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INTRODUCTION

Cerebrovascular Accident (Ischemic)


Ischemic stroke is focal brain infarction that produces sudden neurologic deficits persisting > 1 h.
Common causes are (from most to least common) nonthrombotic occlusion of small, deep cortical
arteries (lacunar infarction) ; cardiogenic embolism; arterial thrombosis that decreases cerebral
blood flow; and artery-to-artery embolism. Diagnosis is clinical, but CT or MRI is done to exclude
hemorrhage and confirm the presence and extent of stroke. Thrombolytic therapy may be useful
acutely in certain patients. Depending on the cause of stroke, carotid endarterectomy, antiplatelet
drugs, or warfarin may help reduce risk of subsequent strokes.
Ischemia usually results from thrombi or emboli. Even infarcts classified as lacunar based on
clinical criteria (morphology, size, and location) often involve small thrombi or emboli.
Thrombosis: Atheromas, particularly if ulcerated, predispose to thrombi. Atheromas can occur in
any major cerebral artery and are common at areas of turbulent flow, particularly at the carotid
bifurcation. Partial or complete thrombotic occlusion occurs most often at the main trunk of the
middle cerebral artery and its branches but is also common in the large arteries at the base of the
brain, in deep perforating arteries, and in small cortical branches. The basilar artery and the
segment of the internal carotid artery between the cavernous sinus and supraclinoid process are
often occluded. Less common causes of thrombosis include vascular inflammation secondary to
disorders such as acute or chronic meningitis, vasculitic disorders, and syphilis; dissection of
intracranial arteries or the aorta; hypercoagulability disorders (eg, antiphospholipid syndrome,
hyperhomocysteinemia);
hyperviscosity
disorders
(eg,
polycythemia,
thrombocytosis,
hemoglobinopathies, plasma cell disorders); and rare disorders (eg, moyamoya disease,
Binswanger's disease). Older oral contraceptive formulations increase risk of thrombosis.
Embolism: Emboli may lodge anywhere in the cerebral arterial tree. Emboli may originate as
cardiac thrombi, especially in the following conditions:
* Atrial fibrillation
* Rheumatic heart disease (usually mitral stenosis)
* Post-MI
* Vegetations on heart valves in bacterial or marantic endocarditis
* Prosthetic heart valves
Other sources include clots that form after open-heart surgery and atheromas in neck arteries or in
the aortic arch. Rarely, emboli consist of fat (from fractured long bones), air (in decompression
sickness), or venous clots that pass from the right to the left side of the heart through a patent
foramen ovale with shunt (paradoxical emboli). Emboli may dislodge spontaneously or after
invasive cardiovascular procedures (eg, catheterization). Rarely, thrombosis of the subclavian
artery results in embolic stroke in the vertebral artery or its branches.
Lacunar infarcts: Ischemic stroke can also result from lacunar infarcts. These small ( 1.5 cm)
infarcts result from nonatherothrombotic obstruction of small, perforating arteries that supply deep
cortical structures; the usual cause is lipohyalinosis (degeneration of the media of small arteries
and replacement by lipids and collagen).

Diabetes
Diabetes is a metabolic disorder characterized by a relative or absolute lack of the hormone insulin
or insulin resistance, or both, which is impaired use of carbohydrates and altered metabolism of
fats and protein. The word diabetes, from the Greek meaning a siphon, suggests urine formation,
the word mellitus, from the Greek meaning honey, suggests sweetness. Type 2 diabetes was
formerly known by a variety of partially misleading names, including adult-onset diabetes,
obesity-related diabetes, or non-insulin-dependent diabetes (NIDDM). It is characterized by
insulin resistance as body cells do not respond appropriately when insulin is present. This is
more complex problem than type 1, but it is sometimes easier to treat, since insulin is still in
many, especially in the initial years. Type 2 may go unnoticed for years in a patient before
diagnosis, since the symptoms are typically milder and can be sporadic. The 3 cardinal signs of
Type 2 DM are polyphagia (excessive hunger), polydipsia (excessive thirst), and polyuria (excessive
urination). Other signs and symptoms of this disease are weight loss or gain, blurred vision,
headaches lethargy, impotence, vaginal discharge, increased vaginal infection, increased wound
healing time, orthostatic hypertension, decreased pedal pulses, paresthesics, and decreased
sensations (extremities). If these signs and symptoms were not given proper or enough attention,
it may lead to the following complications diabetic neurophatics (low of sensation in extremities),
Charcots syndrome, Retinopathy, kidney failure, Atherosclerosis of the heart and large vessels and
amputation.
In 2004, according to the World Health Organization, more than 150 million people
worldwide suffer from diabetes. Its incidence is increasing rapidly, and it is estimated that by the
year 2025 this number will double. Diabetes mellitus occurs throughout the world, but it is
common (especially Type 2) in the more developed countries. In 2002 there were about 18.2
million diabetics in the United States alone. Diabetes is in the top 10, and perhaps the top 5, of the
most significant disease in the developed world, and is gaining insignificance. For at least 20
years, diabetes rates in North America have been increasing substantially. The Centers for Disease
Control has termed the change an epidemic. The National Diabetes Information Clearing house
estimates that diabetes costs $132 billion in the United States alone every year.
Hypertension
Hypertension is a common clinical problem faced by both primary care clinicians and specialists.
While the exact prevalence of resistant hypertension is unknown, clinical trials suggest that it is
not rare, involving perhaps 20% to 30% of study participants. As older age and obesity are 2 of the
strongest risk factors for uncontrolled hypertension, the incidence of resistant hypertension will
likely increase as the population becomes more elderly and heavier. The prognosis of resistant
hypertension is unknown, but cardiovascular risk is undoubtedly increased as patients often have a
history of long-standing, severe hypertension complicated by multiple other cardiovascular risk
factors such as obesity, sleep apnea, diabetes, and chronic kidney disease. The diagnosis of
resistant hypertension requires use of good blood pressure technique to confirm persistently
elevated blood pressure levels. Pseudoresistance, including lack of blood pressure control
secondary to poor medication adherence or white coat hypertension, must be excluded. Resistant
hypertension is almost always multifactorial in etiology. Successful treatment requires
identification and reversal of lifestyle factors contributing to treatment resistance; diagnosis and
appropriate treatment of secondary causes of hypertension; and use of effective multidrug
regimens. As a subgroup, patients with resistant hypertension have not been widely studied.
Observational assessments have allowed for identification of demographic and lifestyle
characteristics associated with resistant hypertension, and the role of secondary causes of
hypertension in promoting treatment resistance is well documented; however, identification of

broader mechanisms of treatment resistance is lacking. In particular, attempts to elucidate


potential genetic causes of resistant hypertension have been limited. Recommendations for the
pharmacological treatment of resistant hypertension remain largely empiric due to the lack of
systematic assessments of 3 or 4 drug combinations. Studies of resistant hypertension are limited
by the high cardiovascular risk of patients within this subgroup, which generally precludes safe
withdrawal of medications; the presence of multiple disease processes (eg, sleep apnea, diabetes,
chronic kidney disease, and atherosclerotic disease) and their associated medical therapies, which
confound interpretation of study results; and the difficulty in enrolling large numbers of study
participants. Expanding our understanding of the causes of resistant hypertension and thereby
potentially allowing for more effective prevention and/or treatment will be essential to improve the
long-term clinical management of this disorder.

NURSING OBJECTIVES
After 6 days of Nurse-Patient Interaction the student nurse will be able to:
Cognitive:

Identify specific theoretical causes and clinical manifestations, and trace the

pathophysiology of the involved disease entity;

Identify nursing problems and construct nursing care plans specifically;

Understand the normal anatomy and physiology of the affected organs that are

affected by the underlying disease condition;


Affective:

describe predisposing and precipitating factors that could possibly contribute to the

occurrence of the disease;


Psychomotor:

Accurately gather nursing history

Enumerate ways of preventing the occurrence of the disease or problem

ANATOMY AND PHYSIOLOGY


The Cardiovascular System
The 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.
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 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.
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, 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.
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 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.
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.
The Endocrine System

The endocrine system is made up of glands that produce and secrete hormones. These hormones
regulate the bodys growth, metabolism (the physical and chemical processes of the body), and
sexual development and function. The hormones are released into the bloodstream and may affect
one or several organs throughout the body.
The role of the endocrine system is to maintain the body in balance through the release of
hormones which transfer information and instructions from one set of cells to another. Many
different hormones move through the bloodstream, but each type of hormone is designed to affect
only certain cells.
Hormones are chemical messengers created by the body. They transfer information from one set
of cells to another to coordinate the functions of different parts of the body. Hormones can act on
some specific cells because they themselves do not actually cause an effect. It is only through
binding with a receptor (part of the cell specifically designed to recognize the hormone) like a key
into a lock - that causes a chain reaction to occur, changing the activity of the cells. If a cell does
not have a receptor for a hormone then there will be no effect. Also, there can be different
receptors for the same hormone, and so the same hormone can have different effects on different
cells.
The major glands of the endocrine system are the pituitary, thyroid, parathyroids, adrenals, pineal
body, thymus, and the reproductive organs (ovaries and testes). The pancreas is also a part of this
system; it has a role in hormone production as well as in digestion. A gland is a group of cells that
produces and secretes chemicals. A gland selects and removes materials from the blood,
processes them, and secretes the finished chemical product for use somewhere in the body. The
endocrine gland cells release a hormone into the blood stream for distribution throughout the
entire body. These hormones act as chemical messengers and can alter the activity of many
organs at once.
The hypothalamus controls all the processes undergone by the anterior and posterior pituitary
glands. It initiates the production of hormones by the APG. The APG is controlled by releasing
hormones which are chemical signals produced by the nerve cells of the hypothalamus, causing
either stimulation or inhibition of hormone production. Secretion of hormones by the PPG is
controlled by nervous system stimulation of nerve cells in the hypothalamus. Parathyroid glands
secrete parathyroid hormone which is essential for the regulation of blood calcium levels. Adrenal
glands produce epinephrine and norepinephrine which are fight-or-flight hormones that prepare
the body for vigorous physical activity. Testes and ovaries produce hormones that are responsible
for secondary sex characteristics, spermatogenesis, and oogenesis. The thymus gland secretes
thymosin which aids in the synthesis of WBC for fighting infection. This gland decreases in size in
some older adults. The pineal body releases melatonin that is thought to decrease the secretion of
LSH & FSH by decreasing the release of hypothalamic-releasing hormones. The thyroid gland,

located on either side of the trachea, is controlled by the thyroid stimulating hormone releases by
the anterior pituitary gland, which was initially stimulated by the TSH releasing hormone from the
hypothalamus.
The pancreas is also part of the body's hormone-secreting system, even though it is also
associated with the digestive system because it produces and secretes digestive enzymes. The
pancreas produces two important hormones, insulin and glucagon. They work together to maintain
a steady level of glucose, or sugar, in the blood and to keep the body supplied with fuel to produce
and maintain stores of energy. The pancreas completes the job of breaking down protein,
carbohydrates, and fats using digestive juices of pancreas combined with juices from the
intestines, secretes hormones that affect the level of sugar in the blood, and produces chemicals
that neutralize stomach acids that pass from the stomach into the small intestine by using
substances in pancreatic juice. It contains Islets of Langerhans, which are tiny groups of
specialized cells that are scattered throughout the organ.
In humans, the pancreas is a 15-25 cm (6-10 inch) elongated organ in the abdomen adjacent to
the small intestine and lies toward the back. It has three regions: a head (abuts a part of the
duodenum), body (at the level of L2 of the spine) and tail (extends toward the spleen).
The pancreatic duct (also called the duct of Wirsung) runs the length of the pancreas and empties
into the second part of the duodenum at the ampulla of Vater. The common bile duct usually joins
the pancreatic duct at or near this point. Many people also have a small accessory duct, the duct
of Santorini, which extends from the main duct more upstream (towards the tail) to the duodenum,
joining it more proximal than the ampulla of Vater.
The pancreas is supplied arterially by the Pancreaticoduodenal arteries and the splenic artery: the
splenic artery supplies the neck, body, and tail of the pancreas; the superior mesenteric artery
provides the inferior pancreaticoduodenal artery; and the gastroduodenal artery provides the
superior pancreaticoduodenal artery.
Venous drainage is via the pancreaticoduodenal veins which end up in the portal vein. The splenic
vein passes posterior to the pancreas but is said to not drain the pancreas itself. The portal vein is
formed by the union of the superior mesenteric vein and splenic vein posterior to the neck of the
pancreas. In some people (some books say 40% of people), the inferior mesenteric vein also joins
with the splenic vein behind the pancreas (in others it simply joins with the superior mesenteric
vein instead).
The pancreas is a compound gland in the sense that it is composed of both exocrine and endocrine
tissues. The exocrine function of the pancreas involves the synthesis and secretion of pancreatic
juices. The endocrine function resides in the million or so cellular islands (the islets of Langerhans)
embedded between the exocrine units of the pancreas. Beta cells of the islands secrete insulin,

which helps control carbohydrate metabolism. Alpha cells of the islets secrete glucagon that
counters the action of insulin.
There are four main types of cells in the islets of Langerhans. They are relatively difficult to
distinguish using standard staining techniques, but they can be classified by their secretion:
Name of cells

Endocrine product

% of islet cells

Representative function

beta cells

Insulin and Amylin

50-80%

lower blood sugar

alpha cells

Glucagon

15-20%

raise blood sugar

delta cells

Somatostatin

3-10%

inhibit endocrine pancreas

PP cells

Pancreatic polypeptide

1%

inhibit exocrine pancreas

The islets are a compact collection of endocrine cells arranged in clusters and cords and are
crisscrossed by a dense network of capillaries. The capillaries of the islets are lined by layers of
endocrine cells in direct contact with vessels, and most endocrine cells are in direct contact with
blood vessels, by either cytoplasmic processes or by direct apposition.
There are two main types of exocrine pancreatic cells, responsible for two main classes of
secretions:
Name of cells

Exocrine secretion

Primary signal

Centroacinar cells

bicarbonate ions

Secretin

Basophilic cells

digestive enzymes

CCK

(pancreatic amylase, Pancreatic lipase,


trypsinogen, chymotrypsinogen, etc.)

Nursing Health History


BIOGRAPHIC DATA:
Client X is a 54 year old female who is currently residing at 506 41 St. Tawiran Extension
Santolan, Pasig City. She was born on April 21, 1956. She was the second among five siblings of
their parents. She was a roman catholic. She was currently married to his husband with their 3
children. She was a former vendor in their community and now decided to be a housewife for the

meantime because of her condition and for her children. In healthcare financing her usual source
was is from children and her husband.
CHIEF COMPLAINT:
Namamanhid ang kaliwang paa ko di ko maigalaw ng maayos parang paralisado,
verbalized by the client.

as

HEALTH HISTORY:
A.

History of Present Illness

Two days prior to admission (PTC) the patient noted numbness, restlessness and weakness
of her left lower extremities associated with dizziness, positive slurring of speech and facial
asymmetry, no chest pain and difficulty of breathing, no consult done. The patient was
hypertensive since she was 40 years old.
Few hours prior to consultation (PTC) on November 10, 2010 at around 7:30 PM client noted
left side body weakness with numbness and episode of nonprojectile vomiting with slight difficulty
of breathing and chest pain. She was immediately rushed at the Emergency Room of Pasig City
General Hospital (PCGH) and was given prompt treatment. She has a working diagnosis of CVA,
possible infarct, HPN
30 minutes prior to admission (PTA), due to constant high BP, slurring of speech, left sided
body weakness with association of shortness of breath and possible stroke (infarct or bleed),
doctors decided to admit her on Female medicine ward under service of Dr. Custodio.
B.

Past History

The client already had mumps but does not have chicken pox and measles during childhood.
She was also able to receive all immunizations during her childhood, as verbalized by her. She
doesnt have any food, drug or environmental allergy.
As stated by the client, she doesnt experience any accidents in the past and this is the
second time she was brought into the hospital after her previous CVA but she was immediately
discharged that time because of her fast recovery. Every time she had his flu it only last for a
maximum of 4 days and she medicate herself with OTC drugs, no consultation was ever made.
C.

Family History

Clients parents were already dead. They were five children in their family, two boys and
three girls. All of them were still alive. Client X stated that the most reason of death of some of her
relative was stroke due to hypertension. She also stated that her father does have stroke and
hypertension. In her mother side; she stated that they have cancer in their family.

D.

Pain Assessment

1st DAY INTERVIEW (November 9, 2010)

3rd DAY INTERVIEW (November 16, 2010)

The client verbalized of having slight chest


pain with a difficulty of breathing. On a pain
scale of 1-10 with 10 being the worst; she
said that it was 7. She manages her pain by
changing her position from flat position into a
moderate high back rest and deep breathing.

The client doesnt verbalize any chest pain


and difficulty of breathing. The pain scale is 0
out of 10. She now manages it well.

FUNCTIONAL HEALTH PATTERNS


1. Health Perception and Health Management Pattern
The client stated that after her previous CVA her general health starts declining at the same time
she also stopped working. She is always at home caring for her children she also added that she
lack in exercise and sometimes she is insensitive of what food should she eat even though she is
aware of right choice of food that she must take. She believes that illness is a part of aging
process that everyone must be prepared and must be conscious to their health. She eats her
meal on a regular basis (breakfast, lunch and dinner). She even loves eating pork, rice and
vegetables. She often buys street foods such as isaw, chicken feet, ulo ng manok and balat ng
baboy. She used to drink a cup of coffee every morning. After her first CVA, client takes
medications such as Felodipine and Aspirin as his maintenance due to his high BP. The important
thing he keeps on his mind while he is in the hospital is that he needs to be aware on
communicable diseases that can be transmitted to him for she is aware of the other cases that
were admitted there. She also added that we can help her through continue monitoring of her
Vital Signs for her to be immediately recovered. She does believe in health customs such as
Tawas and Hilot.
2. Nutrition and Metabolic Pattern
BEFORE ADMISSION
The client usually eats pork and chicken as well as fish and vegetables for five meals
per day; around 8:00 in the morning, her breakfast comprises of 1 cup of rice and usual morning
meals such as hotdog, but she usually buy lugaw, pancit, sopas or champorado since a eatery is
close to their house. She paired it with one cup of coffee. During lunch time, she prepares a meal
comprises of dishes like pork sinigang. She used to eat bananacue and maruya during merienda
time. She consumes 1 cup of rice on the said meal. During dinner, she usually eats pork adobo
and adobong sitaw. She also consumes 1 cup of rice. She drinks 5 glasses of water a day,
approximately 1250 ml of water (1 cup= 250ml). She was not taking any supplements and
vitamins. Theres no change in her appetite and theres no discomfort during eating or drinking.
The client doesnt have any dentures. She also said that there is no food that she is allergic.
DURING CONFINEMENT
The client stated that in the hospital, she doesnt eat a lot for his appetite decreased. Its
because that as of now she was on NGT and she cannot eat the food she wants.
3. Elimination Pattern
BEFORE ADMISSION
The clients bowel elimination pattern is twice a day-every morning and evening. The color
of her stool is from yellow to brown. She also said that she dont have any difficulty in defecation.

In the clients urine elimination pattern; she stated that she urinates for only 2x a day. The color
of her urine is yellowish one. She doesnt have any difficulty in urination. She doesnt have
excess perspiration.
DURING CONFINEMENT
The clients bowel elimination and urine elimination does change. Since the patient is on FCUB, she cannot feel that she is urinating. She defecates 2-3 times a day since she was also
taking laxative (lactulose). The color of the urine is a yellowish one the color of her stool is dark
and it is formed in shape. She has excess perspiration and odor problems.
4. Activity and Exercise Pattern
BEFORE ADMISSION
The client said that she has a sufficient energy for completing desired required activities.
Since she retired from selling in the market; she was not engaged anymore with daily exercise
such as jogging. During her spare time, she used to watch TV as well as chatting with her
neighbors.
DURING CONFINEMENT
Due to the clients condition, she has no sufficient energy for completing desired required
activities. She cant do all things that she usually does when she is admitted in the hospital.

FIRST DAY INTERVIEW (November 9, 2010) THIRD DAY INTERVIEW (November 16, 2010))
She has perceived ability for:

She has perceived ability for:

Feeding 4
Grooming 2
General Mobility 3
Toileting - 1
Cooking N/A
Home maintenance N/A
Dressing 3
Shopping N/A

Feeding 4
Grooming 2
General Mobility 3
Toileting - 2
Cooking N/A
Home maintenance N/A
Dressing 3
Shopping N/A
NOTE:
Level 0: Full Self Care
Level 1: Requires use of equipment or
device
Level
2:
Requires
assistance
or
supervisions from another person
Level 3: Requires assistance or supervision
from another person/or device
Level 4: Is dependent and does not
participate
N/A: Not Applicable

5. Sleep Rest Pattern

BEFORE ADMISSION
The client stated that she has an intermittent sleep, which comprises of 5-8 hrs of sleep.
Shes not taking any nap during afternoon since she is fun of watching TV shows in the afternoon.
Her usual position in sleeping is side lying position. Even she doesnt have a continuous sleep; she
doesnt take any sleeping pills. She also added thats she dont feel any tiredness upon waking up.
She is fond of watching television and chatting with her friends and neighbors
DURING CONFINEMENT
Now that the client is in the hospital, her sleep is always interrupted due to frequent
monitoring of Vital Signs. Her sleep is also interrupted due to the environment in the hospital.
Shes sleeping in a supine position.
6. Cognitive Perceptual Pattern
The client verbalized that shes not using any hearing aid even though she have hearing difficulty
in both ears. She also stated that she doesnt wear any eyeglasses ever since even though she knew
that she cannot see things clearly. She doesnt have any history of check- up in any ophthalmologist.
Her pupils are equally rounded and reactive to light and accommodation. There are no changes in his
memory lately. Client is oriented to time and person. The easiest way for the client to learn things are
through reading. She doesnt have any difficulty in learning new things.
7. Self Perception and Self Concept Pattern
The client describes herself as a simple woman living in a simple way of life. Shes a happy person
and not irritable. Before the illness started, there is no hindrance for her to do any activity without
limitations. But she said that from 2008 until now, there was really lot of changes. She doesnt mind
those people who make her angry for she is an optimist person. She used to just ignore it and just
continue with her own life. The thing that makes her cry is when her husband and children are sick.
She loves her husband so much and she cant take seeing her husband suffering from any pain.
8. Role-Relationship Pattern
The client belongs to an nuclear family. She is living with his husband with their few children. She
doesnt have problems that are difficult to handle. Her family does necessarily depend on her and her
husband when she was still working but she was financially supported by her husband and some
relatives.. Every time their family encounters a problem; they used to talk about it immediately for
them to not prolong their problem. The most common problem that they encounter is financial
problem. Her support system in time of stress is her family especially her husband. She doesnt belong
to any social groups but she has lots of friends. She doesnt feel alone frequently because shes always
with another person in the house. She does not feel isolated in her neighborhood. Her daughter also
added that when her mother will be bringing back home; they will buy him cane or crutches to help
her in moving. Even though there is a health center in their community. Shes not seeking health care
in the said facility.
9. Sexually-Reproductive Pattern
The client admitted that she was active in sexual intercourse during her young age. She also
admitted that she was satisfied in terms of her sexual aspects. She and her husband are not using
any contraceptives during their sexual intercourse.
10. Coping Stress Tolerance Pattern
The client is not tense a lot of time. She used to relax herself by watching television or simply
doing household chores or chatting with her friends. Her major stressors are her problems regarding

money. In order for her to be ok, hes expressing her feelings to her family. They are always available
for her. There are no changes in her life for the last 2 years except for the retirement on his work and
her present condition. When shes suffering on a high level of stress or serious problems, shes solving
it immediately.
11. Value-Belief Pattern
The client said that she is not a religious person. She seldom goes to church but she does pray
every night before she sleep. She also added that she usually pray every time she encounters any
problem. She knows that she cant have everything that she wanted but she accepted that. The most
important thing in her life now is her family more than his health. On a scale of 1-10; 10 being the
highest she chose 10. Thats how much important her family is. She stated that her religious beliefs
and practices do interfere in the hospital.
Physical Examination
AREA

TECHNIQUE

NORMS

FINDINGS

ANALYSIS
and
INTERPRETATION

I. HEAD
1.
Size, Inspection
shape
and Palpation
symmetry of
the skull

Rounded
Rounded (normocephalic);Normal
(normocephalic andsmooth skull contour
symmetrical,
with
frontal, parietal, and
occipital
prominences);
Smooth skull contour

2. Presence Palpation
of
nodules, Inspection
masses, and
depressions

Smooth,
uniformHas no tenderness;
consistence; absencemasses nor nodules
of nodules or masses

3.
Facial Inspection
Features
Palpation

Symmetric or slightlySymmetrical and palpebralNormal


asymmetric
facialfissure
equal
in
size,
features;
palpebralnasolabial
folds
are
fissure equal to size;symmetrical.
symmetric nasolabial

4. Presence Inspection
of
edema
and
hollowness in
the eye.

No
edema
hollowness

andNo hollowness

noNormal

Normal

II. HAIR
1. Evenness Inspection
of
growth, Palpation
thickness, or
thinness
of
hair

Evenly
distributedHair evenly distributed
and
covers
the
whole scalp; maybe
thick or thin

2.
Texture Inspection
and oiliness Palpation
over
the
scalp

Silky; resilient hair

Normal

Silky; smooth and resilientNormal


hair.

3. Presence Inspection
of
infection Palpation
and
infestation

No
infection
infestation

andNo infection and infestation Normal

III. FACE
Facial
Inspection
features,
symmetry of
facial
movements

Symmetric
slightly
asymmetrical
features;

orAsymmetrical
facialAbnormal:
features while talking andPossibly
showing
facialelevating the eyebrow.
weakness
on
the
affected side of the
body
(hemiparesis).
Due to loss of voluntary
control
over
motor
movements.

IV. EYES
A. EYEBROWS
Hair
Inspection
distribution,
alignment,
skin quality
and
movement

Symmetrical and inSymmetrical and alignedNormal


line with each other;with each other; black;
maybe black, brownevenly
distributed,
or blond dependingmovements
are
on
race;
evenlysymmetrical.
distributed

B. EYELASHES
Evenness of Inspection
distribution
Palpation
and direction
of curl

Evenly
distributed;Turned outward eyelashes:Normal
turned outward
hair equally distributed.

C. EYELIDS
Surface
Inspection
characteristi
cs
and
position (in
relation
to
the cornea,
ability
to
blink,
and
frequency of
blinking)

Upper eyelids coverAble to close the eyes andNormal


the small portion ofhas the ability to blink.
the iris, cornea, and
sclera when eyes
open; eyelids meet
completely when the
eyes
are
closed;
symmetrical

D. CONJUNCTIVA
1.
Color Inspection
texture and Palpation
the presence
of lesions in
the
bulbar
conjunctiva

Pinkish or red inPinkish in color;


color; with presencebodies, no ulcers.
of small capillaries;
moist; no foreign
bodies; no ulcers

no

foreign Normal.

2.
Color, Inspection
texture, and Palpation
the presence
of lesions in
the palpebral
conjunctiva

Pinkish or red inPinkish or red in color; withNormal.


color; with presencepresence of small capillaries
of small capillaries;
moist; no foreign
bodies; no ulcers

E. SCLERA
Color
clarity

and Inspection

White
in
color;White sclera with some visibleNormal.
clear; no yellowishcapillaries
discoloration; some
capillaries maybe
visible

F. CORNEA
Clarity
texture

and Inspection

No irregularities onClear and smooth in texture.


the surface; looks
smooth;
clear
or
transparent

Normal

and Inspection

Anterior chamber isDark brown in color; transparentNormal


transparent:
noanterior chamber.
noted
visible
materials;
color
depends
on
the
persons race

G. IRIS
Shape
color

H. PUPILS
1.
Color, Inspection
shape,
and
symmetry of
size

Color depends on thePupil equally round.


persons race; size
ranges from 3-7 mm,
and are equal in size;
equally round

2.
Light Inspection
reaction and
accommodati
on

Constrict
Dilates when looking at farNormal
briskly/sluggishly
objects and constrict when
when
light
islooking at near objects.
directed to the eye,
both directly and
consensual

I. VISUAL ACUITY

Normal.

1.
Vision

Near Inspection

Able
to
newsprint

readPresbyopia (loss of elasticity ofAbnormal.


the lens and thus loss of ability Presbyopia is the
to see close object).
decrease ability of
the
eye
to
accommodate for
near vision. This
occurs as a normal
part of aging and
the lens becomes
less flexible. The
average
age of
onset of presbyopia
is the midforties.
(Essentials
of
Anatomy
and
Physiology
6th
edition by Seeley,
et. Al page 256.

No
edema
tenderness
lacrimal gland

orNo tenderness and edema.


over

J. LACRIMAL GLAND
Palpability
Palpation
and
tenderness
of
lacrimal
gland

Normal.

K. EXTRAOCULAR MUSCLE
Eye
alignment
and
coordination

Inspection

Both
eyesEyed
moves
coordinated move inalignment.
unison, with parallel
alignment

with

parallelNormal.

L. VISUAL FIELDS
Peripheral
visual fields

Inspection

When
lookingLoss of peripheral vision
straight ahead, client
can see objects in
the periphery

Abnormal:
stroke
can result in visualperceptual
dysfunctions
caused
by
disturbances of the
primary
sensory
pathways between
the eye and visual
cortex.

V. EARS
A. AURICLES
1.
Color, Inspection
symmetry of
size
and
position

Color same as facialSame color as the facial skin; tipNormal


skin;
symmetrical;of auricle aligned at the outer
auricle aligned withcanthus of the eye.
outer canthus of eye,
about 10 degrees
from vertical

2.
Texture, Palpation
elasticity and
areas
of
tenderness

Mobile, firm, and notSmooth in texture, flexible andNormal


tender; pinna recoilselastic pinna; no tenderness.
after it is folded

B. HEARING ACUITY TESTS


Clients
Inspection
response to
normal voice
tones

Normal voice tonesCan hear normal volume, tonesNormal.


audible
or words.

VI. NOSE
1.
Any Inspection
deviation in
shape, size,
or color and
flaring
or
discharge
from
the
nares

Symmetric
andSymmetric and straight; uniformNormal
straight;
nocolor with no nasal flaring.
discharge or flaring;
uniform color

2.
Nasal Inspection
septum
Palpation
(between the
nasal
chambers)

Nasal septum intactNasal septum


and in middle
midline.

3. Patency of Inspection
both
nasal
cavities

Air moves freely asBoth nasal cavities are patent.


the client breathes
through the nares

Normal.

4.
Palpation
Tenderness,
masses and
displacement
s of bone and
cartilage

Not
tender;
lesions

noNo tenderness or lesions.

Normal

No tenderness present.

Normal.

intact

and

inNormal

VII. SINUSES
Identification Palpation
of
the
sinuses and
for
tenderness

Not tender

VIII. MOUTH
A. LIPS
Symmetry of Inspection
contour,
Palpation
color
and
texture

Uniform pink color;Uniform pink color; soft, moist,Normal.


soft, moist, smoothsmooth texture; ability to purse
texture; symmetry oflips
contour; ability to
purse lips

B. BUCCAL MUCOSA
Color,
Inspection
moisture,
texture, and
the presence
of lesions

Uniform pink color;Uniform


pink
moist, smooth, soft,smooth, soft
glistening, and elastic
texture

color;

moist,Normal.

C. TEETH
Color,
Inspection
number and
condition
and presence
of dentures

32
adult
teeth;Intact dentures
smooth, white, shiny
tooth
enamel;
smooth,
intact
dentures

Normal.

Pink
gums;
retraction

Normal.

D. GUMS
Color
and Inspection
condition

noPink gums.

E. TONGUE/ FLOOR OF THE MOUTH


1. Color and Inspection
texture
of
the
mouth
floor
and
frenulum

Pink color; moist;Pink color; moist;


slightly rough; thincoating;
moves
whitish
coating;tenderness.
moves freely; no
tenderness

2.
Position, Inspection
color
and
texture,
movement
and base of
the tongue

Central
position;Located
pink color; smoothcenter.
tongue base with
prominent veins

3.
Any Palpation
nodules,
Inspection
lumps
or
excoriated
areas

Smooth with noNo tenderness or masses.


palpable nodules,
lumps,
or
excoriated areas

and

thin whitishNormal.
freely;
no

positioned

in

theNormal

Normal

F. PALATES and UVULA


1.
Color, Inspection
shape,
Palpation
texture and
the presence
of
bony
prominences

Light pink, smooth,Lighter hard palate; more irregular Normal


soft palate, lightertexture
pink hard palate,
more
irregular
texture

2. Position of Inspection
the
uvula
and mobility
(while
examining
the palates)

Positioned
midline
of
palate

G. OROPHARYNX and TONSILS

inPositioned at the center.


soft

Normal

1. Color and Inspection


texture

Pink and smoothPink and smooth.


posterior wall

2.
Size, Inspection
color,
and
discharge of
the tonsils

Pink and smooth;Pink and smooth; no discharge; of Normal.


no discharge; ofnormal size
normal size

3. Gag reflex Inspection

Present

Present

Normal.

Normal

IX. THORAX
A. ANTERIOR THORAX
1.Breathing
pattern

Inspection

Quiet, rhythmic, andNormal


breathing
pattern.Normal.
effortless respirations Symmetrical chest expansions,
no retractions

2. Temperature, Palpation
tenderness,
masses

Skin intact; uniformHas intact skin; has equalNormal


temperature;
chestwarmth on both sides. No
wall
intact;
nomasses.
tenderness;
no
masses

3.
Anterior Auscultation
thorax
auscultation

Bronchovesicular andAbsence of crackles.


vesicular
breathbreath sounds.
sounds

ClearNormal.

B. POSTERIOR THORAX
1.Shape,
Inspection
symmetry, and Palpation
comparison of
anteroposterior
thorax
to
transverse
diameter

Anteroposterior
toSymmetrical chest.
transverse diameter
in ratio 1:2; chest
symmetric

Normal

2.Spinal
alignment

Spine
aligned

Normal.

Inspection

verticallySpine vertically aligned

3. Temperature, Palpation
tenderness,
masses

Skin intact; uniformNo masses nor tenderness: hasNormal


temperature;
chestequal warmth on each side
wall
intact;
no
tenderness;
no
masses

4.
Posterior Auscultation
thorax
auscultation

Vesicular
andAbsence of crackles.
bronchovesicular
breath sounds

Normal.

A. AORTIC and Auscultation


PULMONIC
AREAS

No pulsations

No pulsations felt

Normal

B.

No pulsations; no liftNo pulsations felt

Normal

XI. CARDIOVASCULAR

TRICUSPID Auscultation

AREA
C. APICAL AREA

or heave
Auscultation

D. EPIGASTRIC Auscultation
AREA

Pulsation visible inHas full pulsation


50% of adults and
palpable in most PMI
in 5th LICS at or
medial to MCL

Normal

Aortic pulsations

Normal

Has pulsation

E.
Auscultation S1: Usually heard atHas full and rapid pulsation, 75 Abnormal.
CARDIOVASCU
all sites
bpm.
Blood
LAR
AREAS
Usually louder at theSounds on the aortic and pressure
AUSCULTATIO
apical area
pulmonic areas; has a lub soundindicates
N
S2: Usually heard aton the apex and dub sounds on hypertension.
all sites
the tricuspid area.
Usually louder at theBlood pressure is 180/80 mmHg
base of heart
Systole:
silent
interval;
slightly
shorter duration than
diastole at normal
heart rate (60 to 90
bpm)
Diastole:
silent
interval;
slightly
longer duration than
systole
at
normal
heart rates.
S3: in children and
young adults
S4: in many older
adults
XII. CAROTID ARTERIES
1. Carotid artery Palpation
palpation

Symmetric
pulseHas full pulsation. Symmetrical Normal.
volumes;
fullpulse volume.
pulsations, thrusting
quality;
quality
remains same when
the client breathes,
turns
head,
and
changes from sitting
to supine position;
elastic arterial wall

XII. AXILLAE
1.
Axillary, Inspection
subclavicular,
and
supraclavicular
lymph nodes
XIII. ABDOMEN

No
tenderness,No tenderness,
masses, or nodules
nodules

masses,

orNormal.

1. Skin integrity Inspection

Unblemished
uniform color

skin;Uniform color.

Normal.

2.
Abdominal Inspection
contour

Flat,
roundedHas a flat and concave abdomen Normal
(convex), or scaphoid
(concave)

3. Enlargement Inspection
of
liver
or
spleen

No
evidence
ofNo enlargement of the spleen Normal
enlargement of liverand liver seen.
or speen

4. Symmetry of Inspection
contour

Symmetric contour

5.
Abdominal Inspection
movements
associated with
respirations,
peristalsis
or
aortic
pulsations

Symmetric
Abdominal movements
movements
causedwhen inhaling.
by respiration; visible
peristalsis
in
very
lean people; aortic
pulsations
in
thin
persons at epigastric
area

6.
Vascular Inspection
pattern

No visible
pattern

Has a symmetrical abdominalNormal


contour.
notedNormal

vascularHas no blood vessel visible.

Normal

XIV. MUSCULOSKELETAL SYSTEM


A. MUSCLES
1. Muscle size Inspection
and
comparison
on the other
side

Proportionate to theProportionate to the body; inNormal.


body: even in bothboth sides.
sides

2.
Inspection
Fasciculation
and tremors
in
the
muscles

No fasciculation andNo tremors.


tremors

Normal.

3.
Muscle Palpation
tonicity

Even and firm muscleFirm muscle tone


tone

Normal.

4.
Muscle Palpation
strength

Has equal muscularUnequal muscular strength


strength
on
both
sides

Abnormal.
Patient
is
experiencing
weakness
on
the left side of
his body.

B. JOINTS
1. Joint swelling

Inspection

No
swelling,
noAbsence of swelling, pain orNormal.
warmth, no redness,redness.
no pain, no crepitus

EXTREMETIES

Inspection
Palpation

No
swelling,
noAbsence of swelling, redness orNormal.
warmth, no redness,pain.
no pain.

Neurological Assessment
Category

Normal Findings

Actual Findings

Analysis
Interpretation

Mental Status

Alert

Alert

Level
Consciousness

of Oriented

Patient was able to


response in motor and
verbal activities.

Coherent

Orientation
Language test

Oriented to person, time and


place

and

Patient was oriented.

Coherent
Able to remember

Able to state what happened


to him in the past

Category

Normal Findings

Actual Findings

CN1

Able to smell and Able


to
smell Able to recognize alcohol in cotton
recognize stimuli
alcohol in cotton. merely smelling.

Recall
Cranial Nerves

Olfactory
CNII
Optic

CN III,IV, VI
Occulomotor
Trochlear

20x20 vision, able Presbyopia(loss


to read newsprint
of elasticity of the
lens and thus loss
of ability to see
close object)

Abnormal.
Presbyopia
is
the
decrease ability of the eye to
accommodate for near vision. This
occurs as a normal part of aging and
the lens becomes less flexible. The
average age of onset of presbiopia is
the midforties.

(+)
Extraocular
Movement (EOM);
Lateral Upward and
Downward; pupils
reactive to light

Pupils react to
light. There is
constriction and
consensual
accommodation.
Able to move the
eyes
in
any
direction
in
unison.

The patient has a normal eye


movement; pupils react to light and
able to move his eyes in any
direction.

Able to feel and


clearly
identify
stimulus,
with
bilateral
facial
sensation,
with
active
corneal
reflex
and

Able to feel the Patient response in the test and has


tip of the reflex a normal sense of touch.
hammer
while
covering his eyes
and able to open
mouth
against

Abducens

CN V
Trigeminal

Analysis and Interpretation

CN VII
Facial

CN VIII
Vestibulocochlear
CN IX, X
Glossopharyngeal
Vagus
CN XI
Accessory (Spinal)

CN XII
Hypoglossal

mastication

resistance

Facial
symmetry
and
muscle
movement,
salivation
and
tearing, taste and
sensation in the
ear.

(+)
symmetry

Facial

Able
to
do
facial
according to his feelings

expression

Able to taste; no
difficulty
in
swallowing.

Able
to
hear Cannot maintain Weakness present on left side thus,
clearly,
can balance
cannot maintain balance.
maintain balance
(+)
gag
reflex, Present
gag Patient was able to identify the taste
uvula at the center, reflex, able to of the food.
soft palate rises
swallow and able
to identify the
taste of the food
Able
to
shrug
shoulders against
resistance and able
to turn the head
side and against
resistance.

Cannot able to
shrug shoulders
against
resistance
and
can turn the head
from right to left

Patient was able to move or turn his


head from right to left and but
unable to shrug his left shoulder
against resistance.

Able
to
move Able to protrude Patient able to move tongue without
tongue from side to tongue and move difficulty.
side
it side to side

Muscle Strength
Category

Normal Findings

Actual Findings

Analysis and Interpretation

Right Arm

100%
of
normal 100%
of
normal Patient able to move on his
strength; active motion strength; full muscle right arm with full muscle
against full resistance
movement
against movement without difficulty.
gravity; with support.

Left Arm

100%
of
normal 25%
of
normal Patient not able to move on
strength; active motion strength; full muscle his left arm with full muscle
against full resistance
movement
against movement without difficulty.
gravity

Right Leg

100%
of
normal 100%
of
normal Patient able to move on his
strength; active motion strength; full muscle right leg with full muscle
against full resistance
movement
against movement without difficulty.
gravity; with support.

Left Leg

100%
of
normal 25%
of
normal Patient not able to move on
strength; active motion strength; full muscle his left leg with full muscle
against full resistance
movement
against movement without difficulty.
gravity

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