10 @ 3:20 pm
Please admit under the service of Dr.
Sabal
Start PLR ; L @ 20 gtts/min
Labs: CBC
Na
Hgt
U/A
For further management and treatment of
condition
To provide intravenous access for
emergency drugs
To assess hemoglobin, hematocrit for
possible tissue ischemia, WBC for possible
infection, RBC for possible anemic state.
To assess sodium imbalance such as
hypernatremia as a cause of hypertension
from increase salt intake or hyponatremia
that may cause altered mental status or
muscle weakness.
To rule out possible DM; determine
patient’s blood sugar.
To determine quality of urine. The quality
is a good indicator of blood circulation to
6
Chest Xray
ECG
Captopril 25mg now
Citicholine 1gm q12 IVTT
Atenolol 5mg; 1 tab OD a.m.
Mannitol 200cc initial dose then 100cc
q 6
Vitamin B complex 1 tab OD
the kidneys. To determine also infection of
the urinary tract and initiate medical
management.
To determine arterial vessel structure and
reinforce thrombolic CVD diagnosis. To
note for atherosclerosis plaque
development or other undiagnosed
complications affecting the lungs.
To determine heart’s conduction and
records heart’s electrical activity; to assess
for cardiac arrhythmias.
Patient is hypertensive. This helps lowers
patient’s BP
This is for patient’s post CVD thrombotic
state. This increase cerebral blood flow
thereby acts as a neurotropic drug which is
good for the “rehabilitation” of the brain.
A beta-blocker which lowers patient’s
blood pressure.
To promote urination to decrease
intravascular volume, hence to decrease
ICP and affects blood pressure. Down
filtrate to prevent dehydration
To counter patient’s fatigue and to
promote cerebral neuron functioning.
7
Sperm q 2
BP q shift
For cholesterol, triglyceride, HDL, LDL
BUN, creatinine
Uric Acid
For CT Scan tomorrow
11-19-10 @ 2:00 PM
Simvastatin 40 mg OD PO
Amlodipine 10 mg 1 tab OD
Aspirin ; 325 mg 1 tab OD
Vitamin B complex (Polynerve) 1000; 1
To monitor patient’s neurologic al status.
To monitor patient’s blood pressure and
evaluate effectiveness of anti-hypertensive
medication
This test measures limpidity of patient’s
blood. Higher cholesterol, triglyceride and
LDL mean a higher risk for formation of
atherosclerotic plaque leading to
atherosclerosis and thrombotic ischemia
stroke. A lower HDL will do the same.
To evaluate renal functions.
Patient is elderly. Possible arthritis pain in
joints by increase uric acid deposition.
This will serve as definitive diagnosis for
CVA.
Patient’s cholesterol is increased. This drug
serves to lower blood cholesterol levels.
For patient’s hypertension – 150/90
mmHg. This lowers patient’s blood
pressure.
Aspirin to prevent thrombus formation
and prevent clots.
This is a vitamin B complex drug and is
given to the patient post CVA status. To
maintain proper functioning of brain cells
8
tab BID
11-20-10 @ 2:15 PM
MGH
Home medications
Amlodipine 10 mg 1 tab OD
Polynerve 1000; 1 tab BID
Aspirin ; 325 mg 1 tab OD for 7 days
Simvastatin 40 mg OD PO
Follow-up check up on 11-30-10
and provide energy boost to cells.
Patient is stable. Patient can now go
home.
Amlodipine to maintain a lower blood
pressure; aspirin to
To maintain proper functioning of brain
cells and provide energy boost to cells.
As a prophylaxis against clotting. Prevents
clotting formation.
To maintain normal range of cholesterol
levels.
For evaluation of health condition and
reassessment for any complications which
can be prevented thru early detection and
management.
B. Diagnostic Results
CBC 11-19-10 INTERPRETATIONUNIT REFERENCE
WBC 5.98 10^3/uL 5.0-11.0 Normal values
RBC 4.6 10^6/uL 4.2-5.4 Normal values
Hemoglobin 143 g/dL 120-160 Normal valuesHematocrit 41 % 37.0-47.0 Normal values
Differential count
9
NEUTROPHIL 49 % 48-73 Normal valuesLYMPHOCYTE 39 % 20-45 Normal valuesMONOCYTES 09 % 00-10 Normal valuesEOSINOPHILS 1 % 00-05 Normal values
BASOPHILS 0 % 00-02 Normal valuesPLATELET 192 10^3/uL 150-400 Normal values
11-19-10Creatinine – 0.7 mg/dl | (0.5-1.5) | --normal range, kidneys adequately functions
BUN – 19.21 mg/dl | (10-50) | --within normal range
Uric Acid – 5.5 mg/dl | (3.4-7.0) | -within normal range
Triglycerides – 88.13 mg/dl | (<200) | -within normal range
Cholesterol - 280 mg/dl | (140-220) | -- Hyperlipidemia
HDL – 35.4 mg/dl | (45-65) | -- Hyperlipidemia
LDL – 199.2 mg/dl | (50-120) | -- Hyperlipidemia
Sodium – 142 mmol/dl | (136-146) | -within normal range
Potassium – 3.5 mmol/dl | (3.5-5.3) | -within normal range
HGT – 113 mg/dl |( 60-120) | -within normal range, pt is not diabetic
11-19-10
UA INTERPRETATIONNormal values
Color Yellow Yellow hay/ yellow -normal
Spec. gravity 1.015 1.010-1.030 -within normal range
Sugar negative negative -within normal rangepH 7 5-8 -within normal range
Albumin Negative Negative Normal finding, indicates normal glomerular permeability and adequate reabsorption function of the kidneys
Pus Cells 0-1 none Normal valuesRBC None None Normal values
11-19-10Chest Xray:
IMPRESSION: ATHEROSCLEROTIC AORTA, CARDIOMEGALY.
10
Increase risk for atherosclerosis
Significance: chronic stress of the heart, chronic increase in force of pumping action of the heart. Indicates compensation of heart to decrease blood flow due to narrowing of blood vessels secondary to atherosclerotic aorta. Also indicates the chronic stress experienced by the patient.
11-19-10BRAIN CT SCAN without contrast (plain):
Multiple sequential and tomographic sections of the head from the skull base to the vertex without contrast was performed revealing the ff:
Hypodense areas are seen in the head of the R cerebral cortex parieto-frontal lobe measuring 1x0.5x0.5 cm
No evidence of intracerebral hemorrhage. No abnormal extracranial fluid collection or hematoma. The rest of ventricles are unremarkable. No shifting of midline structures.
Cerebellum and pons are not unsual.
IMPRESSION: SUBACUTE INFARCT RIGHT PARIETO-FRONTAL CORTEX
11
DRUG STUDY
Name of drug
Generic / Brand
Date ordered
Classification Route/ Dose &
frequency
Mechanism of Actions Specific indication
(why drug is ordered)
Contraindications Side effects Toxic
effects
Nursing Responsibility
Amlodipine
11-18-10
Calcium channel blockerAnti-anginalAnti-hypertensive
10 mg 1 tab OD PM / P.O.
Inhibits movement of calcium across the membrane of cardiac and atrial muscle cells, inhibits trans membrane calcium flow
Hypertension 190 / 100 mmHg
-allergy to amlodipine-impaired hepatic or renal function-CHF-Heart block-hypotension
-dizziness-hypotension-headache-fatigue-lethargy-rash-nausea-abdominal discomfort
-take with meals if upset stomach occur-report irregular heart rhythm-monitor BP carefully, watch for hypotension; hold and refer if BP is <90/70 mmHg
12
Name of drug
Generic / Brand
Date ordered
Classification Route/ Dose &
frequency
Mechanism of Actions Specific indication
(why drug is ordered)
Contraindications Side effects Toxic
effects
Nursing Responsibility
Atenolol (Therabloc)
11-18-10
Beta blocker Anti hypertensive
50mg 1 tab OD AM/ PO
Blocks beta adrenergic receptor of the sympathetic, nervous system in the heart are kidney thus decreasing the excitability of the heart decrease cardiac output and oxygen consumption decrease release of renin from kidney and lowering BP.
Hyertension 190/100 mmHg
-sinus bradycardia-2nd or 3rd degree heart block-CHF-hypotension
DizzinessVertigoFatigueConstipationNauseaVomitinghypotension
- monitor BP and pulse carefully, watch for hypotension; hold and refer if BP is <90/70 mmHg-Assess edema and feet, legs daily -avoid stimulating foods such as coffee.
13
Name of drug
Generic / Brand
Date ordered
Classification Route/ Dose &
frequency
Mechanism of Actions Specific indication
(why drug is ordered)
Contraindications
Side effects Toxic effects
Nursing Responsibility
Captopril 11-18-10
Calcium channel blockerAnti-anginalAnti-hypertensive
25mg/STAT order /PO
Inhibits movement of calcium across the membrane of cardiac and atrial muscle cells, inhibits trans membrane calcium flow
Hypertension 190 / 100 mmHg
-allergy to captopril-impaired hepatic or renal function-CHF-Heart block-hypotension
-dizziness-hypotension-headache-fatigue-lethargy-rash-nausea-abdominal discomfort-angio-edema-agranul-ocytosis-proteinuria, -hyper-kalemia
-report irregular heart rhythm-monitor BP carefully, watch for hypotension; hold and refer if BP is <90/70 mmHg
14
Name of drug
Generic / Brand
Date ordered
Classification Route/ Dose &
frequency
Mechanism of Actions Specific indication
(why drug is ordered)
Contraindications Side effects Toxic
effects
Nursing Responsibility
Vit. B complex(Polynerve 1000)
11-18-10
Vitamins, Supplementary nutrients
PO 1 Tab OD
Normal functioning of the brain cells also to counter act patient fatigue supplying enough vit B to body cells
For rehabilitation to stroke,Pt’s fatigue
Allergy to drug components
Nausea, Vomiting
-Ensure proper diet-Assist patient in active/passive ROM exercise-instruct to increase amount protein for tissue repair and carbohydrates for energy needs.
15
Name of drug
Generic / Brand
Date ordered
Classification Route/ Dose &
frequency
Mechanism of Actions Specific indication
(why drug is ordered)
Contraindications Side effects Toxic
effects
Nursing Responsibility
Citicholine
11-18-10
Neutropics & Neurotonics
1gm q12 IVTT
Citicoline activates the biosynthesis of structural phospholipids in the neural membrane, increase cerebral metabolism, increase level of various neurotransmitters.
Patient had CVA. This is of the maintenance of normal brain cell function.
Allergy to drug componentsHypotension
shock, hypotension, chest compression, dyspnea. Skin eruptions; headache, vertigo, excitation; nausea & rarely, anorexia; burning sensation, transient change in BP, malaise.
- In case of stupor caused by acute/severe/progressive head trauma or cerebral surgery, give concomitantly w/ depressant & hypothermic agent.- Observe the 12 rights of administration of drugs.
16
Name of drug
Generic / Brand
Date ordered
Classification Route/ Dose &
frequency
Mechanism of Actions Specific indication
(why drug is ordered)
Contraindications Side effects Toxic
effects
Nursing Responsibility
Mannitol 11-18-10
Osmotic Diuretic
100cc q 6 hours
Elevates the osmolarity of the glomerular filtrate, therby hindering the reabsoprtion of water and leading to a loss of water, sodium, chloride; creates an osmotic gradient thereby lowering ICP and BP.
Hypertension and increase ICP.
Allergy to drug componentsHypotension
Dizziness, hypotension, nausea, anorexia, dry mouth, pulmonary congestion
- Monitor Intake and output accurately- Observe for signs of hypotension-Monitor serum electrolytes periodically-report difficulty breathing ,chest pain, or shortness of breath
17
Generic name of ordered
drug
Date ordered Classification
Dose/frequency/
routeMechanism of action Specific
indicationscontraindi
cationsSide effects/ toxic effects
Nursing precautions
Simvastatin
11-19-10
Antihyperlipidemia
40 mg OD PO
it is a competitive inhibitor of 3-hydroxy-3-methylglutaryl coenzyme for cholesterol synthesis HMG-COA reductase inhibitors (sometimes called "statins") reduce total cholesterol, low-density lipoprotein (LDL) cholesterol and very-low-density (VLDL)-cholesterol concentration in plasma. They also tend to reduce triglycerides and to increase high-density lipoprotein (HDL)-cholesterol concentration. They are considered to exert their hypocholesterolemic action by stimulating an increase in LDL-recpetors on hepatocyte membrane thereby increasing the clearance of LDL from the circulation.
High cholesterolHigh LDLLow HDLCholesterol- 348 mg/dlLDL- 283.2mg/dlHDL-35.4mg/dl
Allergy to drugESRDAcute liver disease
headache, skin rashes, dizziness, blurred vision and dysgeusia
Administer with straw or crushedDo not combine with grape fruit juice-will reduce metabolism.-instruct patient to avoid fatty foods and use vegetable oil instead in cooking foods.
18
Generic name of ordered
drug
Date ordered Classification
Dose/frequency/
routeMechanism of action Specific
indicationscontraindi
cationsSide effects/ toxic effects
Nursing precautions
Aspirin 11-19- Antiplatelet 325 mg 1 Aspirin is an analgesic, Prophylaxis Hypersens GI Avoid
19
10 Nonsteroidal Anti-inflammatory Drugs (NSAIDs) SalicylateAntipyretic
tab OD anti-inflammatory and antipyretic. It inhibits cyclooxygenase, which is responsible for the synthesis of prostaglandin and thromboxane. It also inhibits platelet aggregation.
for thrombus formation from postCVA
itivity (attacks of asthma, angioedema, urticaria or rhinitis), active peptic ulceration; patients with haemophilia or haemorrhagic disorders, gout, severe renal or hepatic impairment, lactation.
disturbances; prolonged bleeding time, rhinitis, urticaria and epigastric discomfort; angioedema, salicylism, tinnitus; bronchospasm.
overdose
Take drug with food/ after meals if GI upset occurs
Report tinnitus, dizziness of severe headache.
20
Generic name of ordered
drug
ClassificationDose/
frequency/route
Mechanism of action Specific indications
contraindications
Side effects/ toxic effects
Nursing precautions
Metoprolol (Neo-bloc)
Beta1-selective adrenergic blockerAntihypertensive
50 mg 1 tab/ PRN (when pt is having dizziness and increase palipatation; when patient subjectively feels she had high blood pressure)
Competitively blocks beta-adrenergic receptors in the heart and juxtaglomerular apparatus, decreasing the influence of the sympathetic nervous system on these tissues and the excitability of the heart, decreasing cardiac output and the release of renin, and lowering BP; acts in the CNS to reduce sympathetic outflow and
Hypertension at home
Contraindicated with sinus bradycardia (HR < 45 beats/min), second- or third-degree heart block (PR interval > 0.24 sec), cardiogenic
Dizziness, vertigo, tinnitus, CHF, cardiac arrhythmia, peripheral vascular insufficiency, claudication, Gastric pain, flatulence, constipation, diarrhea, nausea,
Do not discontinue drug abruptly after long-term therapy, Taper drug gradually over 2 wk with monitoring.Give oral
21
vasoconstrictor tone. shock, CHF, systolic BP < 100 mm Hg; lactation.
vomiting, anorexia, Impotence, decreased libido.
drug with food to facilitate absorption.
22
V. ANATOMY AND PHYSIOLOGYThe Nervous System
The nervous system is a network of specialized cells that communicate information about an
animals surroundings and its self, it processes this
information and causes reactions in other parts of the
body. It is composed of neurons and other
specialized cells called glia, that aid in the function of
the neurons.
The nervous system is divided broadly into two
categories; the peripheral nervous system and the
central nervous system. Neurons generate and
conduct impulses between and within the two
systems. The peripheral nervous system is
composed of sensory neurons and the neurons that
connect them to the nerve cord, spinal cord and
brain, which make up the central nervous system. In
response to stimuli, sensory neurons generate and
propagate signals to the central nervous system
which then process and conduct back signals to the muscles and glands. (Rod R. Seeley et.
al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
The neurons of the nervous systems of animals are interconnected in complex
arrangements and use electrochemical signals and neurotransmitters to transmit impulses
from one neuron to the next. The interaction of the different neurons form neural circuits that
regulate an organism’s perception of the world and what is going on with its body, thus
regulating its behavior. Nervous systems are found in many multicellular animals but differ
greatly in complexity between species
The central nervous system (CNS) is the largest part of the nervous system, and includes
the brain and spinal cord. The spinal cavity holds and protects the spinal cord, while the
head contains and protects the brain. The CNS is covered by the meninges, a three layered
protective coat. The brain is also protected by the skull, and the spinal cord is also protected
by the vertebrae. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5 th edition,
McGraw-Hill Int. NY 10020 2005)
26
Brain is a part of the Central Nervous System, it plays a central role in the control of most
bodily functions, including awareness, movements, sensations, thoughts, speech, and
memory. Some reflex movements can occur via spinal cord pathways without the
participation of brain structures. (Rod R. Seeley et. al, Essentials of Anatomy and
Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
The cerebrum is the largest part of the brain and controls voluntary actions, speech, senses,
thought, and memory. The surface of the cerebral cortex has grooves or infoldings (called
sulci), the largest of which are termed fissures. Some fissures separate lobes. The
convolutions of the cortex give it a wormy appearance. Each convolution is delimited by two
sulci and is also called a gyrus (gyri in plural). The cerebrum is divided into two halves,
known as the right and left hemispheres. A mass of fibers called the corpus callosum links
the hemispheres. The right hemisphere controls voluntary limb movements on the left side
of the body, and the left hemisphere controls voluntary limb movements on the right side of
the body. Almost every person has one dominant hemisphere. Each hemisphere is divided
into four lobes, or areas, which are interconnected.
The frontal lobes are located in the front of the brain and are responsible for voluntary
movement and, via their connections with other lobes, participate in the execution of
sequential tasks; speech output; organizational skills; and certain aspects of behavior,
mood, and memory.
The parietal lobes are located behind the frontal lobes and in front of the occipital
lobes. They process sensory information such as temperature, pain, taste, and touch. In
addition, the processing includes information about numbers, attentiveness to the position of
one’s body parts, the space around one’s body, and one's relationship to this space.
The temporal lobes are located on each side of the brain. They process memory and
auditory (hearing) information and speech and language functions.
The occipital lobes are located at the back of the brain. They receive and process
visual information
24
Arteries carry blood that contains oxygen to the brain. The flow of blood through the arteries
can stop if they are blocked or bleed. This is called a stroke. It is also known as a
cerebrovascular accident or CVA.
The Cardiovascular SystemThe heart and circulatory system make up the cardiovascular system. The heart works as a
pump that pushes blood to the
organs, tissues, and cells of the
body. Blood delivers oxygen and
nutrients to every cell and removes
the carbon dioxide and waste
products made by those cells.
Blood is carried from the heart to
the rest of the body through a
complex network of arteries,
arterioles, and capillaries. Blood is
returned to the heart through
venules and veins. The one-way
circulatory system carries blood to
all parts of the body. This process
of blood flow within the body is
called circulation. Arteries carry oxygen-rich blood away from the heart, and veins carry
oxygen-poor blood back to the heart. In pulmonary circulation, though, the roles are
switched. It is the pulmonary artery that brings oxygen-poor blood into the lungs and the
pulmonary vein that brings oxygen-rich blood back to the heart. (Rod R. Seeley et. al,
Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
Twenty major arteries make a path through the tissues, where they branch into smaller
vessels called arterioles. Arterioles further branch into capillaries, the true deliverers of
oxygen and nutrients to the cells. Most capillaries are thinner than a hair. In fact, many are
so tiny, only one blood cell can move through them at a time. Once the capillaries deliver
oxygen and nutrients and pick up carbon dioxide and other waste, they move the blood back
through wider vessels called venules. Venules eventually join to form veins, which deliver
the blood back to the heart to pick up oxygen. Vasoconstriction or the spasm of smooth 25
muscles around the blood vessels causes and decrease in blood flow but an increase in
pressure. In vasodilation, the lumen of the blood vessel increase in diameter thereby
allowing increase in blood flow. There is no tension on the walls of the vessels therefore,
there is lower pressure.
The heart pumps oxygenated blood to the body and deoxygenated blood to the
lungs. In the human heart there is one atrium and one ventricle for each circulation, and with
both a systemic and a pulmonary circulation there are four chambers in total: left atrium, left
ventricle, right atrium and right ventricle. The right atrium is the upper chamber of the right
side of the heart. The blood that is returned to the right atrium is deoxygenated (poor in
oxygen) and passed into the right ventricle to be pumped through the pulmonary artery to
the lungs for re-oxygenation and removal of carbon dioxide. The left atrium receives newly
oxygenated blood from the lungs as well as the pulmonary vein which is passed into the
strong left ventricle to be pumped through the aorta to the different organs of the body.
About 98.5% of the oxygen in a sample of arterial blood in a healthy human breathing air at
sea-level pressure is chemically combined with haemoglobin molecules. About 1.5% is
physically dissolved in the other blood liquids and not connected to Hgb. The haemoglobin
molecule is the primary transporter of oxygen in mammals and many other species.
Blood pressure (BP) is the pressure exerted by circulating blood upon the walls of
blood vessels, and is one of the principal vital signs. It is a measurement of the force applied
to the walls of the arteries as the heart pumps blood through the body. The pressure is
determined by the force and amount of blood pumped, and the size and flexibility of the
arteries. Blood pressure is continually changing depending on activity, temperature, diet,
emotional state, posture, physical state, and medication use. (Rod R. Seeley et. al,
Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
Various external factors also cause changes in blood pressure and pulse rate. An
elevation or decline may be detrimental to health. Changes may also be caused or
aggravated by other disease conditions existing in other parts of the body.
The blood is part of the circulatory system. Whole blood contains three types of blood
cells, including: red blood cells, white blood cells and platelets.
These three types of blood cells are mostly manufactured in the bone marrow of the
vertebrae, ribs, pelvis, skull, and sternum. These cells travel through the circulatory system
suspended in a yellowish fluid called plasma. Plasma is 90% water and contains nutrients,
26
proteins, hormones, and waste products. Whole blood is a mixture of blood cells and
plasma.
Red blood cells (also called erythrocytes) are shaped like slightly indented, flattened
disks. Red blood cells contain an iron-rich protein called hemoglobin. Blood gets its bright
red color when hemoglobin in red blood cells picks up oxygen in the lungs. As the blood
travels through the body, the hemoglobin releases oxygen to the tissues. The body contains
more red blood cells than any other type of cell, and each red blood cell has a life span of
about 4 months. Each day, the body produces new red blood cells to replace those that die
or are lost from the body.
White blood cells (also called leukocytes) are a key part of the body's system for
defending itself against infection. They can move in and out of the bloodstream to reach
affected tissues. The blood contains far fewer white blood cells than red cells, although the
body can increase production of white blood cells to fight infection. There are several types
of white blood cells, and their life spans vary from a few days to months. New cells are
constantly being formed in the bone marrow.
Several different parts of blood are involved in fighting infection. White blood cells
called granulocytes and lymphocytes travel along the walls of blood vessels. They fight
bacteria and viruses and may also attempt to destroy cells that have become infected or
have changed into cancer cells. (Rod R. Seeley et. al, Essentials of Anatomy and
Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
Certain types of white blood cells produce antibodies, special proteins that recognize
foreign materials and help the body destroy or neutralize them. When a person has an
infection, his or her white cell count often is higher than when he or she is well because
more white blood cells are being produced or are entering the bloodstream to battle the
infection. After the body has been challenged by some infections, lymphocytes remember
how to make the specific antibodies that will quickly attack the same germ if it enters the
body again.
Platelets (also called thrombocytes) are tiny oval-shaped cells made in the bone
marrow. They help in the clotting process. When a blood vessel breaks, platelets gather in
the area and help seal off the leak. Platelets survive only about 9 days in the bloodstream
and are constantly being replaced by new cells.
Blood also contains important proteins called clotting factors, which are critical to the
clotting process. Although platelets alone can plug small blood vessel leaks and temporarily 27
stop or slow bleeding, the action of clotting factors is needed to produce a strong, stable
clot.
Platelets and clotting factors work together to form solid lumps to seal leaks, wounds,
cuts, and scratches and to prevent bleeding inside and on the surfaces of our bodies. The
process of clotting is like a puzzle with interlocking parts. When the last part is in place, the
clot is formed.
When large blood vessels are cut the body may not be able to repair itself through
clotting alone. In these cases, dressings or stitches are used to help control bleeding.
In addition to the cells and clotting factors, blood contains other important
substances, such as nutrients from the food that has been processed by the digestive
system. Blood also carries hormones released by the endocrine glands and carries them to
the body parts that need them. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology
5th edition, McGraw-Hill Int. NY 10020 2005)
Blood is essential for good health because the body depends on a steady supply of
fuel and oxygen to reach its billions of cells. Even the heart couldn't survive without blood
flowing through the vessels that bring nourishment to its muscular walls. Blood also carries
carbon dioxide and other waste materials to the lungs, kidneys, and digestive system, from
where they are removed from the body. (Rod R. Seeley et. al, Essentials of Anatomy and
Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
28
Cholesterol=280 mg/dlHDL – 35.4 mg/dlLDL – 199.2 mg/dl
26
PATHOPHYSIOLOGYName: Teresita GuittierezDiagnosis: Cerebro Vascular Disease ThomboticDefinition:
CVD = is a functional abnormality in the CNS that occurs within the normal blood supply to the brain is disrupted. Thrombotic = is a type of ischemic covered by occlusion of blood vessel supply the brain by thrombus formation.
Predisposing Factors: age, diet, postmenopausal condition, hypertension, ↑Na intake, genetic predisposition to hypertensionPrecipitating Factors: Thrombus formation and occlusion at the site of atherosclerosis with increase stress
Hypertension
Desquamation of endothelial lining
↑ Permeability / adhesion of molecules
Lipids (LDL, VLDL) and platelets assimilate in the area
Non-specific injury to arterial wall (endothelial injury)
Oxidized LDL attracts monocytes and macrophages to the site
Plaques begin to form cells which imbed into the
Lipids are engulf by cells (foam cells) and smooth muscle cells develop
Atherosclerosis Chest X-ray: Atherosclerotic Aorta
Narrowing of blood vessel Decrease blood flow
Decrease tissue cell oxygenation
Chemoreceptors stimulation
Increase force and pumping action of heart
Chronic stress at work
Sympathetic nervous system activation
Myocardial cells hypertrophic adaptation
Chest X-ray: Cardiomegaly
Thrombus formation
Decrease blood flow to brain
Occlusion of blood vessels to brain
Cerebral tissue hypoxia
CEREBRAL ISCHEMIC
CEREBRAL ISCHEMIC CASCADE
Heredity Stress
Salt attracts fluid to blood
↑Na intake
↑ BP
↑ CO
↑ preload
↑ intravascular volume
Diet
↑ cholesterol and lipids (LDL, V DLD) in blood
Chronic high intake of fatty foods such as humba, fried chicken, and chicharon
L3/5-----3/5
R5/5-----5/5
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Cerebral tissue hypoxia
VII. NURSING SYSTEM REVIEW CHART
Name: Teresita Guittierez Date: 11/18/10Pulse:: 121bpm BP: 190/100mmHg Temp.:36.4˚C RR: 15 cpm Height: 5’1’’ Weight: 51 kilosPR: 64 bpmINSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space provided. Indicate the location of the problem in the figure using [X].
EENT: [ X] impaired vision [ ] blind [ ] pain [ ] reddened [ ] drainage[ ] gums [ ] hard of hearing [ ] deaf[ ] burning [ ] edema [ ] lesion [X] teeth Assess eyes, ears, nose, and throatFor abnormality [ ] no problemRESPIRATORY [ ] asymmetric [ ] tachypnea [ ] apnea[ ]rales [ ] cough [ ] barrel chest[ ] bradypnea [ ] shallow [ ] rhonchi[ ] sputum [ ] diminished [ ] dyspnea[ ] orthopenea [ ] labored [ ] wheezing[ ] pain [ ] cyanoticAssess resp.rate, rhythm, depth, and pattern Breath sounds, comfort [ X] no problemCARDIOVASCULAR[ ] arrhythmia [ ] tachycardia [X] numbness[ ] diminished pulse [ ] edema [X] fatigue[ ] irregular [ ] bradycardia [ ] murmur[ ] tingling [ ] absent pulses [ ] painAssess heart sounds, rate, rhythm, pulse, bp,Circulation, fluid retention, comfort [ ] no problemGASTRO INTESTINAL TRACT[ ] obese [ ] distention [ ] mass [ ] dyspagea [ ] rigidity [ ] painAssess urine freq., control, color, odor, comfort /Gyn-bleeding, discharge [ X] no problemGENITOURINARY AND GYNE[ ] pain [ ] urine color [ ] vaginal bleeding[ ] hematuria [ ] discharge [ ] nocturiaAssess urine freq., control, color, odor, comfort/Gyn-bleeding. Discharge[X] no problemNEURO[ ] paralysis [ ] stuporous [X] unsteady [ ] seizures[ ] lethartic [ ] comatose [ ] vertigo [ ] tremors[ ] confused [ ] vision [X] gripAssess motor function, sensation, LOC, strength,Grip, gait, coordination, orientation, speech [ ] no problemMUSCULOSKELETAL and SKIN [ ] appliance [ ] stiffness [ ] itching [ ] petechiae[ ] Hot [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [ ] poor turgor [ ] cool [ ] deformity[ ] wound [ ] rash [ ] skin color [ ] flushed[ ] atrophy [ ] pain [ ] eccymosis[ ] diaphoretic [ ] moistAssess mobility, motion, galt, alignment, joint function/Skin color, texture, turgor, integrity [X] no problem
29
BP: 135/88 mmHgBP: 140/100 mmHgBP: 150/90 mmHg BP: 190/100 mmHg
Unkept hair, kempt hair
Near sighted, can’t read without glassesMild Dizziness upon overexertion
Dental carries at upper right teeth with halitosis
Untrimmed nailsTrimmed nails
Body weakness, left sided
Body weakness, left sided still noted
Body weakness, left sided not noted
Numbness sensation claimedNumbness sensation claimed
Left3/54/55/55/5
Legend:Voilet= Assessment day (11-18-10)Blue= 11-19-10 7am-7pm shiftRed= 11-19-10 7pm-7am shiftLight Blue= 11-20-10 7am-7pm shift
3/54/55/55/5
Right5/55/55/55/5
5/55/55/55/5
Body weakness, left sided not noted
Numbness sensation not claimedNumbness sensation not claimed
NURSING ASSESSMENT II
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31
SUBJECTIVE OBJECTIVECOMMUNICATION:[ ] Healing Loss Comments : ”ga samin[X] visual changes nako kung mag basa”as[ ] denied verbalized by the pt.
[ ] glasses [ ] languages[ ] contact lens [ ] hearing aide Pupil Size: 3mm bilateral [ ] speech difficultiesReaction: Pupil equally round, reactive to light and accomodation.
OXYGENATION:[ ] dyspnea Comments: “wa man koy [ ] smoking history ubo ug dili pud ko galisod None____ og ginhawa”as verbalized[ ] sputum by the patient.[ ] cough[x] denied
Resp. [x] regular [ ] irregularDescribe: Eupneic respiration and depth. Rate within normal limits = 20 cpm___
R: Right lung symmetrical to Left lungL : Left lung is symmetrical to Right lung_
CIRCULATION:[ ] chest pain Comments: “ Gaminhod_ NONE gamay akong wala nga[ ] leg pain tiil” as verbalized by the Patient. [x] numbness of Extremities [ ] denied
Heart Rhythm [x] regular [ ] irregularAnkle Edema: None_________________
Pulse Car. Rad. DP FemR 65 64 ___60______62_L 64 63 ___61______61__Comments: Pulse is palpable and strong in all four extremities
NUTRITION:Diet : low salt, low fat_[ ] N [ ] V Comments: “Ok raman_ Character timbang, wala ko_____ [ ] recent change in maniwang” As___ Weight, appetite verbalized by the patient[ ] swallowing Difficulty [x] denied
[ ] dentures [x] none
Complete Incomplete
Upper [ ] [X]
Lower [ ] [X]
ELIMINATION:Usual bowel pattern [ ] urinary frequency Once a day 3 – 4 times a day [ ] constipation [ ] urgency Remedy [ ] dysuria None_____ [ ] hematuria Date of last BM [ ] incontinence _11-17-10________ [ ] polyuria[ ] diarrhea Character [ ] foly in place Not applicable [x] denied
Comments: “Okey ___ Bowel sounds normo-Raman ako pag-ihi,_ active bowel sound normal pud ako pag -occuring every 15-20sec kalibang color yellow Abd. Distentionog walay dugo ako ihi” present [ ]yes [ ] noas verbalized by the Urine(color, consistencyPatient.___________ odor)__________________ yellow, clear, aromatic__________________
MGT, OF HEALTH ILLNESS:[ ] alcohol [x] denied (amount, frequency) not applicable [ ] SBE NONE Last Pap Smear: not done LMP: march 15, 2003
Briefly describe the patient’s ability to follow treatment (diet, meds, etc.) for chronic health problems (if present).Patient had not consulted any previous physician. This is her first time to be in hospital and admitted. Patients neobloc is just recommended by her daughter without physicians consultations.________________________________________
SKIN INTEGRITY:[ ] dry Comments: “ wala man Koy katol-katol sa ako [ ] itching lawas” as verbalized by _the patient_________[ ] other ___________________ ___________________[X] denied
[ ] dry [ ] cold [ ] pale[ ] flushed [ ] warm [ ] moist [ ] cyanotic*rashes, ulcers, decubitus (describe size, location, drainage) :None noted________________________________________________________________
ACTIVITY/SAFETY:
VIII. NURSING MANAGEMENT IDEAL NURSING CARE PLANS
Nursing Diagnosis: Ineffective cerebral tissue perfusion related inadequate cerebral blood flow.
Interventions Rationale
Independent:
1. Determine factors related to individual
situation/ cause for coma/ cerebral tissue
perfusion and potential increased in ICP.
2. Monitor or document neurological status
frequently and compare with baseline.
3. Monitor vital signs
4. Position with head slightly elevated and in
neutral position and maintain bedrest.
Influences choice of interventions.
Assesses trends in level of consciousness and
potential increase in ICP and is useful in
determining location, extent and progression of the
CNS damage.
Fluctuations in pressure may occur because of
cerebral pressure/ injury in vasomotor area of the
brain. Change in rate of heart rhythm can occur
because of the brain damage.
Reduces arterial pressure by promoting venous
drainage and may improve cerebral circulation or
perfusion.
Dependent:
5. Administer prescribed medications,
supplemental oxygen, anticoagulants,
antihypertensive drugs as ordered.
Reduces hypoxemia, increase of
ICP and may use to improve cerebral blood flow.
Nursing Diagnosis: Risk for Injury related to body weakness secondary to CVA
Interventions Rationale
Independent:
1.) Establish therapeutic relationship, conveying empathy and unconditional positive regard.
To assist patient to identify feelings and begin
to deal with problems.
32
2.) Never leave patient unattended.
3.) Place patient’s bed in a low level when patient is resting or sleeping.
4.) Assist patient in moving/ambulating
5.) Raise side rails up
6.) Place patient’s bedpan at bedside and other personal needed belongings.
To watch patient from falling and prevent injury.
Lower bed causes lower trauma if patient would
accidentally fall.
Patient gait is unsteady. It will help prevent
injury.
Side rails prevent patient from falling.
For easy access and prevention of injury.
Nursing Diagnosis: Impaired physical mobility related to neuromuscular involvement
Interventions Rationale
Independent:
1. Assess functional ability/ extent of
impairment initially and on a regular basis.
2. Change positions at least every 2hrs.
3. Inspect skin regularly, particularly over bony
prominences. Gently massage any reddened
areas and provide aids such as sheepskin
pads as necessary.
4. Encourage patient to assist with the
movement and exercise using the unaffected
extremity to support or move weaker side.
Identifies strengths/ deficiencies and may provide
information regarding recovery.
Reduces risk of tissue ischemia/injury. Affected
side has poorer circulation and reduced sensation
and is more predisposed to skin breakdown/
decubitus.
Pressure points over bony prominences are most
at risk for decreased perfusion/ ischemia.
Circulatory stimulation and padding help prevent
skin breakdown and decubitus development.
May respond as if the affected side is no longer
part of the body and needs encouragement and
active training to reincorporate it as a part of its
own body.
Dependent:
5. Consult with the physical therapist regarding Individualized program can develop to meet
33
active resistive exercises and patient
ambulation.
particular needs/ deal with deficits in balance,
coordination and strength.
Nursing Diagnosis: Disturbed Sensory perception related to altered sensory receptor
Interventions Rationale
Independent:
1. Observe behavioral responses
2. Eliminate extraneous noise/ stimuli as
necessary.
3. Speak in calm, quiet voice, using short
sentences. Maintain eye contact.
4. Ascertain/ validate patient’ perceptions.
Reorient patient frequently to
environment, staff, and procedures.
5. Evaluate visual deficits. Note loss of visual
field, changes in depth perception ,
presence of diplopia(double vision)
Individual responses are variable, but
commonalities such as emotional ability,
lowered frustration threshold, apathy, and
impulsiveness may complicate care.
Reduces anxiety and exaggerated emotional
responses/ confusion associated with sensory
overload.
Patient may have limited attention span or
problems with comprehension. These measures
can help the patient to attend to communication.
Assists patient to identify inconsistencies in
reception and integration of stimuli and may
reduce perceptual distortion of reality.
Presence of visual disorders can negatively
affect patient’s ability to perceive environment
and relearn motor skills and increases risk of
accident/ injury.
Nursing Diagnosis: Anxiety related to situational crisis.
34
Interventions Rationale
Independent:
7.) Establish therapeutic relationship, conveying empathy and unconditional positive regard.
8.) Identify patient’s perception of the treat represented by the situation.
9.) Be aware of defense mechanisms being used by the pt.
10.)Provide accurate information about the situation.
To assist patient to identify feelings and begin
to deal with problems.
To assess level of anxiety
It may interfere the ability to deal with problems,
Helps patient to identify what I s reality based.
ACTUAL NURSING CARE PLAN
S “Medyo gakalipong pa ko kung mangusog ug mag-lihok-lihok ko” as verbalized by the patient.
O BP: 150/90 mmHg Weak in appearance
A Ineffective cerebral tissue perfusion related inadequate cerebral blood flow.
P At the end of 1 hour, the patient will be able to maintain effective cerebral perfusion as evidence by decrease dizziness and a lower blood pressure reading.
35
I Monitored vital signs every 2 hours accurately
R: monitoring vital signs evaluates pt’s condition and effectiveness of care. Encouraged relaxation techniques such as proper deep breathing.
R: Eupneic respiration helps relax a patient and decreases effect of the SNS. Position with head slightly elevated and in neutral position and maintain bedrest.
R: Promotes decrease of ICP through venous drainage and prevents unnecessary spenditure of energy.
Monitor or document neurological status frequently and compare with baseline.R: to ensure patient’s safety and prevent fallsR: Assesses trends in level of consciousness and potential increase in ICP and is useful in determining location, extent and progression of the CNS damage.
Encourage assisted ROM exercises on left extremities and active ROM on right extremities.R: to promote proper blood circulation.
Administered Citicholine 1gm q12 IVTTR: this is a neurotropic drug which increases brain metabolism and cerebral blood flow for improvement of brain function.
E At the end of 1 hour, the patient has improved cerebral perfusion as evidence by relief of dizziness and a lower blood pressure to 140/90 mmHg.
S “Dili ko kalihok-lihok ug kalakaw-lakaw” as verbalized by the patient.
O Left sided-body weakness MOTOR scale: 5/5 3/5
5/5 3/5
A Risk for injury related to left sided body weakness secondary to cerebrovascular accident/ stroke.
P At the end of 24 hours, patient will be free from falls and injury.
I Kept side rails raised.
R: to prevent accidental falling. Did not left patient alone.
R: leaving pt. alone is at risk for developing severe complications if he/she accidentally falls.
Instructed watcher to assist client as needed and put things within client’s reach. R: prevents unnecessary strain for the pt and prevent from falling out of bed..
36
Instruct patient’s watcher to stay with the patient at all timesR: to ensure patient’s safety and prevent falls
Maintained bed in lower position.R: to reduce severe trauma if pt accidentally falls.
Placed on sitting position with tablets crushed and diluted.R: to prevent aspiration and for easy swallowing
E At the end of 24 hours, goal was met. Patient was free from injury.
S “Dili ko kalihok-lihok ug kalakaw-lakaw” as verbalized by the patient.
O Left Sided Body Weakness MOTOR scale: 5/5 3/5
5/5 3/5
A Impaired physical mobility related to left sided body weakness secondary to cerebrovascular accident/ stroke.
P “At the end of 24 hours of nursing intervention, pt. will achieve maximal physical mobility within the limitations imposed by the stroke as evidenced by increase tolerance to range of motion exercises.
I Provided adequate rest before exercises begin.
R: to provide enough energy for compliance of intervention. Placed on moderate high back rest.
R: to promote maximal lung compliance to facilitate breathing during exercises. Assisted with passive range of motion exercises on right extremities and active range of
motion on left extremities.R: to minimized muscle atrophy, promote circulation and prevent contractures.
Assisted in deep-breathing exercises.R: improves abdominal muscle strength and circulation.
Assisted with movement of weaker extremity to support/ move the weaker side.R: to reincorporate it as part of the body.
Assist patient to change position every 2 hours;R: to promote good blood circulation and prevent pressure ulcers.
During side-lying position. Place pillow under the left arm and arm placed in a dependent position with wrist higher than the elbow and elbow higher than the shoulder
37
R: to promote venous drainage and prevent edema. Administer aspirin 1 tab OD
to prevent re clotting of thrombotic site.
E After nursing interventions, pt was tolerated range of motion exercises. Motor scale abilities improved to 4/5 in left extremities in the 1st day of care and 5/5 in the 3rd day of care.
S “Baho ra ba ko, wala pa ko kapanudlay gani”, as verbalized by the patient.
O Uncombed hair Untrimmed nails Halitosis
A Self-care deficit (hygiene and grooming) related to stroke sequealae
PAt the end of 20 minutes, patient will be able to improve self-care and have a sense of well-being.
I
Provide morning care to patient; to improve patient’s well-being by wiping the hands, face and legs with a clean wet towel.
Assist patient in brushing her teeth; to prevent halitosis. Assist patient in combing her hair; to improve patient’s appearance with hair
kept. Provide support and encouragement while patient is grooming herself as patient
will make compensatory movements when grooming and these can produce fatigue.
Assist patient in trimming her nails; to improve sense of well-being. Encourage verbalization of feelings; to relieve disclosed anxiety and provide
emotional support.
E At the end of 20 minutes, patient will was able to improve self-care and have a sense of well-being.
S“Karon pa raba ko na-admit sa entero nako kinabuhi, na-unsa jud diay ko?”, as
verbalized by the patient.
O Patient frequently asks questions pertaining his disease condition and the care given to her.
A Knowledge Deficit about lack of information and exposure to medical process.
P At the end of 20 minutes, patient will be able to gain knowledge about her condition in simple understandable explanation and verbalize in brief the
38
explanation of her disease process.
I
Determined client’s ability or readiness to learnTo serve as basis for level of information to be given
Used local language the client can understand.R: Understandable language facilitates learning.
Begin with information the client already knows and move to info the client doesn’t knowR: This can arouse interest or limit sense of being overwhelmed.
Encouraged expression of feelings and her understanding of her conditionTo provide communication feedback and provide answers
Used simple terms and words in explanation of her disease conditionFor easy understanding
Discussed one topic at a timeTo facilitate learning.
Provided environment conducive to learning: instructed other watcher to minimize their voice.R: To facilitate learning
EAt the end of 20 minutes, patient was able to gain knowledge about her condition through simple understandable explanation and verbalized in brief the explanation of her disease process.
39
IX. HEALTH TEACHINGS
MEDICATION:
Encouraged the patient and significant others to follow the medication that was
prescribed in order to help maintain its good health condition. The following are
prescribed by the doctor for home medications: Atenolol 50 mg 1 tab OD P.O,
Amlopidine 10 mg 1 tab O.D P.O and Vit. B complex BID P.O. And should take her
medicine at the right time, right dose and right frequency.
EXERCISE:
Patient is instructed that she should do active and passive range of motion
exercise at the unaffected area. Do simple exercises such as moving forward and
backward of hands with intervals alternately, stretching, breast walking in the morning at
home for 20-30 mins and deep breathing to prevent recurrence of the disease.
TREATMENT:
Encouraged to take medication on the right time, frequency and dosage in
order to avoid complication of the disease. Encourage to turn side every 2 hours with
assistance of significant others as needed, relaxation technique and avoid being fatigue
40
by adequating resting between work and instructed to avoid getting quickly upon arising
on bed and sit on bed first before standing.
OUT-PATIENT CARE:
The patient with her SO was instructed to return 2 weeks after discharge and
have follow up check up to DR. Sabal 9-11 am at Sabal hospital 2nd floor. Instructed to
call and seek physician help if BP does not lower within normal level with continuance of
drug intake and report any chest pain immediately.
DIET:
The patient is encouraged to lessen cholesterol and fatty food intake such as
egg, humba and fried food, minimize salt intake 2 grams per day, increase serving of
fruits and vegetables such as cabbage, carrots, banana, apple, orange,
malunggay ..etc. and increase serving of carbohydrates to 2 serving of rice.
X. EVALUATION/CONCLUSIONAt the end of more than 24 hours of nursing care to the patient the group has
attained and met their objectives. The group identified possible problems that may rise
from patient’s condition, determined the cause, predisposing factor, precipitating factors
that constitute the health condition, provided appropriate nursing intervention for client’s
care. Furthermore the group imparted the important information as health teachings that
would be useful to patient’s understanding of care regimen and nature of her health
condition and enhanced skills & knowledge as health care provider in the clinical
setting.
41
The group also had enhanced their primary nursing skills in this rotation.
Teamwork was established and camaraderie developed between peers. Also through
working together with this CP the group built friendship that made our work easier and
smoother.
The group was convinced that the care provided was adequate since the patient
had improved condition and was discharged after our care. The group was also
convinced that the patient’s prognosis was good because she was able to improve her
illness condition in a short time and she has medication available at home through the
support of her children. This provides good medication compliance which contributes to
her rehabilitation and maintenance. Morever, the significant other and the patient had
acquired priceless information about the patient’s disease condition which is a plus
factor in changing her negative lifestyle that could lead to a healthier living.
Over-all the case study was enjoying and satisfying.
XI. BIBLIOGRAPHY
o Smeltzer, Medical-Surgical Nursing, 11th Edition, U.S.A.: Lippincott
Wilkins and Williams, pages 1670-1672, 1882-1184
o Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition,
McGraw-Hill Int. NY 10020 2005
o Einbach, Medical-Surgical Nursing, 2009; U.S.A.: Price Publshing, pages
500-501
o http://en.wikipedia.org/wiki/Stroke
o http://nursingcrib.com/tag/brain-stroke
o http://www.eurekalert.org/pub_releases/2008-03/arrs-wbm032808.php
o http://www.holistic-online.com/remedies/Heart/stroke_risk_mod_hypertension.htm
o http://www.wikidoc.org/index.php/Cerebrovascular_accident
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