Professional Documents
Culture Documents
TABLE OF CONTENTS
I.
Introduction
a. Overview of the case
b. Objective of the study
c. Scope and Limitation of the study
II.
Health History
III. Developmental Data
IV. Medical Management
a. Medical orders with rationale
b. Drug Study
c. Laboratory results
V.
Anatomy and Physiology with Pathophysiology
VI. Nursing Assessment
VII. Nursing Management
a. Ideal Nursing Management (NCP)
b. Actual Nursing Management (SOAPIE)
VIII. Referrals and Follow-up
IX. Evaluation and Implications
X.
Bibliography
I.
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3
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28
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33
INTRODUCTION
A.OVERVIEW:
stroke. Ischemia or other blood vessel dysfunctions can affect the person during a
cerebrovascular incident.
A transient ischemic attack (TIA) leaves little to no permanent damage within the brain.
The symptoms of this include facial weakness, visual impairment, loss of coordination, or
balance, a sudden headache, and mental confusion with unintelligible speech. Severe
blockage of the arteries to the brain is known as carotid stenosis.
Carotid artery affects retina, cerebral hemisphere, or both. Retinal Transient blackouts;
the sense of a shade pulled over the eyes. Cerebral Contralateral (opposite sided) paralysis of
a single body part; paralysis of one side of the body; localized tingling, numbness; hemianopic
visual loss; aphasia (loss of speech); rare loss of consciousness. Vertebrobasilar Bilateral
visual disturbance including dim, gray, or blurred vision or temporary total blindness; diplopia
(double vision). Labyrinth/medulla Vertigo; unsteadiness; nausea; vomiting. Brainstem
Slurring dysarthria (tongue weakness causing impaired speech); dysphagia (difficulty
swallowing); numbness, weakness; all four limb paresthesia; drop attacks from sudden loss of
postural tone are basilar in origin; a vertebrobasilar artery occlusion episode causes
symptoms to be induced by abrupt position changes.
Cerebrovascular disease can be divided into embolism, aneurysms, and low flow
states depending on its cause. Major modifiable risk factors
includehypertension, smoking, obesity, and diabetes.
The most common forms of cerebrovascular disease are cerebral thrombosis (40% of
cases) and cerebral embolism (30%), followed by cerebral hemorrhage (20%).[2]
Cerebrovascular disease is primarily one of old age; the risk for developing it goes up
significantly after 65. CVD tends to occur earlier than Alzheimer's Disease (which is rare
before the age of 80). In some countries such as Japan, CVD is more common than AD. CVD
occurs more rarely in younger people due to conditions such as syphilis that lead to artery
damage and strokes.
Name:
C.B
Address:
Birthday:
December 9, 1980
Birthplace:
Bukidnon
Age:
32 years old
Nationality:
Filipino
Religion:
Catholic
Civil Status:
Married
Occupation:
None
Educational
Attainment:
Family Income:
Php 6000/month
Height:
52
Weight:
70 kgs
Admitting
Diagnosis:
Attending
Physician:
Cerebrovascular Disease
Shielamar B. Flores MD
Theorist
Sigmund
Freud
Theory
Stage
Psychosexual
Genital Stage
Result and
Justification
My patient was able to
- It is a theory of how
Libido reawakened
as genital organs
age.
on relationships with
members of the
opposite sex.
Theorist
Theory
Psychosocial
Result and
Justification
Stage
Generativity Vs.
developmental stages
through which a
healthily developing
human should pass
from infancy to
adulthood. In each
stage the person
confronts, and
hopefully masters
new challenges. Each
stage builds on the
40-65)
Achieve the life goals
established for
oneself while
considering the
welfare of future
generations.
My patient has
her own salary to
support for his
children who are in
school and he had
already 5 children
who are married
and can support
their own family.
He has able to
maintain healthy
lifestyle and able to
accept childs
mates.
successful completion
of earlier stages. The
challenges of stages
not successfully
completed may be
expected to reappear
as problems in the
future.
5
Theorist
Theory
Theory of
(Ages 40-60)
must be developed:
Robert
Havighurst
Assisting teenage
on growth and
children to become
responsible and
helped them
whenever there are
Achieving adult
problems. He
continues to learn
depends on his
throughout life.
responsibility,
Happiness is being
Reaching and
achieved when a
maintaining
particular task of a
satisfactory
performance in ones
by the person
occupational career,
Developing adult
Theory
Theory of Cognitive
Jean Piaget
happy adults,
Theorist
Result and
Justification
Stage
Relating oneself to
ones spouse as a
person, To accept
problems; thinks
mainly watching TV
and listening to radio.
He also understands
his current situation
and is aware of the
changes in his
lifestyle. His wife and
development of human
come gradually to
A person logically
scientifically; solves
complex problems;
cognitive structures
directly identify
solutions for his
problems because he
is paralyzed and
unable to talk well
due to CVA.
mature.
development is at the
centre of human
organism and language
is contingent on
cognitive development.
NPO temporarily
For furher
evaluation of his
condition.
To monitor any signs
of deterioration of
health status
Aspiration risk is
greater, so as to
avoid aspiration.
To monitor
abnormalities in the
blood, and fifferent
enzymes and waste
products of the
body.
Venoclysis to supply
blood vessels and
prevent dehydration.
For hydration
purposes
An ACE inhibitors
help reduce blood
pressure and also
increased
prostaglandin
synthesis
A calcium-channel
blocker whichdilates
blood vessel making
the heart easier to
pump blood.
Labs:
Meds:
Captopril 25 mg SL
now then prn if the
BP is 160/100 and
above
Amlodipine 10 mg
OD
Refer to Dr.Jolo
Refer accordingly
IM NOTES
For CT Scan
brain plain
Citicholine 500
mg I tab
To increase oxygen
supply in the blood.
For further
evaluation and
treatment of disease
condition.
For further
evaluation and
referral of the
disease condition.
To note any clot in
the brain.
Simvastatin 20
mg 1 tab OD H.S
A CNS stimulant
which increases
blood supply and
oxygen to the brain.
An anti-
B. Drug Study
Name
of
Drug
Amlod
ipine
Classification
Name
of
Drug
Citich
oline
Classification
Calcium
channel
blocker
CNS stimulant
Dose/
frequen
cy
10mg
OD PO
Mechanis
m of
Actions
Inhibits
influx of
calcium
through the
cell
membrane,
resulting in
a
depression
of
automaticity
and
conduction
velocity in
cardiac
muscle.
Specific
Indication
Dose/
frequen
cy
500 mg
OD PO
Mechanism
of Actions
Specific
Indicatio
n
Citicholine
in CVA,
stimulates
brain
function
Increases
oxygen
supply and
blood to the
brain.
Contraindi
cation
Side
effects
Nsg
Precautions
Treatment
allergy to
for essential amlodipine
hypertensio
n.
CNS:
Dizzine
ss,
light
heade
dness,
fatigue,
letharg
y
1. Monitor
vital signs,
CBC, and
ECG.
2. Instructed
to avoid
grape fruit
juice
3. Can be
taken with or
without meals
4. Note and
report chest
pain, SOB
and dizziness
Contraindic
ation
Side
effects
Nsg
Precautions
Any allergy
or
hypersensitivi
ty to the drug
headac
he,
dizzine
ss,
nausea
and
vomitin
g,
abdomi
nal
cramps
1. May
reduce
dosage with
impaired
renal
function,
2. May take
with meals
3. Monitor
vital signs,
CBC
4. Monitor
mental
status.
9
Name
of
Drug
Captop
ril
Classification
ACE inhibitor
Dose/
frequ
ency
25 mg
SL
when
BP is
160/1
00 or
above
PO
Mechanism
of Actions
Specific
Contraindica Side
Indication tion
effects
Nsg
Precautions
Inhibits
angiotensio
n-converting
enzyme
resulting in
decreased
plasma
angiotensin
II, which
leads to
decreased
vasopressor
activity and
decreased
aldosterone
secretion.
Managem
ent of
hypertensi
on
1. Take 1
hour before
meals,
Name
of
Drug
Specific
Indication
Senna
conce
ntrate
Laxative
to soften
the stool
2tabs
OD
promotes
incorporation
of water into
stool,
resulting in
softer fecal
mass.
Hypersensitiv
ity to
captopril,
other ACE
inhibitor or
any
component
Contraindicat
ion
Abdomi
nal
pain
Nause
a and
vomitin
g
Rash,
gastric
irritation,
headach
e,
dizzines
s,
fatigue,
malaise,
dry
mouth,
N&V
Side
effects
commo
n side
effects
mild
cramps
2.Report
fever, chest
pain, skin
rash and
irregular
heartbeat
3. Withhold
potassiumsparing
diuretics
Nsg Precautions
Advise
patient that
laxative
should only
be used for
short
therapy
Encouraged
patient to
use other
forms of
bowel
regulation,
such as
increasing
bulk in the
diet and
10
increasing
fluid intake
and
increasing
mobility
Name
of Drug
Simvast
atin
Name
of
Drug
perind
opril
Classification Dose/
freque
ncy
Antilipidemics 200mg
1tab
OD HS
Classification Dose/
freque
ncy
anti:
hypertensive
500mg
1tab
OD
Mechanism
of Actions
Specific
Indication
Contraindi
cation
Side
effect
s
active liver
Consti
disease or
pation,
unexplained Dyspe
persistent
psia,
elevations
Flatule
of serum
nce,
transaminas Heada
es
che
porphyria
inhibits
HMG-COA
reductase,
an early
step in
cholesterol
biosynthesis
in
hyperlipide
mia: an
adjunct to
diet to
reduce
elevated
total LDL
Mechanism
of Actions
Specific
Contraindic
Indication ation
Side
effects
Nsg
Precautions
inhibits ACE
activity,
thereby
preventing
conversion
prevention
of stroke
recurrenc
e in
combinati
Palpitati
on,
Edema,
Chest
pain,
1.Use
cautiously in
patient with a
history of
angioedema
in patients
hypersensiti
vity to drug
or other ACE
inhibitor
Nsg
Precautions
1.Instruct
patient to take
drug with the
evening meal
2.Use drug
only after diet
11
of
angiotensin
1 to 2, a
potent
vasoconstrict
or.
Name
of
Drug
Bisaco
dyl
Name
of
Drug
Classification
Mucokenitics/
expectorants
Dose/
frequen
cy
1tab
supp
per
rectum
Classification Dose/
frequency
Mechanism
of Actions
Increases
peristalsis
and motor
activity of
the small
intestines by
acting
directly on
the smooth
muscle.
on with
indapamid
e in
patients
with a
history of
CVA.
Specific
Indicatio
n
Constipati
on relief of
avacuatio
n in
hemorrhoi
ds prep
for barium
enema,
pre and
post op.
Mechanism Specific
of Actions
Indicatio
n
Abnorm
al ECG
unrelated to
ACE inhibitor
therapy
2.Also use
cautiously in
pt. with
impaired
renal
function
Contraindica
tion
Side
effects
Nsg
Precautions
Hypersensitivi
ty to drugs
Nause
a,
Vomitin
g,
Abdom
inal
pain
,
Ulcerat
ive
lesions
of
colon
1.Monitor
frequency
and
character of
stool
2.Swallow
the tablet
whole
3.Do not
crush or
chew the
drug
Contraindi
cation
Side
effects
Nsg
Precautions
12
Cepha cephalosporin
lexin
s
500 mg,
every 8
hours, PO
Interferes
with the
final step in
cell wall
formation,
resulting in
unstable
cell
membranes
that
undergo
lysis. Also,
cell division
and growth
are
inhibited.
GU
infections
and
respirator
y infection
Hypersensit
ivity to
drugs
Diarrhe
a,
nausea
and
vomitin
g,
abdomi
nal
pain,
dizzine
ss, skin
rash,
fever
1. Refrigerate
suspension
after
reconstitution
2. May
reduce
dosage with
impaired
renal function,
3. May take
with meals
4. Consume
2-3 L/day of
fluids to
prevent
dehydration.
c. LABORATORY RESULTS
Name: Gulle, Euberto
WBC: 0-2/hpf
Transparency: clear
RBC: (-)/hpf
Sugar: Negative
Albumin: Negative
pH: 6.0
CT SCAN REPORT
GULLE, EUBERTO
Interpretation:
Plain CT Scan of the brain with serial axial views disclose the following findings.
13
There is a hypodense focus at the left frontal lobe measuring around 7.6 cms in widest
diameter. There is another one at the right occipital lobe measuring around 2.2 cms. There
are tiny hypodensities in the superior left fronto parietal lobes.
There is no abnormal attenuation of the cerebellum and brain stem.
The ventricles are not dilated.
The midline structures are intact.
Petro mastoids, sinuses, orbits and sellar areas are unremarkable.
Impression:
CONSIDER ACUTE TO SUB-ACUTE INFARCTS, LEFT FRONTO PARIETAL LOBES AND
RIGHT OCCIPITAL LOBE.
Gulle, Euberto
CHEST X-RAY
Cardiothroracic ratio 60.58. Both lungs are clear. Trachea, diaphragm, and bronchus are
unremarkable.
Impression:
Moderate Cardiomegaly
HEMATOLOGY
WBC: 13, 700/cumm above normal which suggests infection.
Hemoglobin: 13.8 gm % - normal findings
Hematocrit: 45.3 vol % - normal findings
Platelet count: 277, 000/cumm normal findings
Differential count
Neutrophil: 77 above normal findings which suggest bacterial infection
Lymphocytes: 18 below normal which suggests viral infection
Eosinophil: 05 normal findings
14
15
Overview
Nothing in the world can compare with
the human brain. This mysterious threepound organ controls all necessary
functions of the body, receives and
interprets information from the outside
world, and embodies the essence of the
mind and soul. Intelligence, creativity,
emotion, and memories are a few of the
many things governed by the brain.
The brain receives information through
our five senses: sight, smell, touch, taste, and hearing - often many at one time. It assembles
the messages in a way that has meaning for us, and can store that information in our memory.
The brain controls our thoughts, memory and speech, movement of the arms and legs, and
the function of many organs within our body. It also determines how we respond to stressful
situations (such as taking a test, losing a job, or suffering an illness) by regulating our heart
and breathing rate.
Nervous system
The nervous system is divided into central and peripheral systems. The central nervous
system (CNS) is composed of the brain and spinal cord. The peripheral nervous system
(PNS) is composed of spinal nerves that branch from the spinal cord and cranial nerves that
branch from the brain. The PNS includes the autonomic nervous system, which controls vital
functions such as breathing, digestion, heart rate, and secretion of hormones.
Skull
The purpose of the bony skull is to protect the brain from injury. The skull is formed from 8
bones that fuse together along suture lines. These bones include the frontal, parietal (2),
temporal (2), sphenoid, occipital and ethmoid (Fig. 1). The face is formed from 14 paired
bones including the maxilla , zygoma, nasal, palatine, lacrimal, inferior nasal conchae,
mandible, and vomer.
Inside the skull are three distinct areas: anterior fossa, middle fossa, and posterior fossa (Fig.
2). Doctors sometimes refer to a tumors location by these terms, e.g., middle fossa
meningioma.
Similar to cables coming out the back of a computer, all the arteries, veins and nerves exit the
base of the skull through holes, called foramina. The big hole in the middle (foramen
magnum) is where the spinal cord exits.
Brain
The brain is composed of the cerebrum, cerebellum, and brainstem (Fig. 3).
16
The cerebrum is the largest part of the brain and is composed of right and left
hemispheres. It performs higher functions like interpreting touch, vision and hearing, as
well as speech, reasoning, emotions, learning, and fine control of movement.
The cerebellum is located under the cerebrum. Its function is to coordinate muscle
movements, maintain posture, and balance.
The brainstem includes the midbrain, pons, and medulla. It acts as a relay center
connecting the cerebrum and cerebellum to the spinal cord. It performs many
automatic functions such as breathing, heart rate, body temperature, wake and sleep
cycles, digestion, sneezing, coughing, vomiting, and swallowing. Ten of the twelve
cranial nerves originate in the brainstem.
The surface of the cerebrum has a folded appearance called the cortex. The cortex contains
about 70% of the 100 billion nerve cells. The nerve cell bodies color the cortex grey-brown
giving it its name gray matter (Fig. 4). Beneath the cortex are long connecting fibers
between neurons, called axons, which make up the white matter.
Right brain left brain
The right and left hemispheres of the brain are joined by a bundle of fibers called the corpus
callosum that delivers messages from one side to the other. Each hemisphere controls the
opposite side of the body. If a brain tumor is located on the right side of the brain, your left arm
or leg may be weak or paralyzed.
Not all functions of the hemispheres are shared. In general, the left hemisphere controls
speech, comprehension, arithmetic, and writing. The right hemisphere controls creativity,
spatial ability, artistic, and musical skills. The left hemisphere is dominant in hand use and
language in about 92% of people.
Lobes of the brain
The cerebral hemispheres have distinct fissures, which divide the brain into lobes. Each
hemisphere has 4 lobes: frontal, temporal, parietal, and occipital (Fig 3). Each lobe may be
divided, once again, into areas that serve very specific functions. Its important to understand
that each lobe of the brain does not function alone. There are very complex relationships
between the lobes of the brain and between the right and left hemispheres.
Frontal lobe
Personality, behavior, emotions
Judgment, planning, problem solving
Speech: speaking and writing (Brocas area)
Body movement (motor strip)
Intelligence, concentration, self awareness
Parietal lobe
17
Occipital lobe
Temporal lobe
Memory
Hearing
Deep structures
Hypothalamus - is located in the floor of the third ventricle and is the master control of the
autonomic system. It plays a role in controlling behaviors such as hunger, thirst, sleep, and
sexual response. It also regulates body temperature, blood pressure, emotions, and secretion
of hormones.
Pituitary gland - lies in a small pocket of bone at the skull base called the sella turcica. The
pituitary gland is connected to the hypothalamus of the brain by the pituitary stalk. Known as
the master gland, it controls other endocrine glands in the body. It secretes hormones that
control sexual development, promote bone and muscle growth, respond to stress, and fight
disease.
Pineal gland - is located behind the third ventricle. It helps regulate the bodys internal clock
and circadian rhythms by secreting melatonin. It has some role in sexual development.
Thalamus - serves as a relay station for almost all information that comes and goes to the
cortex (Fig. 5). It plays a role in pain sensation, attention, alertness and memory.
Basal ganglia - includes the caudate, putamen and globus pallidus. These nuclei work with
the cerebellum to coordinate fine motions, such as fingertip movements.
Limbic system - is the center of our emotions, learning, and memory. Included in this system
are the cingulate gyri, hypothalamus, amygdala (emotional reactions) and hippocampus
(memory)
HUMAN BRAIN WITH STROKE
18
A stroke occurs
blood to a
blocked.
cells start to die
Sudden bleeding
cause a stroke if
Heredity
Hypertension
Hyperlipidimia
PRECIPITATING FACTOR
VASOCONSTRICTION
Cerebral Ischemia
Cell Death
Decreased Oxygen
Supply
Intracerebral Hemorrhage
Right
Lower
and upper
extremitie
s
Hypoxia
Altered Cerebral
Metabolism
P
A
R
A
L
Y
S
I
S
Decreased Cerebral
Perfusion
Brain
LocalTissue
Acidosis
Good
Prognosis
NecrosisEdema
Aneurysm
Rupture
Cytotoxic
19
Embolic Stroke
EENT:
[x] Impaired Vision [ ] Blind [ ] Pain [ ] Reddened
[ ] Drainage [ ] Gums [ ] Hard of Hearing
[ ] Deaf [ ] Burning [ ] Edema [ ] Lesion
[x] Teeth [ ] No Problem
[x] Assess Eyes, Ears Nose, and Throat for Abnormalities.
RESPIRATORY SYSTEM:
[ ] Asymmetric [ ] Tachypnea [ ] Apnea [ ] Rales
[] Cough [ ] Barrel Chest [ ] Bradypnea
[] Shallow [ ] Rhonchi [ ] Sputum [ ] Diminished
[ ] Dyspnea [ ] Orthopnea [ ] Labored [ ] Wheezing
[ ] Pain
[ ] Cyanotic
[ ] No Problem
[x] Assess Resp. Rate, Rhythm, Depth, Pattern,
Breath Sounds and Comfort.
CARDIO VASCULAR:
[ ] Arrhythmia [ ] Tachycardia [ ] Numbness
[ ] Diminished Pulses [ ] Edema
[ ] Fatigue [ x ] Irregular
[ ] Bradycardia [ ] Murmur [ ] Tingling [ ] Absent Pulses
[ ] Pain [] No Problem
[x] Assess Heart Sounds, Rate, Rhythm, Pulse,
Blood Pressure, Circulation, Fluid Retention, and Comfort.
Hemiparesis
Normoactive
bowel sounds
Decreased
muscle tone,
limited ROM
20
Dry skin
NEURO:
[x ] Paralysis [ ] Stuporus [ ] Unsteady [ ] Seizures
[ ] Lethargic [ ] Comatose [ ] Vertigo [ ] Tremors
[ ] Confused [ x] Vision [ ] Grip
[] No Problem
[x] Assess Motor Function, Sensation, LOC, Strength,
Grip, Gait, Coordination, Orientation and Speech.
MUSCULOSKELETAL and SKIN:
[ ] Appliance [x ] Stiffness [ ] Itching [ ] Petechiae
[ ] Hot [ ] Drainage [ ] Prosthesis [ ] Swelling
[ ] Lesion [ ] Poor Turgor [ ] Cool [ ] Deformity
[] Wound [ ] Rash [ ] Skin Color [ ] Flushed
[ ] Atrophy [ ] Pain [ ] Ecchymosis [ ] Diaphoretic
[ ] Moist
[ ] No Problem
[x] Assess Mobility, Motion, Gait, Alignment,
Joint Function, Skin Color, Texture, Turgor, and Integrity.
Place an (X) in the area of abnormality. Indicate the location of the problem in the figure if appropriate, using (X).
NURSING ASSESSMENT II
SUBJECTIVE
COMMUNICATION
[ ] hearing loss
[ ] visual changes
[x ]denied
Comments:Okay
naman akong
panan-aw as vb.
By the patient.
OXYGENATION:
[]dyspnea
[x]smoking history
yes
[] cough
[ ]sputum
[x]denied
Comments:Okay
raman akong
pagginhawa
dilinaman sad ko
mag lisud og
ginhawa as vb. By
the patient..
OBJECTIVE
[ ] glasses
[ ]languages
[ ] contact lens
[ ] hearing aide
R
L
Pupil size: 4mm
[ ] speech
difficulties
Reaction: Pupil Equally Round Reactive
to Light and Accommodation
Resp. [x]regular [ ]irregular
Describe: bronchovesicular breath
sounds heard over lungs; RR;20cpm
R:bronchovesicular sounds auscultated
L:bronchovesicular sounds auscultated
CIRCULATION:
[ ]chest pain
[ ] leg pain
[ ] numbness of
extremities
[x] denied
Comments:Dili na
nako mafeel ang sakit
sa pikas nako nga tiil,
as verbalized by the
patient.
NUTRITION:
Diet: Soft diet
[]N[]V
Character:
[ ] recent change in weight
and appetite
[ ] swallowing difficulty
[x]denied
Comments:
okay raman
akong
pagkaon,as vb
by the patient .
[ ] irregular
Carotid
Radial Dorsal PedisFemoral
R 85bpm
84bpm
84bpm
refused
L 85bpm
84bpm
84bpm
refused
Comments: all pulses are palpable
*if applicable: not applicable
[x]dentures
Full
Upper
Lower
partial
[ ]
[ ]
[ ]none
with patient
[x]
[x]
[ ]
[ ]
21
ELIMINATION:
Usual bowel pattern
[ ] urinary frequency
Once a day 1-2 times a day
[]constipation
[ ]urgency
Remedies:
[ ]dysuria
Papaya, pineapple
[ ] hematuria
Date of last BM
[ ] incontinence
Dec. 18, 2012
[ ]polyuria
[ ] diarrhea character
[ x ] foley in place
None
[ ] denied
ACTIVITY/SAFETY:
[ ] convulsion
Comments: dili nako
[ ] dizziness
malihok akong tuo nga
[x] limited motion
lawas as verbalized
of joints
by the patient.
[ ] ambulate
[ ] bathe self
[ ] other
[ ] denied
COMFORT/SLEEP/AWAKE:
[ ] pain
Comments:
(location) frequency Katarong man ko
remedies)
og tulog as
[ ] nocturia
verbalized by the
[] sleep difficulties
patient.
[x] denied
COPING:
Occupation: None
Members of household: *9 members
Most supportive person: Edith Gulle
Comments:
Patient bowel
Normoactive
bowel
sounds(8/mins.)
is
Sounds
normoactive.
Bowel sounds:
Abdominal Distention
Present [ ] yes [x] No
Urine (color,consistency,
odor) yellow,moderate in
amount, aromatic
*if foley balloon catheter
foley in place draining well
[x] dry
[ ]cold
[ ] pale
[ ] flushed [x]warm
[ ] moist
[ ]cyanotic
*rashes, ulcers, decubitus (describe size,
location, drainage) none
[ ] LOC and Orientation: Patient is alert
but is disoriented to time, place and
space.
[ ] Gait [ ] walker [ ] care [] others
[ ] steady [x] unsteady
Sensory and motor losses in face or
extremities
none
[ ] ROM limitations: Patient is having
difficulty to move right upper and lower
extremities due to paralysis.
[ ] facial grimace
[ ] guarding
[ ] other signs of pain
[x] side rail release form signed (60 +
years)
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Nursing Diagnosis
Nursing Interventions:
To determine patients
capabilities
To help improve
patients self-concept
and motivation to
perform
To improve compliance
Rationale
23
Nursing Diagnosis
Nursing Interventions:
Careful observation
helps you adjust
nursing actions to
meet patients needs
Applying therapy
consistently aids
patients
independence
4. Encourage patient to do as
much for self as possible,
giving simple instructions one
at a time
To aid comprehension
Provides expert
assistive for
developing therapy
plan and identifying
special equipment.
Nursing Diagnosis
Nursing Interventions:
Rationale
Rationale
24
5. Administer supplemental
oxygen as indicated
To promote
circulation/venous
drainage
This measures reduce
intracranial pressure
To promote tissue
healing, oxygenation
and metabolism
Mobilizes excess fluid
oliguric renal failure or
edema and prevents
ICP
Reduces hypoxia
which can cause
cerebral vasodilation
and increase
pressure/edema
formation
Dili nako malihok ako tuo nga tiil og kamot as verbalized by the patient.
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E Long Term: At the end of 8 hours of nursing interventions, patient was able to
report increase in activity intolerance. Thus, goal met.
Short Term: At the end of 30 minutes of nursing interventions, patient was able to
demonstrate a decrease in physiological signs of intolerance. Thus, goal met.
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HEALTH TEACHINGS
TREATMENT
OUTPATIENT
(check-up)
DIET
and etc.
Encouraged to eat foods high in fiber like pineapple,
The Clients recovery greatly depends on the interventions provided by the health
care team and the willingness of the patient to understand and participate in the
management of the illness. As a student nurse it doesnt end in the hospital premises.
Discharge instructions must be given to the client and family to ensure compliance of
drug regimen and comprehension of instructions.
For more or better promotion and restoration of the patients health status, the
patient should be referred to a nearby and accessible health care facility or hospital and
for further assessment, consultation and management; the patient is referred to CESH.
Instructions were also made regarding the clients follow- up medical check- up
scheduled 1 week after discharge @ Camp Evangelista Station Hospital outpatient
department .This is to monitor and ensure the clients recovery and improvement of
health status.
BOOKS
The Lippincott Manual of Nursing 8th edition, Lippincott Williams & Wilkins
Medical-Surgical, Brunner and Suddart 11th Ed., Respiratory Function and Gas
Exchange/pneumonia, pp 1347-1355, 1347-1348
NURSES POCKET GUIDE. Diagnoses, Prioritized Interventions, and Rationales
by Marilynn E. Doenges , Mary Frances Moorhouse, and Alice C. Murr,
Kozier, B. et al. Fundamentals of Nursing Concepts. Process and Practices. 11th
edition. Upper Saddle, New Jersey, 2007.
Mosbys Drug Guide for Nurses, 8th edition
Nursing Care Plans, Nursing Diagnosis and Intervention 6 th Edition, by
Gulanick /Myers
Psychiatric Nursing, made Incredibly Easy, Lippincott Williams & Wilkins pp. 58
INTERNET
www.medicinenet.com/Bronchopneumonia/article.htm
www.who.int/topics/bronchopneumonia
www.nursingcribs.com
www.drugs.com
www.youtube.com
www.google.com
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