Case Study Cva Gr1

BULACAN STATE UNIVERSITY College of Nursing City of Malolos, Bulacan
A CASE STUDY OF A 52 YEAR OLD FEMALE CLIENT WITH A CEREBRO VASCULAR ACCIDENT ISCHEMIC INFARCTION
Submitted by: Alonzo, Albert N. Antonino, Arra Jane K. Baile, Corazon Y. Bognot, Amie Rose M. Cabiles, Trizzle Lee F. Cabrera, Hazel R. Calonzo, Bernadette C. Castro, Jerskeem C. Cuaderno, Angela C. De Jesus, Angeli Mae V. De Leon, Abigail A.
Submitted to: Teresita M. Dela Cruz R.N. Bernardo S. Oliver R.N. Jesusa L. Capispisan R.N. Adelaida Borbe R.N.
TABLE of CONTENTS ITRODUCTION page 3 OBJECTIVES..page 5 NURSING HEALTH HISTORYpage 7 GENOGRAM..page 9 FUNCTIONAL HEALTH PATTERNpage 10 GROWHT AND DEVELOPMENTpage 16 ANATOMY AND PHYSIOLOGY.page 19 PHYSICAL ASSESSMENT...page 25 PATHOPHYSIOLOGY..page 33 REVIEW OF SYSTEMS.page 38 LABORATORY RESULTS.page 39 MEDICAL MANAGEMENT (IVF, DRUGS, O2).....page 47 NURSING CARE PLANS...page 61 . DISCHARGE PLANNING.page 69 CONCLUSION....page 71 BIBLIOGRAPHYpage 72
INTRODUCTION
Stroke, previously known medically as a cerebrovascular accident (CVA), is the rapidly developing loss of brain function(s) due to disturbance in the blood supply to the brain. This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a hemorrhage (leakage of blood). As a result, the affected area of the brain is unable to function, leading to inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or an inability to see one side of the visual field. A stroke is a medical emergency and can cause permanent neurological damage, complications, and even death. It is the leading cause of adult disability in the United States and Europe and it is the number two cause of death worldwide. Risk factors for stroke include advanced age, hypertension (high blood pressure), previous stroke or transient ischemic attack (TIA), diabetes, high cholesterol, cigarette smoking and atrial fibrillation. High blood pressure is the most important modifiable risk factor of stroke. The traditional definition of stroke, devised by the World Health Organization in the 1970s, is a "neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours". This definition was supposed to reflect the reversibility of tissue damage and was devised for the purpose, with the time frame of 24 hours being chosen arbitrarily. The 24-hour limit divides stroke from transient ischemic attack, which is a related syndrome of stroke symptoms that resolve completely within 24 hours. With the availability of treatments that, when given early, can reduce stroke severity, many now prefer alternative concepts, such as brain attack and acute ischemic cerebrovascular syndrome (modeled after heart attack and acute coronary syndrome respectively), that reflect the urgency of stroke symptoms and the need to act swiftly. In an ischemic stroke, blood supply to part of the brain is decreased, leading to dysfunction of the brain tissue in that area. There are four reasons why this might happen: 1.Thrombosis (obstruction of a blood vessel by a blood clot forming locally) 2.Embolism (obstruction due to an embolus from elsewhere in the body, see below), 3.Systemic hypoperfusion (general decrease in blood supply, e.g. in shock) 4.Venous thrombosis. Intracranial hemorrhage is the accumulation of blood anywhere within the skull vault. A distinction is made between intra-axial hemorrhage (blood inside the brain) and extra-axial hemorrhage (blood inside the skull but outside the brain). Intra-axial hemorrhage is due to intraparenchymal hemorrhage or intraventricular hemorrhage (blood in the ventricular system). The main types of extra-axial hemorrhage are epidural hematoma (bleeding between the dura mater and the skull), subdural hematoma (in the subdural space) and subarachnoid hemorrhage (between the arachnoid mater and pia mater). Most of the hemorrhagic stroke syndromes have specific symptoms (e.g. headache, previous head injury
Stroke symptoms typically start suddenly, over seconds to minutes, and in most cases do not progress further. The symptoms depend on the area of the brain affected. The more extensive the area of brain affected, the more functions that are likely to be lost. Some forms of stroke can cause additional symptoms. For example, in intracranial hemorrhage, the affected area may compress other structures. Most forms of stroke are not associated with headache, apart from subarachnoid hemorrhage and cerebral venous thrombosis and occasionally intracerebral hemorrhage. Stroke is diagnosed through several techniques: a neurological examination (such as the Nihss), CT scans (most often without contrast enhancements) or MRI scans, Doppler ultrasound, andarteriography. The diagnosis of stroke itself is clinical, with assistance from the imaging techniques. Imaging techniques also assist in determining the subtypes and cause of stroke. There is yet no commonly used blood test for the stroke diagnosis itself, though blood tests may be of help in finding out the likely cause of stroke. An ischemic stroke is caused by a thrombus (blood clot) occluding blood flow to an artery supplying the brain. Definitive therapy is aimed at removing the blockage by breaking the clot down (thrombolysis), or by removing it mechanically (thrombectomy). The more rapidly blood flow is restored to the brain, the fewer brain cells die. Other medical therapies are aimed at minimizing clot enlargement or preventing new clots from forming. To this end, treatment with medications such as aspirin, clopidogrel and dipyridamole may be given to prevent platelets from aggregating. In addition to definitive therapies, management of acute stroke includes control of blood sugars, ensuring the patient has adequate oxygenation and adequate intravenous fluids. Patients may be positioned with their heads flat on the stretcher, rather than sitting up, to increase blood flow to the brain. It is common for the blood pressure to be elevated immediately following a stroke. Although high blood pressure may cause some strokes, hypertension during acute stroke is desirable to allow adequate blood flow to the brain. Various systems have been proposed to increase recognition of stroke by patients, relatives and emergency first responders. A systematic review, updating a previous systematic review from 1994, looked at a number of trials to evaluate how well different physical examination findings are able to predict the presence or absence of stroke. It was found that sudden-onset face weakness, arm drift (e.g. if a person, when asked to raise both arms, involuntarily lets one arm drift downward) and abnormal speech are the findings most likely to lead to the correct identification of a case of stroke (+ likelihood ratio of 5.5 when at least one of these is present). Similarly, when all three of these are absent, the likelihood of stroke is significantly decreased ( likelihood ratio of 0.39). While these findings are not perfect for diagnosing stroke, the fact that they can be evaluated relatively rapidly and easily make them very valuable in the acute setting.
According to the World Health Organization, Stroke could soon be the most common cause of death worldwide causes 10% of deaths worldwide.15 million people suffer stroke worldwide each year. Of these, 5 million die and another 5 million are permanently disabled. High blood pressure contributes to over 12.7 million strokes worldwide. 30 to 50% of stroke survivors suffer post stroke depression, which is characterized by lethargy, irritability, sleep disturbances, lowered self esteem, and withdrawal. Disability affects 75% of stroke survivors enough to decrease their employability In the Philippines, stroke affects 486 out of 100,000 Filipinos or roughly half a million Filipinos yearly. Reason for choosing the study: This case was chosen to be studied because it can explain further the real meaning and process of Cerebro vascular Accident. Importance of the study This study was a part of the partial requirement in NCM 104 (R.L.E.) of third year college students of the Bulacan State University. This study regarding Cerebro Vascular Accident (infarct) may serve as a reference for each student who will encounter this case soon in their future career as professional nurses. It may also help in developing and widening the knowledge of each health care provider to be more skillful and competent in rendering care among their client with same case.
OBJECTIVES:
General Objective: This is a case that aims to educate a patient and to be able to prove relative Nursing management regarding Cerebro Vascular Accident (infarct) Specific Objectives Student Centered: To be able to build rapport with the client during the whole Nursing Intervention. To gain sufficient knowledge and skills regarding proper patient care for patient who had Cerebro Vascular Accident(infarct)
To be able to assess signs and symptoms occurring with the patient who had Cerebro Vascular Accident(infarct). To be able to gain knowledge on different body processes involved in Cerebro Vascular Accident(infarct) . To be able to deal and communicate with the patient who had Cerebro Vascular Accident(infarct)
Client Centered: To be able to lessen the pain and anxiety felt by the patient To be able to receive proper and correct Nursing Intervention in line with his condition To allow the patient to cooperate during the whole process of post Nurse-Patient interaction To allow the patient express his feelings about his condition. To teach the patient in rendering the proper care for himself. To be able to educate the patient about the proper diet for his condition. To be able to teach the patient about the proper exercise for his condition To be able to educate the patient about the disease so that it will prevent it to re occur
NURSING HEALTH HISTORY

Biographic Data Name: Patient C.C. Age: 52 years old Address: Tukod, San Rafael, Bulacan Date of Birth: June 1, 1958 Gender: Female Position in the Family: Mother Marital Status: Widowed Religion: Roman Catholic Race: Filipino Educational attainment: High school level (undergraduate 1st year level) Name of School Maguinao Cruz na Daan NHSSan Rafael, Bulacan, School Year 1973-1974
Occupation: Housewife Source of Health care: PhilHealth and support from the family Date of Admission: January 22, 2011 Date of Discharge: Admitting Diagnosis: T/c CVA infarct
B. REASON FOR SEEKING HEALTHCARE "Habang umiihi ako, nahilo ako bigla kaya napatukod ang kamay ko sa pader", as verbalized by the client. Her primary reason for seeking healthcare was because of sudden dizziness.
C. HISTORY OF PRESENT ILLNESS According to our patient, her health status was in good condition before that incident occurs. She can perform well in her daily tasks at home. Until one day on January 22, 2011, while planting in their yard, she suddenly felt a headache, then went home to take a rest and immediately took a biogesic medicine. While shes voiding she suddenly felt dizziness. On the same day, she decided to consult to the doctor and seek advice. At the hospital, the client complains of dizziness, and headache then they found out that her blood pressure was 170/150 mmHg from the normal BP of 130/90 mmHg. During hospitalization, the client verbalized that she was not able to defecate for days and that she feels weak and unable to move her left extremities which is why she needs assistance when sitting, standing, walking, and when performing hygiene, feeding, and toileting. D. PAST MEDICAL HISTORY When she was a child, she doesn't often have a serious illness. Sometimes she also got some common illness like fever, cough, and cold. She had a BCG vaccine as evidenced by a mark on her left arm and an Oral Polio Vaccine. Patient C doesn't have any allergies and she doesnt have any previous accident. And Patient C doesn't have any hospitalizations before. E. FAMILY HISTORY Her father died because of a kidney problem and because of smoking. Her mother is hypertensive. One of her sister also had an attack like her. She has 14 siblings and 12 of them already passed away and she cannot recall the causes of their death anymore.
GENOGRAM MATERNAL SIDE G.M. + G.F. + PATERNAL SIDE
G.M. +
G.F. +
E.C.
C.C. #
D.C. +
A.C. +
LEGEND: Female Male
T.C. +
P.C. +
O.C. +
A.C. +
G.C. +
O.C. +
C.C. $
S.C. +
P.C. +
Y.C. +
Y.C. +
B.C. $
M.C .#
+ *
Deceased Hypertension
$ Stroke
# Kidney stones
II. FUNCTIONAL ASSESSMENT
FUNCTIONAL HEALTH PATTERN
PRIOR TO HOSPITALIZATION
DURING HOSPITALIZATION
1. HEALTH PERCEPTIONHEALTH MAINTENANCE PATTERN
The client's general health had been good, according to the patient, on the scale of 1 to 10 her health status was 8/10 because she was able to perform all the desired activities at home. Even though there are times that she experiences cough and colds. She often loses her appetite and sometimes eats only what is available in the kitchen. Patient CC is a smoker, since she was 36 years old and she consumes about 12-15 sticks (1 pack) of cigarettes per day. She didn't even try to quit smoking, it becomes an addiction to her. She does not drink alcohol. She also doesn't go to hospitals regularly for check up, because she doesnt rely much to healthcare providers when shes feeling something wrong, but rather the first thing she would do is to take over-the-counter drugs like biogesic and decolgen, and take a rest. She also believes in faith healers and "manghihilot", according to her there's nothing wrong to that.
According to our patient, her health status was 4/10 because of her condition. She often felt dizziness and had lost her appetite due to bitter taste because of medicine. Most of the time, she needs the assistance of her eldest son, and could not perform most of her previous tasks such activities like eating, toileting and taking medications. She knows that the medication prescribed was a big help to ease the pain and to avoid further infection. But she believes that it is better for her to be at their home and it can help her condition better than staying in the hospital.
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2. NUTRITIONAL AND METABOLIC PATTERN
72-hour Diet Recall (prior to admission) Day 2 Day 1 Breakfast : Breakfast : 150 ml of coffee, 1 bowl noodles 2 pcs. of and 2pcs. pandesal and Pandesal,60ml of 240 ml of water. water Lunch : bowl of Chicken tinola, cup of rice & 240 ml of water. Lunch : 1 pc. Fried bangus (medium size), cup of rice and 240 ml of water
Day 3 Breakfast : 2 sliced bread & 150 ml of coffee
Day 1 (01-2411)
Breakfast : 2 tablespoon of rice, cup of sopas soup, and 120 ml of water.
Day 2 (01-25-11) Breakfast : 2 tablespoon of rice, cup of sinigang na baboy soup, and 240 ml of water. Lunch : 2 tablespoon of rice, cup of sinigang na baboy soup, and 240 ml of water. Dinner : NPO
Day 3 (01-26-11) Breakfast : 2 tablespoon of rice, cup of sinampalukang manok soup, and 240 ml of water. Lunch : 2 tablespoon of rice, cup of sinampalukang manok soup, and 240 ml of water. Dinner : cup of rice, cup of noodles soup, and 120 ml of water.
Lunch : 1 pc. of fried bangus belly, regular fries, cup of rice and 240 ml of water. Dinner : 1 pc. of fried tilapia, cup of rice and 240 ml of water.
Dinner : 1 pc. Fried tilapia, cup of rice, & 240 ml of water.
Dinner : cup of rice and 1 serving of pinakbet & 240 ml of water
Lunch : 2 tablespoon of rice, cup of tinolang manok soup, and 120 ml of water. Dinner : 2 tablespoon of rice, cup of tinolang manok soup, and 120 ml of water.
Prior to her illness the patient drinks about 240-480 ml of water every day. She eats 3 times a day. She has no diet restrictions or any eating discomforts. She is fond eating fried foods, salty and fattyfoods, fruits and vegetables. She often eats in fast-food chain. She doesnt have a complete set of teeth, and she has dentures.
Patient C often eat minimum amount of food, she usually eat soup and about 2 table spoon of rice. She also drink about 240 ml of water or less.
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3. ELIMINATION PATTERN
URINE FREQUENCY CHARACTERISTICS AMOUNT Voiding 2-3 times a Odor: Aromatic 700-800 day Color: Yellow amber ml a day STOOL Defecating FREQUENCY Once a day COLOR and ODOR Brown Foul odor CONSISTENCY Formed
URINE FREQUENCY CHARACTERISTICS AMOUNT Voiding With foley Odor: Aromatic 2500-3000 catheter Color: Yellow amber ml a day STOOL Defecating FREQUENCY -COLOR -CONSISTENCY --
The patients elimination is greatly affected by her condition, she hasnt defecated yet for five consecutive days, the patients urine increases. The patient has a foley catheter The patient usually defecates in early morning everyday and inserted and was urinating yellow amber urine because of the her stool is formed and brown in color with foul odor. She diuretic mannitol prescribed to her, to decrease cerebral does not have any discomfort in defecating. She urinates 2-3 edema. times a day including 2 times at night and her urine is yellow amber in color and with aromatic odor. She does not have any problem in controlling her urination and doesnt have any discomfort urinating. She does perspire too much especially when she was doing household chores. And she has body odor.
4. ACTIVITY-EXERCISE PATTERN
Level 0 Full self-care Level I Requires use of equipments or device Level II Requires assistance or supervision of another person Level III - Requires assistance or supervision of another person or
Perceived ability Feeding Dressing Home Maintenance Bathing Grooming Toileting General Mobility Cooking
Level 0 0 0 0 0 0 0 0
Perceived ability Feeding Dressing Home Maintenance Bathing Grooming Toileting General Mobility Cooking
Level 2 2 N/A 2 2 2 3 N/A
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device Level IV Dependent and does not participate
Bed Mobility Shopping
0 0
Bed Mobility Shopping
3 N/A
The patient has sufficient energy to complete the activities of The client does not have sufficient energy for completing her desired activities. Her level of being dependent lies on daily living like eating, toileting, taking a bath, dressing up, leisure things which the patient verbalized as a form of her grooming, cooking, washing the dishes, and cleaning the relaxation like watching television house . Doing household chores is her form of exercise. Her ways of relaxation are watching television, and sleeping.
5. SLEEP-REST PATTERN
DAY
SLEEPING TIME 11 pm 12 pm 12 pm 12 pm 12 pm 1 am 12 pm
WAKE UP TIME 5 am 5 am 5 am 5 am 5 am 5 am 5 am
January 15, 2011 January 16, 2011 January 17, 2011 January 18, 2011 January 19, 2011 January 20, 2011 January 21, 2011
TOTAL OF SLEEP A DAY 6 hours 5 hours 5 hours 5 hours 5 hours 4 hours 5 hours
In the hospital, the client cannot sleep continuously, she cant even sleep at a span of 4 hours. She is having hard time to sleep because she is worrying about her stay in the hospital. She thinks that her condition will get better if shes in their house rather than in the hospital.
The patient normally sleeps 5 hours a day. From 12 pm to
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5am. She usually sleeps 4-6 hours a day. Her sleep is not continuous especially when she is tired and she does have problem in falling asleep. Sometimes until 1am she is still awake in watching television. She does not take any sleep medications. The patient doesnt take a nap during afternoon. She watches television as her form of relaxation.
6. COGNITIVE-PERCEPTUAL PATTERN
The patient has a visual problem but she doesnt have hearing difficulty. She wears an eyeglass with a grade of 175, but according to her she only bought it to a street vendor and it is not the appropriate grade of eyeglass for her. According to her she easily learns things when it is being demonstrated. If she feels any discomfort or pain she usually takes medication to relieve it like mefenamic acid. The client feels good about her self most of the time. She is a self-centered person. She thinks about her family sayings and doesnt care what other people might think of her. As much as possible she tries not to be angry. The client lives with her mother and 4 children with her livein partner. She had a second husband after her 1st husband died. She belongs to an extended family. They handle usual family problems by talking about it. She does not belong to any social group but she has close friends whom she can talk to and is in good terms with their neighborhood. The client doesnt usually share her circumstances. When
Still she does have a visual difficulty/ problem. She is wearing an eyeglass with inappropriate grade for her eyes because she doesnt go for an eye specialist for check-up.
7. SELF-PERCEPTION AND SELFCONCEPT PATTERN
When she was admitted to the hospital she often thinks where to get money to pay/financial assistance and billings for her hospitalization. The patient verbalized that her live-in partner is with her most of the time. Her partner and her eldest son are the ones who provide all her needs during hospitalization.
8. ROLE-RELATIONSHIP PATTERN
9. COPING-STRESS TOLERANCE
The client says that, she is worried about her hospitalization
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PATTERN
they have big problems, she and her partner are talking about it to find ways to solve it, and most of the time they were able to solve it. The patient had her first menstruation when she was 15 years old, she has a 28-day cycle of menstruation that lasts for 5 days. She consumes 2-3 pads a day. She had her last menstruation at the age of 48. She had her first sexual intercourse when she was 17 years old. Patient CC is T-7, P-0, A-0, and L-7. She has 7 term births, no premature births, no abortion, and 7 living children. The client says, she does not get the things she likes out of her life. Religion is important to her and believes that it helps when difficulties arise. She also asks God for her and her familys good health.
because of financial matters.
10. SEXUALITY AND REPRODUCTIVE PATTERN
She and her partner dont have sexual intercourse. There is an abstinence during hospitalization.
11. VALUE-BELIEF PATTERN
The client prays for her condition and her familys health. Also on how they can pay for the hospital bills. She believes in God and has a strong faith. According to her, God can help her whenever she has a problem.
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GROWTH AND DEVELOPMENT
Freuds Five Stages of Development

STAGE CHARACTERISTICS SIGNIFICANT BEHAVIOR
Genital(last stage)
Energy is toward full sex maturity and function and Patient C falls under this stage because of his age. development of skills needed to cope with the In her age of 52, She is mature enough to assume her role as a housewife. environment. This is a stage of maturity and creation and enhancement of life. So this is not just about creating new life (reproduction) but also about intellectual and artistic creativity. The task is to learn how to add something constructive to life and society. This is the person who has worked it all out. This person is psychologically welladjusted and balanced. According to Freud to achieve this state you need to have a balance of both love and work.
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Eriksons Eight Stages of Development STAGE Integrity vs. Despair (old adult) CHARACTERISTICS the significant relations during this stage is the mankind or my kind the psychological virtues that must be achieve during this stage is Wisdom SIGNIFICANT BEHAVIOR Client C falls under this stage because of his age, at this time of her life shes trying to correct her mistakes in the past. She tries to contemplate her accomplishments. She is contented in her life and never regret with her mistakes in the past.
Piagets Phases of Cognitive Development PHASES AND STAGES Formal Operation Phase(11years old to adulthood) CHARACTERISTICS logically resolves all types of problems(including complex problems) thinks scientifically cognitive structures mature SIGNIFICANT BEHAVIOR Patient C falls under this stage because of her age. She can now solve problems together with her family. She is mature enough in terms of handling problems and the way she thinks.
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Kohlbergs Stages of Moral Development LEVEL Post conventional morality CHARACTERISTICS The person lives autonomously and defines moral values and principles that are distinct from personal identification with group values. She/he lives according to principles that are universally agreed on and that the person considers appropriate for life. SIGNIFICANT BEHAVIOR Patient C knows her social roles and she doesnt want to be stagnant because of her present condition. She makes sure that everything she do is in line with the rules and will not affect the society.
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REVIEW OF ANATOMY AND PHYSIOLOGY

The Central Nervous System Brain
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NERVOUS SYSTEM The nervous system is a network of specialized cells that communicate information about an organism's surroundings and itself. It processes this information and causes reactions in other parts of the body. It is composed of neurons and other specialized cells called glial cells (plural form 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 processes and conducts signals back to the muscles and glands. Nervous tissue is composed of two main cell types: neurons and glial cells. Neurons transmit nerve messages. Glial cells are in direct contact with neurons and often surround them. The neuron is the functional unit of the nervous system. Humans have about 100 billion neurons in their brain alone. While variable in size and shape, all neurons have three parts. Dendrites receive information from another cell and transmit the message to the cell body. The cell body contains the nucleus, mitochondria and other organelles typical of eukaryotic cells. The axon conducts messages away from the cell body. CENTRAL NERVOUS SYSTEM The nervous system is your body's decision and communication center. The central nervous system (CNS) is made of the brain and the spinal cord and the peripheral nervous system (PNS) is made of nerves. Together they control every part of your daily life, from breathing and blinking to helping you memorize facts for a test. Nerves reach from your brain to your face, ears, eyes, nose, and spinal cord... and from the spinal cord to the rest of your body. Sensory nerves gather information from the environment, send that info to the spinal cord, which then speed the message to the brain. The brain then makes sense of that message and fires off a response. Motor neurons deliver the instructions from the brain to the rest of your body. The spinal cord, made of a bundle of nerves running up and down the spine, is similar to a superhighway, speeding messages to and from the brain at every second. The brain is made of three main parts: the forebrain, midbrain, and hindbrain. The forebrain consists of the cerebrum, thalamus, and hypothalamus (part of the limbic system). The midbrain consists of the tectum and tegmentum. The hindbrain is made of the cerebellum, pons and medulla. Often the midbrain, pons, and medulla are referred to together as the brainstem.
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Anatomy and Physiology of the Brain The BRAIN The brain is divided into the cerebrum, cerebellum, and the brain stem. At the base of the skull is the foramen magnum, an opening through which the spinal cord forms a continuous connection with the brain. The brain has 3 coverings. They are the pia mater (the innermost layer), the arachnoid (the middle), and the dura mater (the outermost, tough layer). Pia is directly continuous with the brain and spinal cord. It is a vascular layer through with blood vessels pass to the internal central nervous system (CNS) to nourish the neural tissue. The area between the pia and the avascular arachnoid is the subarachnoid space, and it contains the cerebral arteries. The dura is composed of two layers; the inner most is referred to as the meninges. The brain contains gray matter and white matter. Gray matter is external and the myelinated white matter is internal. CEREBRUM The cerebrum is the largest part of the brain and is divided into 2 hemispheres and consists of 4 lobes: frontal, parietal, temporal, and occipital. On its surface, or cortex, are located the centers from which motor impulses are carried to the muscles and to which sensory impulses come from the various sensory nerves. It contains an area in its inner core referred to as the thalamus. The thalamus is composed of 2 ovoid structures and is an important relay station in the brain. All the main sensory pathways form synapses with the thalamic nuclei on their way to the cerebral cortex. These pathways also serve as vehicles for transmitting pain, emotions, etc. The location of specific functions within the brain is related to the concept of complementary specialization. The cerebral hemisphere associated with language comprehension skills and sequential analytic processes is referred to as the categorical hemisphere. This was previously referred to as the dominant hemisphere; however, the other cerebral hemisphere is not considered to be nondominant, it just has a different type of specialization. The other hemisphere focuses primarily on recognition of faces, music, and visual spatial relationships; therefore, it is referred to as the representational hemisphere. For approximately 96% of right-handed individuals, the left hemisphere is the categorical hemisphere. Thus, the left hemisphere contains areas for language comprehension (Wernicke's area) and speech and word formation (Broca's area). Injury to this hemisphere is associated with language disorders. CEREBELLUM AND BRAIN STEM The cerebellum regulates coordinated activities such as gait and performance of motor tasks. The brain stem includes the midbrain, pons, and medulla oblongata. The midbrain connects the pons and the cerebellum with the cerebral hemispheres. The cerebellum is located below and behind the cerebrum. The pons is located in
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front of the cerebellum between the midbrain and the medulla. It serves a bridge between the 2 halves of the cerebellum as well as between the medulla and the cerebrum. It contains important centers for controlling the heart, respiration, and blood pressure and gives rise to 4 cranial nerves. CEREBRAL CORTEX Cells appear quite similar, but functions will vary depending on their location within the cortex. There are 4 lobes: frontal, parietal, occipital, and temporal. The frontal lobes are thought to contain areas associated with emotional attitudes and the development of thought processes. Nerve fibers from all portions of the cortex converge in each hemisphere and make their exit in the form of tight bundles ("internal capsule"). These cross the corresponding bundle from the opposite side; therefore, a right stroke means left-sided weakness. Cerebrospinal Fluid Each cerebral hemisphere has a central cavity, a ventricle that is filled with clear cerebrospinal fluid. It traverses from the ventricle through narrow tubular openings to the subarachnoid space to bathe the entire surface of the brain and spinal cord. The average amount of cerebrospinal fluid (CSF) is 150 mL. Neural Tissue NEURONS The neuron is the structural, genetic, and functional unit of the nervous system and is composed of cell bodies, dendrites, and axons. The cell bodies are located in layers on the surface of the brain, or cortex, and comprise what is referred to as gray matter. The neurons contain intracellular structures found in many cells, such as the nucleolus, microtubules, golgi apparatus, and rough endoplasmic reticulum. Intracellular structures specific for neurons include neurofilaments, synaptic vesicles, and Nissl substance. Neurons use glucose as their energy source and are dependent on oxidative metabolism. They produce and release neurotransmitters. Neurotransmitters are chemicals synthesized in the neurons that are stored in synaptic vesicles in the axon terminals. They are released from the axon terminal by exocytosis and are also reabsorbed and recycled. These chemicals cause changes in the cell permeability of neuron, making it more or less able to conduct an impulse.
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NEUROGLIA Neuroglia are the supporting cells for the neurons of the CNS, whereas Schwann cells have this function in the peripheral nervous system (PNS). The neuroglia comprise about 40% of the brain and spinal cord. They outnumber the neurons approximately 4 to 1. Four distinct neuroglia cell types have been identified: microglia, ependyma, astroglia, and oligodendroglia. Microglia have phagocytic properties to ingest and digest tissue debris. They are found throughout out the CNS and are also believed to have a role in fighting infection. Ependyma line the ventricular system and are involved in the production of CSF. Oligodendroglia are the glial cells responsible for myelin production within the CNS. Astroglia (astrocytes) are located between blood vessels and neurons, possibly controlling movement of macromolecules between the blood, CSF, and brain as the blood-brain barrier. When there is death of neurons due to injury, astrocytes proliferate and fill in the space formerly occupied by the nerve cell body and its processes. This activity is known as replacement gliosis. MYELIN Myelin is a white lipid-protein complex that provides insulation along a nerve process. It prevents the flow of sodium and potassium ions across the neuronal membrane almost completely where it is present. Within the CNS, nerve fibers with myelin sheaths are found within the white matter. Fibers that have no myelin are found within the gray matter.
Cerebral Circulation The CNS, like all body tissue, is dependent upon an adequate blood supply for its nutrients and for removal of metabolic waste products. The arterial blood supply to the brain is complex. However, an understanding of blood flow enables some correlation of area of injury with symptoms. CAROTID ARTERIAL SUPPLY On the right, the brachiocephalic trunk (innominate) artery divides into the right common carotid and the right subclavian. On the left, the left common carotid and left subclavian arteries each arise directly from the aortic arch. There are both internal and external carotid arteries that branch off from the common carotids at about the level of the thyroid gland (carotid sinus). The carotid sinuses respond to changes in arterial blood pressure to reflexively maintain blood supply to the brain and the rest of the body. The external carotids branch off into vessels that supply the face. The internal carotids enter the skull and divide into the anterior and middle cerebral arteries. The middle cerebral arteries are considered to be continuations of the internal carotid arteries
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VERTEBRAL-BASILAR ARTERIAL SUPPLY Right and left vertebral arteries originate from the subclavian arteries of their respective sides. The vertebrals enter the skull via the foramen magnum. At the level of the brainstem, they fuse to form the basilar artery. This continues to the level of the midbrain where it branches to form the posterior cerebral arteries. CEREBRAL ARTERIES Cerebral arteries are classified as either penetrating or conducting. The conducting arteries form an extensive network over the surface of the brain. The penetrating arteries are nutrient vessels that are derived from the conduction arteries. They enter the brain at right angles and provide the blood supply for the deep cerebral structures. ARTERIAL CIRCLE OF WILLIS The internal caro-tids and the vertebral-basilar arteries are 2 separate systems delivering blood to the brain. They do however, unite to form the crcle of Willis through a specialized system of communicating arteries. There is usually only slight blood flow through these arteries; however, they serve as a fail-safe mechanism in case of dramatic changes in arterial blood pressure. Collateral circulation may gradually develop when there is an alteration in normal blood flow. Most cerebral collateral circulation is between major arteries via the circle of Willis
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PHYSICAL ASSESSMENT
Name: Patient CC Age: 52 y/o Gender: Female
AREAS TO BE ASSESSED y Vital Signs 1. Body Temperature 2. Pulse Rate 3. Respiratory Rate 4. Blood pressure
METHOD
NORMAL FINDINGS
ACTUAL FINDINGS
REMARKS
Inspection (use of thermometer) Inspection, Palpation Inspection Inspection
36.5-37.5 C 80(60-100) beats/min 18(12-20) cycles/min 120/80 mmHg
36.7 C 96 beats/min 21 cycles/min 130/90 mmHg
NORMAL NORMAL NORMAL NORMAL (the client was considered having a normal blood pressure of 130/90)
A. General Survey 1. Body built, height and weight Inspection
Underweight = <18.5 Normal weight = 18.524.9 Overweight = 25-29.9 Obesity = BMI of 30 or greater
Endomorph 49 59 kg BMI: 28.15 THE PATIENTS WEIGHT IS INAPPROPRIATE TO HER HEIGHT.
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2. Posture and gait, standing, sitting and walking 3. Overall hygiene and grooming Body and breathe odor
Inspection
Relaxed, erect posture, coordinated movement
Cant walk , cant stand, and cant sit without assistance
DUE TO WEAKNESS AND CONTRALATERAL HEMIPLEGIA DUE TO INABILITY TO PERFORM SELF CARE AND LESS PRIVACY DUE TO INABILITY TO PERFORM SELF CARE AND LESS PRIVACY DUE TO PAIN PRESENT ON RIGHT ARM AND HEADACHE DUE TO PAIN PRESENT ON RIGHT ARM, HEADACHE AND CONTALATERAL HEMIPLEGIA NORMAL NORMAL DUE TO CONTRALATERAL HEMIPLEGIA
Inspection
Clean, neat
Unclean nails and unkempt hair
4.
Inspection 5. Signs of distress ,in posture or facial expression 6. Obvious signs of health or sickness
No body odor ,no breath odor
With breath and body odor
Inspection
No distress
With distress
Inspection
Healthy appearance
weak in appearance
7. Attitude 8. Affect/mood, appropriateness of responses 9. Quantity and quality of speech B. Integumentary 1. Skin
Inspection Inspection
Cooperative Appropriate to situation Understandable, moderate pace
Cooperative Appropriate speech is slightly not understandable and has disassociation of thoughts
Inspection
Inspection, Palpation
Generally uniform in color brown and uniform in color; no edema; with DUE TO DECREASE except for areas most expose mole on the lower right eye; skin springs back to CIRCULATION ON THE to sun, no edema, no lesions, previous state; LEFT SIDE OF THE
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2. Nails
3. Skull
4. Hair and Scalp
5. Face
warm to touch, moisture on BODY skin folds and when pinched cold to touch in the left side should spring back to previous state Nail curvature is convex; pink DUE TO DECREASE Nail curvature is convex, smooth texture; nail bed nail bed; blood brings back CIRCULATION IN THE is slightly pale in color ; capillary refill of 4 Inspection, Palpation after performing a blanch test LEFT SIDE OF THE seconds of less than 3 seconds BODY Normocephalic; symmetric; Small, rounded with smooth skull contour; no Inspection, Palpation no nodules and depressions; NORMAL nodules, masses noted ; no tenderness no tenderness Thick and resilient hair, Hair evenly distributed to the scalp; thick hair; evenly distributed; scalp must scalp is white in color and no redness; no Inspection, Palpation be white in color and have no NORMAL tenderness or masses on the scalp; oily; no signs redness, rashes, lice, nits, or of infestation dandruff Facial movements are DUE TO symmetric; symmetric or CONTRALATERAL Inspection asymmetrical facial features slightly symmetric facial HEMIPLEGIA features Hair evenly distributed; skin intact; symmetrically aligned; equal movements Evenly distributed; downward Inspection or outward curl Bulbar: transparent: Inspection, Palpation capillaries sometimes present Palpebral: shiny and smooth Inspection DUE TO CONTRALATERAL HEMIPLEGIA NORMAL DUE TO DECREASE CIRCULATION IN THE LEFT SIDE OF THE
C. Eyes 1. Eyebrows Hair evenly distributed and properly aligned; intact skin; asymmetric movements Evenly distributed; curled slightly outward Bulbar: transparent: capillaries are present Palpebral: shiny and smooth ; pale palpebral conjunctiva
2. Eyelashes 3. Bulbar and Palpebral Conjunctiva
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BODY 4. Sclera 5. Cornea 6. Iris 7. Pupil Inspection 8. Lacrimal Gland 9. Extraocular Muscles 10. Visual Fields 11. Visual acuity D. Ears 1. Auricle Color same as the facial skin; symmetrical; aligned with the Inspection / Palpation outer canthus of the eyes; pinna recoils after it is folded Inspection Inspection E. Nose 1. Nasal Septum 2. Patency of Airways Inspection Palpation Nasal septum intact and Nasal septum intact and in midline midline Air moves freely in and out of Air moves freely in and out of the nasal cavities NORMAL NORMAL Uniform in color same with the facial skin; aligned with outer canthus of the eyes, pinna recoils after it is folded NORMAL NORMAL NORMAL Inspection/ Palpation Inspection Inspection Inspection Inspection White Transparent Round; dark in color and flat Black in color, equal in size and round; reactive to light and accommodation No edema or tearing Coordinated movement The client can see the object in periphery Able to read newsprint White Transparent Round; dark in color and flat Reactive to light and accommodation; black in color, round and smooth No nodules, masses, and lesions; no tenderness Coordinated movement and in good alignment The client can see the object in periphery Unable to read newsprint without reading glass NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL
2. External Ear Canal 3. Hearing Acuity
No discharges With presence of earwax Normal voice tone audible; Respond normally to normal voice tone; was able able to hear ticking of watch to hear the ticking of watch on both ears
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the nasal cavities 3. Sinuses F. Mouth 1. Lips 2. Buccal Mucosa 3. Teeth 4. Gums 5. Tongue 6. Uvula 7. Tonsils Inspection 8. Gag reflex G. Neck and Lymph Nodes 1. Lymph Nodes 2. Trachea 3. Thyroid Gland H. Thorax 1. Posterior and Anterior Inspection/ palpation / Symmetric; ratio of 1:2 to the Symmetric; ratio of 1:2 to the anteroposterior NORMAL Inspection/ palpation Inspection/ palpation Inspection/ palpation No swollen lymph nodes; No tenderness and masses Midline of the neck Lobes are not palpable No swollen lymph nodes; No tenderness and masses Located midline in neck No visible masses or enlargement NORMAL NORMAL NORMAL Inspection Inspection Inspection Inspection Inspection / Palpation Inspection/ palpation Inspection Uniform in color, soft, moist, smooth in texture Lips are dry and slightly pale in color DUE TO DECREASE FLUID INTAKE DUE TO SMOKING DUE TO AGING PROCESS NORMAL NORMAL NORMAL NORMAL NORMAL Palpation Not tender No noted tenderness NORMAL
Uniform pink color Pale in color Smooth, shiny, white teeth 18 adult teeth, yellowish, no dentures but with enamel; 32 adult teeth presence of plaque Pink gums, smooth and firm gums, smooth and firm texture texture Central position, pink color, Pink in color ; Has raised papillae moves freely Uvula vibrates when Uvula vibrates when speaking; midline position speaking; midline position Pink and smooth, no Pink and smooth, no discharge, normal size or not discharge, normal size or not visible visible Present Present
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Thorax
Auscultation
I. Breast Inspection, Palpation
J. Abdomen UPPER EXTREMETIES 1. Motor strength
Inspection, palpation
anteroposterior part; spine part; no tenderness; equal respiratory excursion; vertically aligned; no Without adventitious breath sounds. tenderness; equal respiratory excursion; bilateral vocal fremitus; no abnormal breath sounds Rounded shape, slightly unequal in size; generally Moderate in size; areola is big and round, dark symmetric; skin uniform in brown in color; nipples are round and everted ; color, smooth and intact; both breast are soft and warm; sagged breast; skin round and everted nipple; uniform in color; stretched marks visible discharges are present Unblemished skin, uniform Unblemished skin, uniform color color
NORMAL
NORMAL
Inspection 2. Muscle Tone Palpation 3.Presence of lesions, deformities and varicosities LOWER EXTREMITIES 1. Motor strength Inspection
Equal strength on each body side Normally firm No lesions; no deformities; no tenderness;
Weakness on the left side of the body
Not firm muscle tone on the left side of the body
DUE TO CONTRALATERAL HEMIPLEGIA DUE TO CONTRALATERAL HEMIPLEGIA NORMAL
Inspection
No lesions; no deformities; no tenderness;
Equal strength on each body side
Weakness on the left side of the body
DUE TO CONTRALATERAL HEMIPLEGIA
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2. Muscle Tone Palpation 3. Presence of lesions, deformities and varicosities Normally firm No lesions; no deformities; no tenderness; no edema
DUE TO PARALYSIS ON Not firm muscle tone on the left side of the body THE LEFT SIDE OF THE BODY No lesions; no deformities; no tenderness; no edema NORMAL
Inspection
MUSCULOSKELETAL SYSTEM Muscles 1. Inspect for the muscles size. 2. Muscle tonicity Inspection Equal strength on each body side Normally firm Unequal, right is much larger than left DUE TO CONTRALATERAL HEMIPLEGIA DUE TO CONTRALATERAL HEMIPLEGIA BODY
Inspection
Decreased muscle tone on the left side of the body
Bones 1. Structures and deformities of the skeleton RANGE OF MOTIONS 1.Upper Extremities Observation Painless, Effortless No pain, weakness at left side of the body DUE TO CONTRALATERAL HEMIPLEGIA DUE TO CONTRALATERAL HEMIPLEGIA Inspection Normally firm No deformities NORMAL
2.Lower Extremities
Observation
Painless, Effortless
No pain, weakness at left side of the body
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SIGNIFICANT FINDINGS Endomorph Cant walk , cant stand, and cant sit without assistance appropriate, sometimes disoriented With distress weak in appearance Unclean nails, unkempt hair With breath and body odor speech is slightly not understandable and has disassociation of thoughts cold to touch on the left side of the body Delayed capillary refill (4 seconds) asymmetrical facial features asymmetric movements pale palpebral conjunctiva The client cant see the object in periphery Lips are dry and slightly pale in color Weakness on the left side of the body Decreased muscle tone on the left side of the body
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PATHOPHYSIOLOGY
A. Schematic Diagram
Patient CC, 52 y/o Non Modifiable Factors: Age Heredity/ Genetics Modifiable Factors: Overweight (BMI of 28.15) High fat diet High salt diet Smoking 12-15 sticks/day (36y/o started)
y y
y y y y
Lipid deposits and turbulent blood flow in intima arterial cerebral wall Damage of arterial wall Inflammatory response Ingestion of lipids Atheroma formation Narrowing of arterial lumen Plaque ruptures Thrombosis
Occlusion of cerebral artery Vascular wall becomes weakened or fragile Leaking of blood from the fragile vessel wall Cerebral hemorrhage Mass of blood forms and proliferates Closure of tissue and arteries Cerebral hypoperfusion Impaired distribution of oxygen and glucose Tissue hypoxia and cellular starvation Cerebral ischemia Decreased oxygen supply Stimulation of mitochondria Production of Lactic acid
Narrowing of blood vessel Decreased capacity of the vessel to carry blood components Increased cardiac load Increased pressure in the blood vessel Hypertension
Dizziness
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Local acidosis Anaerobic environment Decreased production of ATP by neurons Decreased depolarization Increased cellular death ACUTE TO SUB-ACUTE ISCHEMIC INFARCTION at the Right temporal and parietal lobes attenuated
CT SCAN Result
Frontal horn, occipital horn, body of lateral ventricles appear attenuated
Interruption in transportation of electrical impulses to the neuromuscular receptors Contralateral hemiparesis and hemiplegia on the left side of the body Numbness of the left side of the body Decreased muscle tone Weakness of the left side of the body 35
Paralysis on the left side of the body Slight slurred speech Loss of coordination and balance
B. Definition of the Disease Ischemic stroke occurs when an artery to the brain is blocked. The brain depends on its arteries to bring fresh blood from the heart and lungs. The blood carries oxygen and nutrients to the brain, and takes away carbon dioxide and cellular waste. If an artery is blocked, the brain cells (neurons) cannot make enough energy and will eventually stop working. If the artery remains blocked for more than a few minutes, the brain cells may die. The most common problem is narrowing of the arteries in the neck or head. This is most often caused atherosclerosis, or gradual cholesterol deposition. If the arteries become too narrow, blood cells may collect and form blood clots. These blood clots can block the artery where they are formed (thrombosis), or can dislodge and become trapped in arteries closer to the brain (embolism). Another cause of stroke is blood clots in the heart, which can occur as a result of irregular heartbeat (for example, atrial fibrillation), heart attack, or abnormalities of the heart valves. While these are the most common causes of ischemic stroke, there are many other possible causes. Examples include use of street drugs, traumatic injury to the blood vessels of the neck, or disorders of blood clotting. The common signs and symptoms of stroke are trouble with walking, stumble or experience sudden dizziness, loss of balance or loss of coordination. Trouble with speaking and understanding. You may experience confusion. Slur of words or be unable to find the right words to explain what is happening to you (aphasia). Paralysis or numbness on one side of your body or face. It may develop sudden numbness, weakness or paralysis on one side of your body. Trouble with seeing in one or both eyes. Suddenly have blurred or blackened vision, or may see double. Also headache were a sudden, severe "bolt out of the blue" headache, which may be accompanied by vomiting, dizziness or altered consciousness, may indicate you're having a stroke. B. Modifiable and Non-modifiable Factors C.1. Non-modifiable Factors Age- the risk for stroke increases at one gets older because of the slow degeneration of cells in the body causing different complications Heredity- The risk of having a stroke is higher for people whose parents or siblings have had a stroke C.2. Modifiable Factors 36
Overweight leads to inadequate energy consumption. Thus the energy provided by the food we eat exceeds our daily body requirement that leads to increase in fat content of the body and results in weight increase thus giving way to other body complications. Excess weight can double the risk of an ischemic stroke High Fat Diet- increase fat diet, increase risk of hypertension and stroke due to decrease energy consumption High Salt diet- increase salt/sodium diet increase risk of hypertension due to increase blood volume Smoking - Tobacco use, whether it is smoking or chewing tobacco, increases risks of hypertension and stroke. The risk is especially high if you started smoking when young. The risk of stroke is two to three times greater for smokers versus nonsmokers.
D.Signs and Symptoms of the Condition
SIGNS AND SYMPTOMS Dizziness Loss of balance or coordition
RATIONALE Due to decrease oxygen supply in the brain Due to decrease oxygen supply in the brain, numbness and weakness of the left side of the body
Due to loss of function on the right hemisphere of the brain which affect the left side of the body Due to decrease muscle tone of the body
DATE OF OCCURENCE January 22, 2011 January 22, 2011
Contralateral hemiplegia
January 22, 2011
Hemiparesis
January 22, 2011
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REVIEW OF SYSTEMS SYSTEM

y SPECIAL SENSES (Eyes, Ears, Nose, Tongue) SIGNIFICANT FINDINGS Pale palpebral conjunctiva
y Lips are dry and slightly pale in color
y NERVOUS SYSTEM y
Hypoperfusion -- shortage of the blood supply due to factors in the blood vessels, with resultant damage or dysfunction of tissue. Contralateral hemiplegia- paralysis on the left side of the body Muscle weakness, decrease muscle function and sensation on the left side of the body Posture instability, decrease bone function on the left side of the body Decreased muscle tone on the left side of the body Hypertension high blood pressure (elevation of arterial blood pressure above the normal range
y MUSCULOSKELETAL SYSTEM y y y
CIRCULATORY SYSTEM
GASTROINTESTINAL SYSTEM
Constipation
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LABORATORY RESULTS
Diagnostic Laboratory Procedure
Date Ordered and Date Result
Indications or Purpose
Result
Normal Values (unit used in the Hospital)
Analysis and interpretatio n of the results
Nursing Responsibilities
HEMATOLOGY:
Gives valuable diagnostic confirmation about hematologic/other body systems, prognosis, response to treatment and recovery.
Hemoglobin
DO: January 22,2011 DR: January 22,2011
measures the amount of oxygen-carrying protein in the bloods Meausures the percentage of red blood cells in a given volume of whole blood Is used to evaluate any type of decrease or increase in the # of RBCs as measured by liter of blood
157 g/l
110-165 g/l
The result is within normal range
PRIOR: >Verify the doctors order. >Explain the procedure to patient >Tell the patient that a blood sample will be taken. >Tell the patient slight discomfort may be felt when skin is punctured
Hematocrit
.488 l/l
.350-.500 l/l
RBC
5.11 x1012/l
3.80-5.80 x1012/l
DURING: > Collect a venous sample according to the protocol of the laboratory. >Transport time for culture specimen must be minimized. >Handle specimen carefully. 39
WBC Count
maintained at a stable number until the immune system detects the presence of a foreign invader
14.6 x109/l
3.5-10.0 x109/l
The result is above the normal range This indicates bacterial infection
Lymphocytes
Indicates the amount of lymphocytes participating with macrophages at a site of a local injury.
36.1 %
17.0 48.0 %
AFTER: > Apply manual pressure/dressing to the punctured site in removal of needle > Monitor punctured site for bleeding and signs of infection >Document the time, date and the procedure. >Inform them that the results will be out as soon as the specimen is interpreted in the laboratory.
Granulocyte
Indicates raised in bacterial infection
64.1 %
43.0 76.0 %
Platelet Count
Measures clotting potential
230 x109/l
150 390 x 109/l
MCH (mean corpuscular hemoglobin)
Is a calculation of the average amount of oxygen-carrying hemoglobin inside a red blood cell
30.8 pg
26.5 33.5 pg
40
MCV (mean corpuscular volume)
is a measurement of the average size of your RBCs
96 fl
80 97 fl
MCHC DO: January 22,2011 (mean DR: January 22,2011 corpuscular hemoglobin concentration ) RDW DO: January 22,2011 DR: January 22,2011
is a calculation of the average concentration of hemoglobin inside a red cell
322 g/l
315 350 g/l
Measures the different sizes and shapes of the red cell
12.7 %
10.0 15.0 %
MPV
Reflects the average volume of platelets
9.7 fl
6.5 11.0 %
PDW
Determine the size of the platelets and may indicate underlying disease such as thrombocytopenia
9.2 %
10.0 18.0 %
The result is below the normal range not necessarily indicate disease
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BLOOD CHEMISTR Y:
to assess for renal function
Glucose
This is a measurement of a blood sugar level
100.7 mg/dl
70 120 mg/dl
Uric acid
Is used to detect high levels of this compound in blood in order to help diagnose gout
3.6 mg/dl
2.5 6 mg/dl
PRIOR: >Verify the doctors order. >Explain the procedure and purpose of the test to the patient. >Tell the patient that a blood sample will be taken. >Inform the patient that she may feel some discomfort from the needle puncture and tourniquet. DURING: >Collect a venous sample according to the protocol of the laboratory. >Transport time for culture specimen must be minimized. >Handle specimen carefully. AFTER: >Apply pressure on the venipuncture site >Monitor for signs of infection. >Assess for bleeding. 42
Cholesterol
Used to estimate risk for developing a disease specifically heart disease
170.7 mg/dl
150 250 mg/dl
Trigliceride
Used to identify the risk of developing heart disease
84.4 mg/dl
35 135 mg/dl
HDL-C
Is used along with other lipid tests to screen for unhealthy levels of lipids and to determine the risk of developing heart disease
41 mg/dl
Greater than 35 mg/dl
LDL-C
Used either to assess a persons risk for heart disease or to follow response to therapy to lower cholesterol
112.9 mg/dl
Less than 150 mg/dl
>Document the time, date and the procedure.
Creatinine
with high BUN levels, may indicate problems with the kidney
0.9 mg/dl
0.5 1.7 mg/dl
Electrolytes:
Sodium
plays an important role in 142 mEq/dl the water/salt balance in your body
135 155 mEq/dl
Potassium
Determined for proper 3.89 mEq/dl fluid balance across the cell membrane which allows nerves to conduct electrical impulses and so communicate between cells and muscles to contract.
3.4 5.3 mEq/dl
Chloride
It helps monitor acidbase balance and water balance
111.2 mEq/dl
98 107 mEq/dl
The result is above normal range This indicates 43
dehydration or used of diuretics
URINALYSIS:
The urinalysis is used as a screening and/or diagnostic tool because it can help detect substances or cellular material in the urine associated with different metabolic and kidney disorders.
Color
Pigments may result Yellow from medications, dietary sources, or diseases.
Straw yellow to amber
PRIOR: >Verify the doctors order. >Explain to the patient the importance of the procedure. >The first morning sample is the most valuable because it is more concentrated and more likely to yield abnormal results >Assist the patient.
Transparency DO: January 22,2011 DR: January 23,2011
Determined the presence of blood cells, yeast, and bacteria
Turbid
transparent
Deviation from normal Due to presence of RBC in urine
Sugar
is used to monitor persons with diabetes
Negative
negative
DURING: >Provide privacy. >Advise the patient to catch the midstream of the urine. >Transport time for culture specimen must be minimized. >Handle specimen carefully
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Albumin
determining the presence of glomerular damage
Negative
negative
Reaction
This is a measure of acidity for your urine
Acidic
Acidic
AFTER: >Relay the results to the attending physician >Document all the necessary information like the time and date it was performed.
Specific Gravity
A measure of the ability of the kidneys to concentrate urine by conserving water.
1.030
1.005 1.040
RBC
Detects abnormal levels of either red cells or hemoglobin Determined kidney rather than lower urinary tract
3-5 HPF
0-3 HPF
The result is above normal range
Cast
Detects/indicate kidney disorder
few
few
EPITHELIA L CELLS
Identifies the kidneys, rather than the lower urinary tract.
few
few
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BACTERIA
few
few
CT scan (Computed tomography scan)
Used to define normal and abnormal structures in the body and/or assist in procedures by helping to accurately guide the placement of instruments or treatments.
-A hypodense focus is noted in the right temporal and parietal lobes, extending further through the vertex effacing the immediate and adjacent parenchyma -the ipsilateral frontal horn, occipital horn, and body of the lateral ventricles appear attenuated Impression: Acute to subacute ischemic infarct, right temporal regions, with signs of mass effect.
>Verify the doctors order. >Explain to the patient the importance of the procedure. >ask the patient to lie on a narrow table that slides into the center of the CT scanner (depending on the study being done) >advises patient in still preventing movement that may cause blurred vision. >special dye are used to creates clearer imagescheck for allergies >remove jewelries and wear hospital gown
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MEDICAL MANAGEMENT
Treatment Date ordered/ date performed/ date change or DC General description Indication and purposes Client response to treatment Nursing responsibilities
Oxygenation 3-4L/min via nasal cannula
Date ordered: January 22, 2011 Time: 2:30pm Date discontinue: January 25, 2011
Date ordered: January 22, 2011 Time: 2:30pm Date discontinue: January 25, 2011 Time: 1:00pm Oxygenation 3-4L/min via nasal cannula Oxygen therapy is a treatment in respiratory care. The purpose is to increase oxygen saturation in tissue where the saturation level are too low due to illness or injury
It deliver low concentration of oxygen (24% to 45%) at flow rate of 3-4L/min in this minimal oxygen is required.
The patient did not experience difficulty of breathing. y It increase the oxygen to the tissue to prevent hypoxia.
Prior y Assess the vital sign for the baseline. y Determine the need for oxygen therapy and verify the doctors ordered y Place cautionary signs reading NO SMOKING oxygen in use on the door at the foot of the bed. During y Monitor patient condition. y Frequently checked the humidifier. After y Check the patient nares and ears of any signs of irritation y Document the procedure performed 47
Treatment
Date ordered/ date performed/date change or DC Date ordered: January 22, 2011 Time: 2:30am Date changed: January 23, 2011
General description
Indication and purposes Used to replace fluids in dehydration go with blood transfusion, hyponatremia, and burn victim. y It is indicated as a source of water and electrolyte. y
Client response to the treatment Client remains free of signs and symptoms of dehydration
Nursing responsibilities
PNSS 1L x 25gtts/min + 3 amps neural B
Isotonic (same osmolarity as our body fluids. y Normal saline is a sterile nonpyrogenic solution for fluid and electrolyte replenishment. y
Prior y Assess vital signs for baseline y Check flow rate according to the doctors ordered y Identify the patient y Explain need for supplement to patient family and answer any question During y Monitor IV site for the sign of infiltration y Monitor the patient for the signs of mental confusion After y Monitor the patient for the sign of fluid over load (difficulty of breathing) y Monitor patient intake and output 48
Treatment
Date ordered/ date performed/date change or DC Date ordered: January 23, 2011 Time: 12:30am
General description
Indication and purposes
Client response to the treatment
D5NM x 25gtts/min
Hypotonic solution means have low concentration of solute.
Used to provide free water and treat cellular dehydration. y These solute promote waste elimination by the kidney
Client remains free of signs and symptoms of dehydration
Prior y Assess vital signs for baseline y Check flow rate according to the doctors ordered y Identify the patient y Explain need for supplement to patient family and answer any question During y Monitor IV site for the sign of infiltration y Monitor the patient for the signs of mental confusion After y Monitor the patient for the sign of fluid over load (difficulty of breathing) y Monitor patient intake and output 49
DRUG STUDY
Generic/Brand name GENERIC NAME: Baclofen HCL BRAND NAMES: Kemstro and Lioresal CLASSIFICAT ION: Muscle relaxant, antispastic Route, Dosage,Frequency 80mg PO O.D. Indications/Actions Contraindications Adverse Reactions Neuropsychiatric: Indications: y Baclofen is useful for the alleviation of signs and symptoms of spasticity resulting from multiple sclerosis, particularly for the relief of flexor spasms and concomitant pain, clonus, and muscular rigidity. Actions: y Precise mechanism not known;GABA analogue does not appear to produce clinical effects by actions on GABA-minergic systems; inhibits y y Contraindicate y d with allergy to baclofen; skeletal muscle spasm resulting from rheumatic disorders Use cautiously with stroke, cerebral palsy, Parkinsons disease, seizure disorders, lactation, pregnancy Confusion (1 to 11%), headache (4 to 8%), insomnia (2 to 7%); and, rarely, euphoria, excitement, depression, hallucinations, paresthesia, muscle pain, tinnitus, slurred speech, coordination disorder, tremor, rigidity, dystonia, ataxia, blurred vision, nystagmus, strabismus, miosis, mydriasis, diplopia, dysarthria, epileptic seizure. y Baclofen may cause drowsiness, y weakness, di zziness, head ache, seizures, nau sea, vomiting , low blood pressure, con stipation, con fusion, respiratory depression, i nability to sleep, and increased y urinary frequency or urinary retention. Assess muscle spasticity before and periodically during therapy Abrupt cessation may result in fever, mental status changes, exaggerated rebound spasticity and muscle rigidity. Advise patient not to miss scheduled refill appointments and to notify health care professional promptly if signs of withdrawal occur. Advise patient to repot signs and symptoms of hypersensitivity (rash, itching) promptly. Observe patient for drowsiness, dizziness or ataxia. May be alleviated by a change in dose. Decrease in muscle spasticity and musculoskeletal pain with an increase ability to perform activities of daily living. Side Effects Nursing Responsibilities
Cardiovascular:
50
both monosynaptic and polysynaptic spinal reflexes;CNS depressant.
Hypotension (0 to 9%). Rare instances of dyspnea, palpitation, chest pain, syncope.
Gastrointestinal: y Nausea (4 to 12%), constipation (2 to 6%); and, rarely, dry mouth, anorexia, taste disorder, abdominal pain, vomiting, diarrhea, and positive test for occult blood in stool.
Genitourinary: y Urinary frequency (2 to 6%); and, rarely, enuresis, urinary retention, dysuria, impotence, inability to ejaculate, 51
nocturia, hematuria. Other: y Instances of rash, pruritus, ankle edema, excessive perspiration, weight gain, nasal congestion. Some of the CNS and genitourinary symptoms may be related to the underlying disease rather than to drug therapy. The following laboratory tests have been found to be abnormal in a few patients receiving baclofen: increased SGOT, elevated alkaline phosphatase, and elevation of blood sugar.
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Generic name/ Brand name
Date ordered/Taken/Given/ Date change or DC Date ordered: January 22, 2011 Date taken/given: January 22, 2011 January 23, 2011 January 24, 2011 January 25, 2011 January 26, 2011
Route of administration/Dosag e/Frequency 75mg sublingual PRN Bp 160/90
General action/Classification/Me chanism of action y y Antihypertensive Stimulate alphaadrenergic receptors in the CNS which result in symphathetic outflow inhibiting vasoconstriction center. y Decreased blood pressure.
Client response to medication
Generic name: Clonidine hydrochloride Brand name: Catapres
Management of mild to moderate hypertension.
Nervousness, nausea, dizziness
Prior Checked the doctors ordered y Identified the patient y Checked the BP During y Instruct the client to place the medication under tongue After y Monitor BP and pulse frequently , report significant changes y Document the medication given y
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Date ordered/Taken/Given /Date change or DC Date ordered: January 22, 2011 Date given: January 22, 2011 January 24, 2011 January 25, 2011 January 26,2011
Route of administration/Dosag e/Frequency 750mg TIV q8h
General action/Classification/Me chanism of action y y Antibacterial Bind to bacterial cell wall membrane, causing cell death.
Generic name: Cefuroxime Brand name: Ceftin
Treatment of meningitis y Respiratory tract infection. y Skin structure infection. y
Diarrhea, nausea, cramps of legs
y y
Prior Checked the doctors ordered Identified the patient ANST done before giving the medication y Dilute cefuroxime according to hospital policy During Closed the IV flow before infuse the medication Administered slowly over 35min Checked IV site for infiltration After Documented the medication given. Regulate the IV drop on the same rate
54
Date ordered/Taken/Given /Date change or DC Date ordered/given: January 22, 2011 Date change of DC: January 22, 2011 January 25, 2011
Route of administration/Dosag e/Frequency 500mg tablet PO q4h Temp. 38C
General action/Classification/Me chanism of action y Antipyretic and analgesic y Inhibit the synthesized of prostaglandin that may severe as mediator of pain and fever primarily in CNS
Generic name: Parcetamol Brand name: Biogesic
Mild pain and fever
N/A
Prior Checked the doctor ordered y Checked the temperature During y Administered with full glass of water After y Document the medication given y
55
Date ordered/Taken/Given /Date change or DC January 22, 2011
Route of administration/Dosag e/Frequency Dosage: 23% 75cc Route: TIV Frequency/ q6h x 3days, 3-4tts/min Date given: January 24, 2011 January 25, 2011 January 26, 2011
General action/Classification/Me chanism of action y Osmotic diuretics Increased the osmotic pressure of the glomerular filtrate thereby inhibiting absorption of water and electrolyte. y Mobilization of excess fluid in oliguric renal failure or edema y Reduction of increase intracranial pressure y Increase urinary excretion of toxic materials. y
Generic Name: Mannitol Brand Name: Osmitrol
Adjunct in the treatment of edema and ICP
Headache, urinary retention and thirst
Prior Checked the doctors ordered y Identified the patient y Asses vital sign or any electrolyte imbalance y Insert FC as doctors ordered During y Observed infusion site frequently for infiltration y Regulated the gtt/min depend on the physician ordered y Monitor the vital sign, I/O of the patient throughout the administration y
After y Document
56
medication given y Laboratory test of serum electrolyte should be monitor routinely throughout the course of therapy.
57
Date ordered/Taken/Given /Date change or DC Date ordered: January 22, 2011 Date given: January 22, 2011 January 24, 2011 January 25, 2011 January 26, 2011
Route of administration/Dosag e/Frequency 50mg TIV q8h
General action/Classification/Me chanism of action y Antiulcer agent y Inhibition the action of histamine at the h2 receptor site located primarily in gastric parietal cells, resulting inhibition of the gastric acid secretion.
Generic name: Ranitidine Brand name: Zantac
Prophylaxi s of duodenal and gastric ulcer Treatment and prevention of heart burn, acid ingestion and sour stomach
Headache and dizziness
y y
Prior Checked the doctors ordered Identified the patient Checked the IV site During Close the IV flow before infuse the medication Administered the medication to IV slowly Checked again the IV site for sign of infiltration After Regulate again the IV on the same rate Document the medication given
58
Date ordered/Taken/Given /Date change or DC Date ordered: January 25, 2011
Route of administration/Dosag e/Frequency 10mg tablet BID
General action/Classification/Me chanism of action y Unknown. Produce antiinflammatory analgesic, and antipyretic effect, possibly by inhibiting prostaglandin synthesis.
Generic name: Ketorolac tromethamine Brand name: toadol
Date taken: January 25, 2011 January 26, 2011 Time: 8pm-6am
Manageme nt moderate severe, acute pain
Constipation, dizziness, nausea
Prior Checked the doctors ordered y Identified the patient During y Administered with full glass of water After y Document the medication given. y
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Treatment
Date ordered/Taken/Given /Date change or DC January 22, 2011
General description
Indication/purposes
Client response to treatment y Discomfort or pain during insertion y Urinary tract infection
Foley catheter
Urinary catheterization is introduction of a catheter through the urethra into the urinary bladder. This is usually performed only when absolutely necessary because the danger exist of introducing microorganisms in to the bladder.
y To relieve discomfort due to bladder distension or to provide gradual decompression of a distended bladder y To assess the amount of residual urine if the bladder empties in completely. y To obtain a urine specimen. y To facilitate accurate measurement of urinary output hourly
Prior Identify the doctors ordered y Explain the procedure to the client y Wash hands and done gloves y Provide privacy During y Test the balloon first if functional y Lubricate the catheter before inserting y Cleanse the meatus y Instruct the client to take deep breath y Collect urine specimen y Attach the drainage end to collecting tubing and bag After y Monitor the urine output per hour y Ask the relative to empty the bag y Document the procedure y
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NURSING CARE PLANS

PRIORITIZATION DIAGNOSIS PRIORITIZATION RATIONALE
Ineffective cerebral tissue perfusion related to vascular occlusion secondary to disease condition as evidenced by headache/dizziness
High
Ineffective tissue perfusion is included in circulation and is in the ABCs of life, thus in the high priority. It is the decrease in blood flow resulting in the failure to nourish the tissues at the capillary level.
Constipation related to insufficient physical activity secondary to stroke as evidenced by immobility
Medium
Next to the ABCs of life is the Maslows hierarchy of needs, constipation belongs to the physiological bracket and is the first level in the hierarchy. Elimination of the waste products of digestion from the body is essential to health.
Impaired physical mobility related to neuromuscular impairment as evidenced by weakness on the left side of the body
Medium
Impaired physical mobility also belongs to the physiological needs same as constipation. Decreased ability to perform activities of daily living interferes with the task to satisfy the physiologic needs of the body.
Health seeking behavior related to lack of knowledge in health promotion behaviors
Low
Health seeking behavior is included in the safety and security. It is in the second level in the Maslows hierarchy of needs thus, next to the physiologic needs. Security needs are important for survival, but they are not as demanding as the physiological needs.
61
Self care deficit in bathing/hygiene,dressing/grooming, feeding and toileting related to neuromuscular impairment secondary to cerebrovascular accident (CVA)
Low
Self care deficit is included in the self esteem,the fourth level of the Maslows Hierarchy of Needs. The Self esteem comes from within; it is related to the assessments of own adequacy,performance and capacity in the various arenas of live such as activities of daily living.
62
ASSESSMENT
DIAGNOSIS
SCIENTIFIC KNOWLEDGE
PLANNING
IMPLEMENTATION
RATIONALE
EVALUATION
SUBJECTIVE: Nahihilo at sumasakit ang ulo ko,as verbalized by the patient.
OBJECTIVE: y Headache y y Confusion Postural hypotension when getting up Hemiparesis
Ineffective Cerebral Tissue Perfusion related to vascular occlusion secondary to disease condition as evidenced by headache
high fat and high salt SHORT TERM diet,overweight, GOAL: smoking,age, heredity In 3-6 hours of nursing intervention Occlusion within the patient will be vessels or artery able to increase cerebral tissue intravascular perfusion as pressure evidenced by: 1. loss of headache Increased resistance to flow 2. demonstration of techniques/ scarring of vessel behaviors that enable increase in thrombus formation cerebral tissue perfusion emboli formation blocks the vessel in the brain stroke decreased oxygenation hypoxia In 1-2 days of nursing intervention the patient will be able to demonstrate cognition as LONG TERM GOAL:
INDEPENDENT: Position head slightly elevated and in neutral position. To reduce arterial pressure by promoting venous drainage and may improve cerebral perfusion. Continual stimulation of Central Nervous System can increase ICP. Increased ICP will further decrease cerebral blood flow. To determine cerebral oxygenation. Smoking causes vasoconstriction and may further compromise perfusion.
SHORT TERM GOAL: After 3-6 hours of nursing intervention, goals to increase cerebral tissue perfusion were: Met __ Partially met __ Unmet as evidenced by: 1. loss of headache
Provide quiet and restful environment.
Avoid measures that may trigger increased ICP. (ex: straining and positioning with neck on flexion) Monitor continuously for level of consciousness. Encourage client to quit smoking.
2. demonstration of techniques/ behaviors that enable increase in cerebral tissue perfusion
LONG TERM GOAL: After 1-2 days of nursing intervention goals for the patient to demonstrate cognition 63
DEPENDENT:
headache/dizziness
evidenced by: 1. attentiveness, concentration and cognitive orientation
were: Administer analgesics and diuretics as ordered. Administer supplemental oxygen as indicated. To provide pharmacological treatment to patient. To reduce hypoxemia that can cause cerebral vasodilation. Met __ Partially met __ Unmet as evidenced by:
References: y http://nursingcr ib.com y Brunner's and Suddarth's MedicalSurgical Nursing 10th ed.
2.
communicates clearly and appropriately for age and ability
1.
COLLABORATIVE: Refer to neurology. Review specific dietary changes and restrictions such as low salt low fat diet. To collaborate care To educate patient about the importance of proper diet.
attentiveness, concentration and cognitive orientation
2. communicates clearly and appropriately for age and ability
64
ASSESSMENT
DIAGNOSIS
SCIENTIFIC KNOWLEDGE CVA frontal lobe is affected
PLANNING
IMPLEMENTATION
RATIONALE
EVALUATION
SUBJECTIVE: Limang araw na akong hindi nadudumias verbalized by the patient.
Constipation related to insufficient physical activity secondary to stroke as evidenced by immobility
SHORT TERM GOAL:
INDEPENDENT: To enhance easy defecation.
SHORT TERM GOAL: After 2-4 hours of nursing intervention, goals to participate patient in bowel program were: Met __ Partially met __ Unmet as evidenced by: 1. Understanding of factors and appropriate intervention related to situation. 2. Demonstration of techniques/ behaviors that enable good bowel habits.
OBJECTIVE: y Abdominal mass y y y y y Immobility Left hemiparesis Poor diet Dry skin Needs assistance upon getting up in bed Slowed movement (+) flatus
Encourage fluid intake of In 2-4 hours of 2500-3000 ml/day within nursing intervention cardiac tolerance. decreased the patient will be physical and able to participate motor in bowel program Assist in perianal skin movements as evidenced by: condition frequently, noting 1. Understanding changes or beginning decreased GI activity of factors and breakdown. and motility appropriate intervention abdominal Assist patient to assume a related to distention high-Fowlers position with situation. knees flexed. constipation 2. Demonstration of techniques/ Encourage physical activity behaviors that and regular exercise within References: enable good limits of the patient. bowel habits. y http://nursingcr ib.com LONG TERM GOAL: In 1-2 days of Stress the avoidance of nursing intervention straining during defecation. the patient will be
To prevent skin excoriation and breakdown.
This position best uses gravity and allows for valsalva maneuver. Ambulation and/or abdominal exercises strengthen abdominal muscles that facilitate defecation and contraction of the intestines. To prevent change in vital signs, bleeding
LONG TERM GOAL: 65
able to demonstrate changes in lifestyle as necessitated by causative/contributi ng factors as evidenced by:
Provide health teaching about the relationship of diet, exercise and increased fluid intake as indicated.
After 1-2 days of nursing intervention, To inform patient goals for the patient to about its importance in demonstrate changes in lifestyle were: elimination pattern.
and dizziness.
1. Soft abdomen 2.
DEPENDENT: Fiber resist enzymatic digestion and absorbs liquids in its passage along the intestinal tract and thereby produces bulk, which acts as a stimulant for defecation.
__ Met Partially met __ Unmet as evidenced by: 1. 2. abdomen Compliance to proper treatment such as adequate hydration and increased fiber intake.
Consult with Compliance to proper dietitian to provide well treatment balanced diet such as high in fiber. adequate hydration and increased fiber intake. COLLABORATIVE: Encourage and support treatment of underlying medical cause where appropriate.
To improve body function including the bowel.
66
ASSESSMENT SUBJECTIVE CUE: Hindi ko maikilos ang kaliwang bahagi ng katawan ko,as verbalized by the client
DIAGNOSIS
SCIENTIFIC KNOWLEDGE high fat and high salt diet,overweight, smoking,age, heredity
PLANNING
IMPLEMENTATION
RATIONALE
EVALUATION SHORT TERM GOAL: After 4 hours of nursing intervention goals to Verbalize willingness toand demonstrate participation in activities were Met __ Partially met __ Unmet as evidenced by: 1.verbalization of treatment regimen and safety measures 2. demonstration of techniques/ behaviors that enable resumption of activities LONG TERM GOAL: After 2 days of nursing intervention goal to maintain position of function and skin integrity were Met __ Partially met __ Unmet as evidenced by: 1. absence of contractures, footdrop and decubitus 2. increased strength of affected body part 3.increase tolerance in activities 67
Impaired physical mobility related to neuromuscular impairment as evidenced by OBJECTIVE CUES: weakness on the y Weakness on the left side of the body left side of the body y Limited range of motion on the left extremities Postural instability during standing and walking
Vital signs: BP: 130/90 mmHg Temp: 36.4C RR: 21 cpm PR:96 bpm
SHORT TERM Independent: GOAL: Encourage in participation In 4 hours of in self-care, nursing intervention occupational/divisional/recr the client will be eational activities able to verbalize Occlusion within willingness to and Identify energy conserving vessels of the demonstrate techniques for activities of brain participation in daily living such as placing parenchyma activities as needed objects within reach evidenced by: Disruption of 1.verbalization of Encourage adequate intake blood treatment regimen of fluids (8-10 glasses a supply in the and safety measures day) and nutritious foods brain 2. demonstration of area techniques/ such as fresh fruits and behaviors that vegetables, lean meats and ischemia enable resumption dairy products. of activities Tissue and brain Encourage use of standing cell LONG TERM aids and mobility devices necrosis GOAL: such as walkers and have In 2 days of client/care provider stroke nursing intervention demonstrate knowledge the client will be about/safe use of device Destruction of able to maintain Neuromuscular position of function junctions and skin integrity as Reinforce principle of evidenced by progressive exercise, Interruption in 1. absence of emphasizing that joints are transportation of contractures, to be exercised to the point electrical impulses to footdrop and of pain, not beyond the neuromuscular decubitus receptors
Enhances self-concept and sense of independence Limits fatigue, maximizing participation promotes well-being and maximizes energy production promotes independence and enhances safety
no pain no gain is not always true
A safe
left hemiparesis weakness of the left side of the body Postural instability Impaired physical mobility
2. increased strength of affected body part 3. increase tolerance in activities
Instruct significant others regarding need to make home environment safe like placing pointed objects away from the patient. Dependent : Administer Antispasmodic medications (Baclofen HCL,80 mg PO O.D.) as indicated
environment is a prerequisite to improved mobility. To reduce muscle spasms or spasticity that interfere with mobility To develop individual exercise/ mobility program and identify appropriate adjunctive devices
References: y http://nursing crib.com y Brunner's and Suddarth's Medicalsurgical Nursing 11th ed.
Collaborative: Consult with physical/occupational therapist as indicated
68
DISCHARGE PLANNING
A. GENERAL CONDITION OF THE PATIENT UPON DISCHARGE The patient is conscious and coherent upon discharge. B. METHODS M - EDICATIONS 1. Baclofen HCL 2.
E - XERCISE / ENVIRONMENT The patient was advised to have complete bed rest until strength is regained. Have turnside to side every 2 hours to prevent bed soars. Encourage client to have at least 15 to 30-minute exercise everyday. Walking around the house is a good exercise. Instruct safety measures like using assistive devices.
T REATMENT for improving strength and walking. Occupational therapy for regaining dexterity of the arms and hands. Should undergo speech therapy to learn talking and swallowing. Oxygen inhalation if necessary and if possible 3-4 liters per minute. Adhere to therapeutic regimen. H - EALTH TEACHING Encourage and explain to client the importance of adhering to treatment regimen. Tell to client that adherence to treatment will aid to faster recovery and reduce the risks of having complications. Ensure that client understands the importance of maintaining a healthy diet and everyday exercise. 69
Teach patient the foods to eat and the foods to avoid. Teach the family members how to prepare low sodium and low fat diet. Encourage environmental modification to enhance safety and prevent injury. O - UT-PATIENT CHECK -UP The client will have a follow up check up after the discharge at February 8, 2011 D - IET Encourage client to have a nutritious diet High in fiber and low in fats and low in salt Fruits and vegetables are recommended S - PIRITUALITY Encourage the client to attend mass or other spiritual classes to boost self esteem and worth.
70
CONCLUSION
Stroke, previously known medically as a cerebrovascular accident (CVA), is the rapidly developing loss of brain function(s) due to disturbance in the blood supply to the brain. This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a hemorrhage (leakage of blood). As a result, the affected area of the brain is unable to function, leading to inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or an inability to see one side of the visual field. A stroke is a medical emergency and can cause permanent neurological damage, complications, and even death. It is the leading cause of adult disability in the United States and Europe and it is the number two cause of death worldwide. Risk factors for stroke include advanced age, hypertension (high blood pressure), previous stroke or transient ischemic attack (TIA), diabetes, high cholesterol, cigarette smoking and atrial fibrillation. High blood pressure is the most important modifiable risk factor of stroke. In this case study, our patient was suffering from the said disease. Also, the disease caused complication and results to Left Hemiparesis. We can say that we gained knowledge because of this. The different nursing interventions, proper diet, lifestyle modification, and medications are just some of the things we have learned when making this case study. We have concluded that with this particular case study, our knowledge as student nurses was greatly enhanced. In the future ahead, we strongly believe that we can render holistic care to those patients who had Cerebrovascular Accident. Furthermore, as a group, our cooperation and relationship with our members grew stronger. We hope that this experience will help us to be a competent registered nurse in the future.
71
BIBLIOGRAPHY
y Book References
Doenges, Marilyn, et al. Nurses Pocket Guide: Diagnoses, Prioritized Interventions and Rationales. 11th ed. New York: F.A. Davis Company, 2006. Print. Kelly, William, et al. Nursing 2003 Drug Handbook. 23rd ed. New York: Lippincott Williams and Wilkins, 2003. Print. Kozier, Barbara, et al. Fundamentals of Nursing Concepts, Process and Practice. 7th ed. Singapore: Pearson Education South Asia Pte. Ltd., 2004. Print. Brunner & Suddarth, et al. Textbook of Medical-Surgical Nursing 11th ed.

y Online References http://www.scribd.com/doc/25136620/Pathophysiology http://www.scribd.com/doc/37777006/3-PATHOPHYSIOLOGY http://www.scribd.com/doc/35906741/pathophysiology-CVA-final2 http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=609957 http://www.ucsfhealth.org/conditions/stroke/signs_and_symptoms.html http://www.wikipedia.org/Stroke
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BULACAN STATE UNIVERSITY College of Nursing City of Malolos, Bulacan

NURSING HEALTH HISTORY

GENOGRAM MATERNAL SIDE G.M. + G.F. + PATERNAL SIDE

II. FUNCTIONAL ASSESSMENT

FUNCTIONAL HEALTH PATTERN

1. HEALTH PERCEPTIONHEALTH MAINTENANCE PATTERN

2. NUTRITIONAL AND METABOLIC PATTERN

Day 3 Breakfast : 2 sliced bread & 150 ml of coffee

Dinner : 1 pc. Fried tilapia, cup of rice, & 240 ml of water.

Dinner : cup of rice and 1 serving of pinakbet & 240 ml of water

Level 2 2 N/A 2 2 2 3 N/A

device Level IV Dependent and does not participate

Bed Mobility Shopping

Bed Mobility Shopping

The patient normally sleeps 5 hours a day. From 12 pm to

7. SELF-PERCEPTION AND SELFCONCEPT PATTERN

The client says that, she is worried about her hospitalization

because of financial matters.

10. SEXUALITY AND REPRODUCTIVE PATTERN

11. VALUE-BELIEF PATTERN

GROWTH AND DEVELOPMENT

 Freuds Five Stages of Development

REVIEW OF ANATOMY AND PHYSIOLOGY

Inspection (use of thermometer) Inspection, Palpation Inspection Inspection

36.5-37.5 C 80(60-100) beats/min 18(12-20) cycles/min 120/80 mmHg

36.7 C 96 beats/min 21 cycles/min 130/90 mmHg

A. General Survey 1. Body built, height and weight Inspection

Endomorph 49 59 kg BMI: 28.15 THE PATIENTS WEIGHT IS INAPPROPRIATE TO HER HEIGHT.

Relaxed, erect posture, coordinated movement

Cant walk , cant stand, and cant sit without assistance

Unclean nails and unkempt hair

No body odor ,no breath odor

With breath and body odor

Cooperative Appropriate to situation Understandable, moderate pace

4. Hair and Scalp

2. Eyelashes 3. Bulbar and Palpebral Conjunctiva

2. External Ear Canal 3. Hearing Acuity

I. Breast Inspection, Palpation

J. Abdomen UPPER EXTREMETIES 1. Motor strength

Weakness on the left side of the body

Not firm muscle tone on the left side of the body

DUE TO CONTRALATERAL HEMIPLEGIA DUE TO CONTRALATERAL HEMIPLEGIA NORMAL

No lesions; no deformities; no tenderness;

Equal strength on each body side

Weakness on the left side of the body

DUE TO CONTRALATERAL HEMIPLEGIA

Decreased muscle tone on the left side of the body

No pain, weakness at left side of the body

Frontal horn, occipital horn, body of lateral ventricles appear attenuated

SIGNS AND SYMPTOMS Dizziness Loss of balance or coordition

DATE OF OCCURENCE January 22, 2011 January 22, 2011

January 22, 2011

January 22, 2011

REVIEW OF SYSTEMS SYSTEM

y Lips are dry and slightly pale in color

Diagnostic Laboratory Procedure

Date Ordered and Date Result

Normal Values (unit used in the Hospital)

Analysis and interpretatio n of the results

DO: January 22,2011 DR: January 22,2011

The result is within normal range

DO: January 22,2011 DR: January 22,2011

The result is within normal range

Freuds Five Stages of Development