Professional Documents
Culture Documents
INTRODUCTION
A Cerebrovascular Accident is the medical term for a stroke. A stroke is when
blood flow to a part of your brain is stopped either by a blockage or a rupture of a blood
vessel. There are important signs of a stroke that you should be aware of and watch out
for. A left-side stroke happens when the blood supply to the left side of the brain is
interrupted. Without oxygen and nutrients from blood, the brain tissue quickly dies. The
cerebrum is the largest part of the brain. It is made of a left and a right hemisphere. In
most people, the left hemisphere is in charge of the functions on the right-side of the
body. It is also involved in abilities such as the ability to speak, or use language. There
are two main types of stroke: ischemic and hemorrhagic.
Hemorrhagic stroke accounts for about 13 percent of stroke cases. It results from
a weakened vessel that ruptures and bleeds into the surrounding brain. The blood
accumulates and compresses the surrounding brain tissue. The two types of
hemorrhagic strokes are intracerebral (within the brain) hemorrhage or subarachnoid
hemorrhage.
Globally, measurements undertaken by the WHO revealed an up to ten-fold
difference in age-adjusted and sex-adjusted mortality rates and burden (measured in
disability-adjusted life year loss rates (DALYs)) among countries. Both were
considerably higher in low-income countries (North Asia, Eastern Europe, Central Africa,
and South Pacific) compared to high-income countries (Western Europe, North
America). 795,000 new or recurrent strokes occur per year in the US, accounting for
approximately 1 in 18 deaths. In Europe, the incidence of stroke varies from 101.1 to
1
239.3 per 100,000 in men and 63.0 to 158.7 per 100,000 in women. Within 5 years of a
stroke, over half of patients aged 45 years will die: 52% of men and 56% of women.
Stroke is the second leading cause of death above the age of 60 years, and the
fifth leading cause of death in people aged 15 to 59 years old. Every year, 15 million
people worldwide suffer a stroke. Nearly six million die and another five million are left
permanently disabled. Stroke is the second leading cause of disability, after dementia.
Disability may include loss of vision and / or speech, paralysis and confusion. Stroke is
less common in people under 40 years, although it does happen. In young people the
most common causes are high blood pressure or sickle cell disease. In many developed
countries the incidence of stroke is declining even though the actual number of strokes
is increasing because of the ageing population. In the developing world, however, the
incidence of stroke is increasing. In China, 1.3 million people have a stroke each year
and 75% live with varying degrees of disability as a result of stroke. The predictions for
the next two decades suggest a tripling in stroke mortality in Latin America, the Middle
East, and sub-Saharan Africa.
Nationally, according to the latest WHO data published in April 2011 Stroke
Deaths in Philippines reached 40,245 or 9.55% of total deaths. The age adjusted Death
Rate is 82.77 per 100,000 of population ranks Philippines #106 in the world.
Locally, there are no records of incidence of stroke published online for Davao
Del Norte. However, in Davao City, Councilor Rene Elias Lopez said stroke is now the
top cause of morbidity in the city, with 1,800 people dying from the disease in 2008.
OBJECTIVES
The study aims to present all the information we have gathered about the case of
our patient who has an admitting diagnosis of T/C Cerebrovascular accident; CAP-MR.
Moreover, this intends to share the knowledge based on information gathered to the
patient, the significant others and to our fellow nursing students.
Specifically, this study intends to:
ordered with their action in alleviating the underlying causes of present condition.
Identify the needs of the patient and formulate effective nursing care plans
II. ASSESSMENT
A Biographical Data
Name: Patient Magandang Buhay
Age: 62 years old
Birthdate: June 05, 1958
3
naabot
man
gud
gahapon
ang
amigo
sakong
igsuon
maam.
iyang mata tapos wala daw siyay makita. Then, Dr. Dejan explained to them,
that the cause maybe of that manifestation is that stroke has affected the frontal
lobe of the brain of the patient.
D Past Medical History
Dili ni mao ang una nga giaatake siya ug stroke maam, kadaghan na man. Ang
pinaka bago lang katong pagkamatay sakong igsuon. Grabe man gud jud iyang
kaguol ato, dli jud niya madawat ang nahitabo. Pero naka recover na pud bia na
siya maam kay gipa therapy man namo na siya tapos naa pud siya gina
maintain na tambal, mga para sa highblood, stroke ug diabetes, as verbalized
by the patients watcher.
E Personal, Family and Socio-Economic History
Patient Magandang Buhay belongs to a middle class family. Currently, she
doesnt have a job and is living with his youngest daughter, since her other children
already have their own family. But despite that fact, they still continue to support the
patient in all her needs, especially when it comes to her health. The patients father
was hypertensive and died also because of Stroke. The patient has five siblings and
two of them were also Hypertensive. The patient doesnt have any vices according
to the watchers verbalization.
F Patient Need Assessment
Date: February 04, 2015
Name of patient: Patient Magandang Buhay
Age: 62 years old
Sex: F
Status: Widow
Skin Character and Color: Brownish skin complexion, warm to touch and
dry. Good skin turgor noted.
Life Supporting Apparatus: With O 2 inhalation @ 3LPM via nasal cannula.
II.
III.
IV.
V.
the watcher.
Urination: Able to urinate250-450 cc amber-colored urine within the shift.
Other observations: With Foley catheter attached to urobag
Rest and Sleep
7
VII.
consciousness.
Character: N/A
Location: N/A
Frequency: N/A
Duration: N/A
Behavior: N/A
Other Observations: None
Stimulation/ Activity
Work: She currently doesnt have a work and is already dependent; shes
living with her youngest child, since her other children already have their
own family.
Recreation or past time: Hes doing household chores.
Hobbies or vices: Wala jud na siyay bisyo maam. Magtanaw ra na siyag
TV sa balay kung walay ginabuhat, as verbalized by the watcher.
Safety Security needs
Neuro VS: score of 14 out of 15
Mental status: She was stuporous, has decreased level of consciousness,
asleep most of the time and was only responsive to verbal stimulation.
Emotional Problems: None
Other objective cues: Has sluggish pupil reaction at left with a gauge of
1mm and fixed pupil reaction at right with a gauge of 3mm; has weak
handgrip but moderate leg movement; has spontaneous eye opening to
speech, oriented verbal response, and obeying motor response
8
VIII.
IX.
X.
Self-actualization
PHYSICAL ASSESSMENT
General Survey
Patient Magandang Buhay, 62 years old, male, stands 5 feet and 5 inches tall
and weighs 70kg. With the following VS as monitored and recorded upon admission
Temp = 36o C; BP= 190/100 mmHg; PR = 77 bpm; RR = 20cpm. With IVF bottle # 1
PNSS 1L @ KVO rate infusing well. She was stuporous, has decreased level of
consciousness, asleep most of the time and was only responsive to verbal stimulation.
Vital Signs Monitoring Sheet
Name: Patient Magandang Buhay
Sex: F
Room/Bed: 309
Date/Shift
Time
12/07/201
6:25 PM
Age: 62 Y.O
Temperatur
Blood
Respirator
Card3iac
e
35.7
Pressure
260/130
y Rate
22
Rate
88
39.3
36.8
180/100
180/190
200/140
21
22
87
96
200/110
180/100
150/80
150/100
150/80
150/100
25
28
25
25
24
20
98
96
97
98
86
90
4
311
12/08/201
6:30 PM
8:00 PM
12:00 AM
4
117
12/08/201
1:00
2:00
2:30
3:00
4:00
8:00
AM
AM
AM
AM
AM
AM
36.7
36
37
37
10
4
73
12/08/201
10:00 AM
12:00 NN
1:00 PM
4:00 PM
37.3
140/90
150/100
170/100
140/90
6:00 PM
8:00 PM
12:00 MN
37.4
36.5
36.7
150/90
150/90
150/90
21
22
22
87
83
88
4:00 AM
6:00 AM
8:00 AM
37.1
36.8
160/100
180/90
150/80
22
22
20
80
89
86
10:00 AM
12:00 NN
2:00 PM
4:00 PM
36.6
37.1
37.3
37
180/100
140/100
190/90
160/90
21
20
20
22
84
85
81
76
8:00 PM
12:00 MN
37.4
37
160/80
180/100
20
20
75
76
4:00 AM
8:00 AM
37
36.9
160/90
160/100
20
21
78
90
10:00 AM
12:00 NN
2:00 PM
36.8
37.2
37.1
170/100
130/100
160/90
20
20
21
91
88
89
37.1
19
89
21
86
4
311
12/09/201
4
117
12/09/201
4
73
12/09/201
4
311
12/10/201
4
117
12/10/201
4
73
11
REVIEW OF SYSTEMS
Integumentary System
Generally, patient Magandang Buhay has brownish skin that is warm to touch,
with the presence of hair, with good skin turgor and capillary refill of 2 seconds after
blanching.
HEENT
HEAD
Head is normocephalic, can lift head fully and turn them from side to side. Hair is
short, thick and evenly distributed. No dandruff, head and scalp lesions not
noted.
EYES
Eyes are symmetrical and black in color; No eye discharges noted. The patient
sluggish pupil reaction at left with a gauge of 1mm and fixed pupil reaction at
right with a gauge of 3mm when diverted to light; Pale and palpebral conjunctivae
not noted, with white and anicteric sclera. Eyelashes are equally distributed.
EARS
Both symmetrical; with no discharges noted within both ears. There were no
lesions, wounds or discoloration noted upon inspection, and there were no
problems in hearing.
NECK
12
Short and mobile. Able to perform the different neck ROM exercises or
maneuvers. No tracheal deviations felt upon placing a finger along one side of
the trachea, noting the space and comparing with the opposite side. No swollen
lymph nodes upon palpation.
THROAT
Gums are in good condition. Tongue midline and mobile with visible papillae.
Tonsils are not inflamed. Pinkish hard and soft palate. Gag reflex is present.
Pulmonary System
With crackles heard upon auscultation; regular breathing pattern and symmetrical
chest expansion. Theres an equal rise and fall of the chest with normal depth of
respiration.
Cardiovascular System
Normal lubbdubb heard upon auscultation and apical pulse heard per
auscultation. No heaves and thrills heard. No murmurs, regular cardiac rate and
rhythm heard upon auscultation.
Gastrointestinal System
Abdomen is distended, and has the same color as the rest of the body. 5-15 clicks
per minute heard upon auscultation.
Musculoskeletal System
13
Unable to perform ADL alone and assistance is really needed. Has weak handgrip
but moderate leg movement; has spontaneous eye opening to speech, oriented
verbal response, and obeying motor response, which gives her an overall GCS
score of 14.
Genito-urinary System
Was able to urinate 250-450 cc amber-colored urine. With Foley catheter
attached to urobag.
14
URINALYSIS
February 3, 2015
LABORATORY
RESULT
NORMAL VALUE
UNIT
IMPLICATION
ON
Color
Straw
Light yellow to a -
Normal
Sugar
Normal
Albumin
Reaction
amounts.
Negative Negative
5.0
4.5 - 7.2
Normal
Normal
Sp gravity
Crystlas
1.010
-
1.005 to 1.025
-
Normal
-
Casts
Epithellial cells
Mucous threads
Pus cells
RBC
0-2
6-8
Few
0-2
0-2
hpf
hpf
Normal
Normal
Above
EXAMINATION
S/
DETERMINATI
normal.
The presence of
abnormal
numbers of red
cells is urine due
to
glomerular
damage, tumors
which erode the
urinary
tract
15
anywhere
along
urinary
tract
stones,
renal
infarcts,
acute
tubular
necrosis,
and
upper
lower
urinary
uri
tract
infections,
nephrotoxins,
and
Bacteria
Pus in clumps
hpf
physical
stress.
-
ELECTROLYTES
Paramet
er
Sodium
Potassium
Calcium
Result
Limit
139
4.48
1.10
136-145
3.50-5.00
1.12-1.32
Unit
mmol/L
mmol/L
mmol/L
Interpretation
Normal.
Normal.
Normal.
(ionized)
16
February 4, 2015
BLOOD CHEMISTRY
Paramete
Result
Limit
9.45
4.11-5.89
Unit
Interpretation
r
FBS
mmol/L
Increased.
glucose
High
levels
most
of
frequently
indicate diabetes,
but
many
in
those
with pre-
other
diseases
and
Acromegaly;
(response
to
trauma, heart
attack,
instance);
17
Chronic
kidney
failure;
121.30
45-84
umol/L
cancer;
and
Pancreatitis.
Increased. Generally, a high serum
creatinine level means that your
kidneys aren't working well. Your
creatinine level may temporarily
increase if you're dehydrated, have
a low blood volume, eat a large
amount of meat or take certain
medications.
The
dietary
SGPT
15
32
Total
276
150-200
u/L
same effect.
Normal.
mg/dL
Cholestero
l
Triglycerid
66
<200
mg/dL
es
18
High
63
45-65
mg/dL
Density
Lipoprotei
n (HDL)
Low
199.80
66-178
mg/dL
Density
Lipoprotei
density
lipoprotein.
It's
also
This
is
why
HDL
is
LDL stands
lipoprotein.
for
It's
lowalso
HBA1C
6.10
4-6
HEMATOLOGY
19
LABORATORY
RESULT
NORMAL
EXAMINATIONS/
VALUE
DETERMINATION
Hemoglobin
133
134.00-
Hematocrit
Leukocytes No. of
0.40
9.77
160.00
0.36-0.45
5-
Concen.
Segmenters
0.86
10x10^9
0.40-0.60
UNIT
IMPLICATION
g/L
Normal
Normal
Normal
Elevated.
Segmenters
or
that
bacterial
respond
to
infection.
High
represent
infection,
inflammation,
stress
Lymphocytes
0.12
0.25-0.40
and
and
an
physical
malignancy,
count
and
cancer.
20
Low
0.01
0.01
288.0
Blood type
Rh type
0.01-0.12
0.01-0.05
0.005
0.01-0.05
150-
to
the
damage
Normal.
440x10^9
URINALYSIS
LABORATORY
RESULT
NORMAL VALUE
UNIT
IMPLICATION
ON
Color
Light
Light yellow to a -
Normal
Sugar
Yellow
dark amber color
Negative 0
to
trace -
Normal
Albumin
Trace
EXAMINATION
S/
DETERMINATI
amounts.
Negative
An albumin test
checks urine for
the presence of a
21
of
protein
called
albumin. Albumin
is normally found
in
filtered
by
kidneys.
the
When
the kidneys
are
working properly,
albumin
is
not
present
in
the
small
amounts
of
trace
albumin
in
urine specimen is
usually
not
significant
22
finding. It means
a
very
amount
small
of
protein shows up
Reaction
6.5
4.5 - 7.2
in the specimen.
Normal
Sp gravity
Crystlas
1.005
-
1.005 to 1.025
-
Normal
-
Casts
Epithellial cells
Mucous threads
Pus cells
Few
8-11
Few
0-2
hpf
Normal
Increased.
Indicates
that
there is presence
RBC
10-15
0-2
hpf
of infection.
Increased.
presence
The
of
abnormal
numbers of red
cells is urine due
to
glomerular
damage, tumors
which erode the
urinary
anywhere
tract
along
23
trauma,
urinary
tract
stones,
renal
infarcts,
acute
tubular
necrosis,
and
upper
lower
urinary
uri
tract
infections,
nephrotoxins,
and
Bacteria
Pus in clumps
hpf
physical
stress.
-
NERVOUS SYSTEM
25
The CNS works with the peripheral nervous system (PNS). The PNS is made up
of nerves that branch out from the spinal cord to relay messages from the brain to
different parts of the body. Together, the CNS and PNS allow a person to walk, talk, and
throw a ball and so on.
The brain is the bodys control centre. It constantly receives and interprets nerve
signals from the body and responds based on this information. Different parts of the
brain control movement, speech, emotions, consciousness and internal body functions,
such as heart rate, breathing and body temperature.
The brain has 3 main parts: cerebrum, cerebellum and brain stem.
Cerebrum
The cerebrum is the largest part of the brain. It is divided into 2 parts (halves)
called the left and right cerebral hemispheres. The 2 hemispheres are connected by a
bridge of nerve fibres called the corpus callosum.
26
The right half of the cerebrum (right hemisphere) controls the left side of the
body. The left half of the cerebrum (left hemisphere) controls the right side of the body.
The outer surface of the cerebrum is called the cerebral cortex or grey matter. It
is the area of the brain where nerve cells make connections, called synapses, that
control brain activity. The inner area of the cerebrum contains the insulated (myelinated)
bodies of the nerve cells (axons) that relay information between the brain and spinal
cord. This inner area is called the white matter because the insulation around the axons
gives it a whitish appearance.
The cerebrum is further divided into 4 sections called lobes. These include the
frontal (front), parietal (top), temporal (side) and occipital (back) lobes.
The frontal lobe controls movement, speech, behaviour, memory, emotions and
intellectual functioning, such as thought processes, reasoning, problem solving,
decision making and planning.
The parietal lobe controls sensations, such as touch, pressure, pain and
temperature. It also controls spatial orientation (understanding of size, shape and
direction).
The temporal lobe controls hearing, memory and emotions. The left temporal
lobe also controls speech.
27
Cerebellum
The cerebellum is the next largest part of the brain. It is located under the
cerebrum at the back of the brain. It is divided into 2 parts or hemispheres and has grey
and white matter, much like the cerebrum.
movement
posture
balance
reflexes
midbrain
pons
medulla oblongata
The brain stem controls:
breathing
body temperature
blood pressure
heart rate
29
ventricles and over the surface of the brain and spinal cord. The brain controls the level
of CSF in the body.
Meninges
The brain and spinal cord are covered and protected by 3 thin layers of tissue
(membranes) called the meninges:
CSF flows in the space between the arachnoid layer and the pia mater. This
space is called the subarachnoid space.
The tentorium is a flap made of a fold in the meninges. It separates the cerebrum
from the cerebellum.
The supratentorial area of the brain is the area above the tentorium. It contains
the cerebrum, the first and second (lateral) ventricles, the third ventricle, and glands and
structures in the centre of the brain.
The infratentorial area is located at the back of the brain below the tentorium. It
contains the cerebellum and brain stem. This area is also called the posterior fossa.
Corpus callosum
30
Pituitary gland
The pituitary gland is a small, pea-sized organ in the centre of the brain. It is
attached to the hypothalamus and makes a number of different hormones that affect
other glands of the bodys endocrine system. It receives messages from the
hypothalamus and releases hormones that control the thyroid and adrenal gland, as
well as growth and physical and sexual development.
Ventricles
The ventricles are fluid-filled spaces (cavities) within the brain. There are 4
ventricles:
The first and second ventricles are in the cerebral hemispheres. They are called
lateral ventricles.
31
The third ventricle is in the centre of the brain, surrounded by the thalamus and
hypothalamus.
The fourth ventricle is at the back of the brain between the brain stem and the
cerebellum.
The ventricles are connected to each other by a series of tubes. The fluid in the
ventricles is cerebrospinal fluid (CSF). The CSF flows through the ventricles, around the
brain in the space between the layers of the meninges (subarachnoid space) and down
the spinal cord.
Pineal gland
The pineal gland is a very small gland in the third ventricle of the brain. It
produces the hormone melatonin, which influences sleeping and waking patterns and
sexual development.
Choroid plexus
The choroid plexus is a small organ in the ventricles that makes CSF.
Cranial nerves
There are 12 pairs of cranial nerves that perform specific functions in the head
and neck area. The first pair starts in the cerebrum, while the other 11 pairs start in the
brain stem. Cranial nerves are indicated by number (Roman numeral) or name.
Types of cells in the brain
The brain is made up of neurons and glial cells:
neurons
These cells carry the signals that make the nervous system work.
They cannot be replaced or repaired if they are damaged.
glial cells (neuroglial cells)
These cells support, feed and protect the neurons.
32
vertebrae, sacrum and coccyx bony sections that house and protect the spinal
cervical the vertebrae from the base of the skull to the lowest part of the neck
right side of the body; Speech/language problems; Slow, cautious behavioral style and
Memory loss.
Hemorrhagic
stroke
accounts
for
and
compresses
the
Actual
Rationale
Uncontrolled increase of blood pressure can
cause a vessel to explode or burst. Thus,
causes
hemorrhagic
stroke.
(http://www.strokeassociation.org/STROKEORG/
AboutStroke/UnderstandingRisk/Understanding
-StrokeRisk_UCM_308539_SubHomePage.jsp#)
Uncontrolled diabetes can cause increase
Uncontrolle
d diabetes
viscosity
of
blood
in
the
blood
stream.
(http://www.strokeassociation.org/STROKEORG/
AboutStroke/UnderstandingRisk/Understanding
35
-StrokeRisk_UCM_308539_SubHomePage.jsp#)
High
cholesterol
Smoking
Excessive alcohol
intake
The
role
of
alcohol
consumption
as
an
36
(http://stroke.ahajournals.org/content/30/11/23
07.full)
Race
African-Americans
(opens
in
new
obesity.
(http://www.strokeassociation.org/STROKEORG/
AboutStroke/UnderstandingRisk/Understanding
-StrokeRisk_UCM_308539_SubHomePage.jsp#)
Age (>65)
of
one
in
four
strokes.
(https://www.google.com.ph/?gfe_rd=cr&ei=9JOVLPoO8uL8QeCyoC4DA&gws_rd=ssl#q=ratio
nale+for+65+years+old+person+with+stroke
)
Family
history of stroke
37
the
disease.
(http://www.strokeassociation.org/STROKEORG/AboutSt
roke/UnderstandingRisk/)
Stress
ischemic
stroke.
(http://www.abc.net.au/health/thepulse/stories/
2012/10/09/3605871.htm)
VI. SYMPTOMATOLOGY
Symptoms
Weakness
Actual
Rationale
Numbness
can
occur
from
dysfunction
or numbness of
cortex.
38
the body
(http://www.merckmanuals.com/professional/n
eurologic_disorders/approach_to_the_neurolog
ic_patient/numbness.html)
Loss of speech,
difficulty talking,
or understanding
saying
Loss of vision or
ch/disorders/Stroke/
Vision loss can be both a symptom and result
dimming (like a
curtain falling) in
resources/library/stroke-and-vision-loss
Sudden, severe
headache with no
known cause
as
the
brain
communicating
with
is
having
nerves
in
difficulty
a
certain
area.http://www.healthline.com/health/stroke/
complications
of
or
unstable walking,
usually combined
with
Loss
balance
another
symptom
affected.
http://www.stroke.org.uk/factsheet/balanceproblems-after-stroke
VII. PATHOPHYSIOLOGY
A Written Pathophysiology
Strokes are divided into two main categories: Ischaemic and Haemorrhagic.
SIGNS AND SYMPTOMS:
-
40
Haemorrhagic strokes are due to the rupture of a blood vessels leading to compression
of brain tissue from an expanding haematoma. In addition, the pressure may lead to a
loss of blood supply to affected tissue with resulting infarction. Intracerebral
haemorrhage is the accumulation of blood anywhere within the brain, i.e.
intraparenchymal haemorrhage, intraventricular haemorrhage. This will form a gradually
enlarging haematoma (blood pool). Intracerebral Haemorrhages can be caused by local
vessel abnormalities (hypertension, vasculitis, vascular malformation) or systemic
factors (drugs, trauma, tumours and sickle cell anaemia/leukaemia). Haemorrhaging
directly damages brain tissue and raises intracranial pressure giving headaches,
vomiting nausea and eventually coma and death. Subarachnoid haemorrhage is the
gradual collection of blood in the subarachnoid space of the Dura. These can be
traumatic or spontaneous. Spontaneous haemorrhages occur through saccular (berry)
aneurysms and through extensions of intracranial haemorrhaging or due to similar
causes. Approximately one third of those who suffer a subarachnoid haemorrhage die.it
is the subarachnoid space which can pathologically fill with blood.
41
B Diagram of Pathophysiology
Predisposing Factors:
-
Precipitating Factors:
- Hypertension
- Stress
42
The ruptured cerebral vessels may constrict to limit blood loss. However,
the vasospasm will result to further ischemia and necrosis of brain tissues.
6.
Cognitive Impairments
Depression
Increase functional
activities as strength
improves
GOOD PROGNOSIS
43
BAD PROGNOSIS
VIII. PLANNING
A NURSING CARE PLAN
Date /
Time
Decem
ber 10,
2014
7-3
shift
Assessment
Need
Subjective cues:
Gi-ubo sya sir,
dili sya
kaginhawa kaau
as verbalized by
the watcher.
P
H
Y
S
I
O
L
O
G
I
C
A
L
Objective cues:
-VS: BP- 160/100
PR- 90
RR- 27
Temp- 36.9
O2 sat= 97%
Need
-productive
cough
-crackles heard
upon
auscultation.
-(+) use of
accessory
muscle when
Nursing
Diagnosis
Ineffective
Breathing Pattern
r/t
tracheobronchial
inflammation and
increased sputum
production
secondary to
CAP-MR
Rationale:
Pneumonia is inf
lammation of the
terminal airways
Oxyg and alveoli
enatio caused by acute
n
infection by
patter various agents.
n
Community
Acquired
Objective
of Care
Within the
shift, will
be able to:
a. Identify
or
demonstra
te
behaviors
to achieve
airway
clearance.
b. Display
patent
airway
with
breath
sounds
clearing.
Nursing
Interventions
-Monitored VS.
R: To monitor
patients condition
and compared with
baseline data.
-Placed on MHBR
position.
R: It promotes
relaxation and helps
in promoting
effective airway
clearance.
-Assisted in turning
to sides every 30
minutes.
R: To promote
circulation as well
as to prevent
further
complications in the
pulmonary system.
-Encouraged to
increase OFI.
Evaluation
Within the
shift, GOAL
PARTIALLY
MET, as
evidenced
by:
a. being able
to
identify/demo
nstrate
behaviors to
achieve
airway
clearance
such as deep
breathing
and coughing
exercises.
b. crackles
lung sound
still heard
44
breathing
- with O2
inhalation @
2LPM via nasal
cannula
-lying flat on bed
Pneumonia
(CAP) is a
disease in which
individuals who
have not recently
been hospitalized
develop an
infection of the
lungs. It is an
acute
inflammatory
condition thats
result from
aspiration of
oropharyngealse
cretions or
stomach contents
in the lungs.
Therefore, airway
clearance is not
effective.
Reference:
http://nursingcrib.
com/
R: It helps to soften
and expectoration
of secretions.
-Encouraged to do
deep breathing and
coughing exercises.
R: Deep breathing
exercises facilitate
maximum
expansion of the
lungs and smaller
airways. Coughing
is a reflex and a
natural self-cleaning
mechanism that
assists the cilia to
maintain patent
airways.
-Demonstrated
proper back and
chest tapping to
watchers.
R: It can aid to
mobilization and
expectoration of
secretions.
upon
auscultation.
Dependent:
-Administer meds as
45
prescribed.
R: To continuously
treat underlying
causes and
symptoms.
Date Retrieved:
December 11,
2014
Collaborative:
-Encouraged
watchers to assist
patient in turning to
sides as well as in
performing ADL.
R: To prevent
further
complications and
to prevent accidents
that may lead to
injury.
Date /
Time
Decem
ber 10,
2014
7-3
shift
Assessment
Need
Subjective
cues:
Wala baya jud
kusog iyang
tuo nga parte
sa lawas sir
P
H
Y
S
I
O
Nursing
Diagnosis
Self-care
deficit r/t right
sided body
weakness
secondary to
Cerebrovascul
ar accident
Objective
of Care
Within the
shift, there
will be
demonstrati
on of selfcare, as
Nursing
Interventions
-Established rapport.
R: To gain trust and
cooperation.
-Monitored VS.
R: To have a baseline
data.
Evaluation
Within the shift,
GOAL
PARTIALLY
MET, as
evidenced by:
a. Being
46
as verbalized
by the
watcher.
L
O
G
I
C
Rationale:
Motor deficit
are the most
Objective
obvious effect
cues:
of stroke.
-VS: BPN
Symptoms are
160/100
E
caused by
PR- 90
E
destruction of
RR- 27
D
motor neurons
Temp36.9
Nutrition, in the
-hand grip and clothing pyramidal
pathways
leg movement
and
at the right
eliminati (nerve fibers
in the brain
side of the
on
and passing
body are
through the
absent
spinal cord to
- Inability to
the motor
feed self
tract.) When
independently
this happens,
-Inability to
activities of
dress self
daily living can
independently
be impaired
-Inability to
and even selfperform
care.
toileting task
independently
-total
evidenced
by:
unable to
place the
unnecessar
y things at
bedside on
his own.
b. Being able
to change
clothes
with
minimal
assistance.
c. Being
unable
to take a
bath
without
total
assistan
ce.
47
assistance
during ADL like
bathing and
clothing
-
Reference:
http://nursesla
bs.com/cerebr
ovascularaccidentnursing-careplans/.
Date
Retrieved:
December 11,
2014
expenditure and
frustration.
- Provided privacy
while patient is
toileting.
R: Lack of privacy
may inhibit the
patients ability to
evaluate their bowel
& bladder.
-Stretched and
tucked properly the
linens.
R: To prevent the
feeling of being
uncomfortable when
lying in bed.
Dependent:
-Administer meds as
prescribed.
R: To continuously
treat underlying
causes and
symptoms.
Collaborative:
-Encouraged
watchers to assist
48
Date/Ti
me
Decembe
r 11,
2014
7-3 shift
Assessmen Need
Nursing
t
Diagnosis
Subjective
S
Activity
cues:
A
Intolerance r/t
Dili kalihok
F
right sided
akong tuo na
E
body
kamot og
T
weakness
tiil, as
Y
secondary to
verbalized.
Cerebrovascul
A
ar accident
Objective
N
cues:
D
Rationale:
Objective of
Care
Long Term Goal:
a Participate
willingly in
necessary/de
sired
activities.
b Use identified
techniques to
enhance
activity
Nursing
Interventions
-Monitored VS.
R: To monitor
patients condition
and compared
with baseline data.
- Ascertained
ability to stand
and move about,
and degree of
assistance
Evaluatio
n
GOAL MET,
as
evidenced
by:
a. Able to
participate
willingly in
necessary/
desired
49
- hand grip
and leg
movement
at the right
side of the
body are
absent
- turns to
sides with
assistance
-needs total
assistance in
ambulation
-unable to
perform ADL
alone
S
E
C
U
R
I
T
Y
The sudden
death of some
brain cells due
to lack of
oxygen when
the blood flow
to the brain is
impaired by
blockage or
rupture of an
artery to the
brain, this can
cause body
weakness or
paralysis of
the one side of
the body,
depending on
the area of the
brain that is
affected. This
will lead the
patient to
have
intolerance to
some
activities.
Reference:
intolerance.
necessary or use
of equipment
R: To determined
current status and
needs associated
with participation
in needed/desired
activities.
- Assessed
emotional and
psychological
factors affecting
the current
situation.
R: Stress or
depression maybe
increasing the
effects of an
illness, or
depression might
be the result of
forced inactivity.
- Increased
exercise or activity
levels gradually.
R: To conserve
energy
- Planned care to
carefully balance
activities.
b. Able to
use
identified
techniques
to enhance
activity
intolerance
.
50
http://www.me
dicinenet.com/
script/main/art
.asp?
articlekey=26
76. Date
Retrieved:
December 11,
2014
abilities in this
area.
- Planned for
progressive
increase of activity
level/participation
in exercise
training, as
tolerated by the
client.
R: Both activity
intolerance and
health status may
improve with
progressive
training.
- Assisted client in
learning and
demonstrating
appropriate safety
measures.
R: To prevent
injuries
Dependent:
-Administered
meds as
prescribed.
R: For continuous
52
treatment of
underlying cause
and symptoms.
Collaborative:
-Encouraged
watchers to
support the
patient by
assisting in
performing ADL.
R: To provide
safety and avoid
accidents that
may cause injury.
53
B DISCHARGE PLAN
Areas
Objective
Activities
1 Encourage the patient to comply
with the prescribed medication.
This prevents further
Medication
between activities.
important.
1. Explain the purpose of
the medication that is
Treatment
prescribed by the
physician.
2. Inform the significant of
the treatment others that
they should be involved
in the treatment of the
client.
3. Encourage to take
medications religiously.
1 Instruct to take extra care in
doing daily ADL especially in
ambulation.
2 Instruct the client to have a
Health teachings
Out - patient
the diet.
58
59
Gener
ic
Name
Furose
mide
Bran
d
Nam
e
Lasix
Classificati
on
Mechanism of
action
Indication
Side Effects/
Adverse
Reaction
Fluid and
electrolyte
imbalance.
Rashes,
Side
photosensi
Effects/
tivity,
Adverse
nausea,
Reaction
diarrhoea,
Pain
blurred
Induration
vision,
Phlebitis
dizziness,
Rash
headache,
Diarrhea
hypotensio
Thrombocyt
n. Bone
osis
marrow
Leucopenia
depression
Glossitis
(rare),
Respiratory
hepatic
super
dysfunctio
infections
n.
Hyperglyca
emia,
glycosuria,
ototoxicity.
Potentially
Fatal:
Rarely,
sudden
death and
cardiac
arrest.
Hypokalae
mia and
magnesiu
Time
and
Dosag
e
40mg
OD
IVTT
Nursing
Responsibili
ties
-Reduce
dosage if
given with
other
Time & antihypertensi
Nursing
Dosage ves;
Responsibilit
readjust
dosage
ies
gradually as
1 gram BP
-Assess
responds.
every
patients
12 hours -Administer
Previous
ANST (-) with
sensitivity
food or
IVTT
reaction
milk
to to
penicillin
prevent
GIor
other
upset.
cephalosphori
-Give
early in
ns.
the day so
that increased
-Assess will
urination
patient
for
not
disturb
signs and
sleep.
symptoms
of infection
-Avoid
IV use
before
andis
if oral use
during
the
at
all possible.
treatment
-Obtain C&S
-WARNING:
Do
before
not mix
beginning
parenteral
solution with
highly acidic 60
solutions with
pH below 3.5.
-Do not
infections.
oplasmicm
embrane.
These
enzymes
are
involved in
cell-wall
synthesis
and cell
division. By
binding to
these
enzymes,
Ceftriaxone
results in
the
formation
of
of defective
cell walls
and cell
death.
drug therapy
to identify
if correct
treatment has
been initiated.
-Report signs
such as
petechiae,
ecchymotic
areas,
epistaxis or
other forms
of unexplaine
d bleeding.
61
Generi
c
Name
Citicoli
ne
Bran
d
Nam
e
Choli
nerv
Classificati Indication
on
Action
CNS
stimulant,
Peripheral
Vasolidlator
Citicoline
activates
the biosynthesis
of structural pho
spholipids in the
neuronal
membrane,
increases
cerebral
metabolism and
increases the
level of various
neurotransmitte
rs, including
acetylcholine
and dopamine.
Citicoline has
shown
neuroprotective
affects in
situations
of hypoxia and
ischemia.
Cerebrovasc
ular
Diseases,
accelerates
the recovery
of conscious
ness and
overcoming
motor deficit
Side
Effects/
Adverse
Reaction
citicoline
may exert
a
stimulating
action of
the parasy
mpathetic,
as well as a
fleeting
and
iscretehypo
tensor
effect.
-Watch out
for hypotensive
effects.
-Must not be
administered
along with
medicaments
containing
62
Generic
Brand Classi
Indication
SideSide
Time Time
Nursing
Generi Brand
Classificat
MechanismAction
Indication
Nursing
Name
Name
ficatio
Effects/
and
Responsibilities
c
Name
ion
of action
Effects/
and
Responsibiliti
n
Adverse
Dosag
Name
Adverse
Dosag es
Reaction
e
Reaction
e
Omepraz
Omep Proton
ShortInhibits
term
Suppresses
Diarrhea,
40 mg10mg
-Assess
other
Losarta Cozaar
AntiHypertensi
CNS1 -Monitor
ole
ron
pump
treatment
gastric
nausea,
patient
n
hypertensi
vasoconstricti
on,
dizziness,IVTT tab medications
OD patients
BP.
inhibito
of active
secretion
by fatigue,
maybe-Monitor
taking for
ve
ve and
Nephepatic
asthenia, OD
Generi Brand Classificati
Mechanism
Indication
Side
Time
Nursing
r
duodenalulcer,
constipatio
effectiveness
aldosterone-inhibiting
ally in type
fatigue,
patientsand
who
c Name Name on
of
action
Effects/
and
Responsibilities
gastroesopha
interaction.
secreting hydrogen/p
2 diabeticn, headache,
are also taking
Adverse
Dosag
gealreflux
otassium
vomiting,
-Monitor
therapeutic
action of
patients, to
insomia. CVdiuretics
for
Reaction
e
disease
ATP
as
flatulence,
effectiveness
and
angiotensin II
reduce risk edema,
symptomatic
Amlodip Norvas Calcium
Inhibits the
Alone or
10mg
(GERD),
enzyme
utycaria,
adverse
reaction at
by blocking
of
chest pain.
hypotension.
CNS:
-Monitor blood
ine
c
channel
transport
with other
1 tab
including
dry mouth,
the beginning
angiotensin system
II
CVAinin
EENT-nasal
-Assess
headache,
pressure
and pulse
blocker
of calcium into agents in
OD
erosive
the
gastric
dizziness,
of
therapy
and renal
receptor on
patients
congestion,
patients
dizziness,
before therapy,
myocardial
the
esophagitis
parietal
periodically
the surface of
withcell: headache
sinusitis,
function
during
dose titration,
and vascular
manageme fatigue CV:
and vascular
characterize
throughout
the
hypertensi pharyngitis,
-Tell
patient
to
peripheral
and periodically
smooth muscle nt
symptomatic
as
a
gastric
therapy
.
smooth
on and left sinus
avoid salt
during
cells, resulting of hyperten edema,
GERD.
Long
acid
pump
-Assess
GI system:
muscle and
ventricular disorder.
substitutes
angina, GItherapy.
Monitor EC
in the
sion,
term other tissue inhibitor,
bowel
sounds
8 hrly,
hypertroph Abdominal
bradycardia
G during prolonged
inhibition
angina
treatment
since yit block
abdomen
cells
pain,
nausea,
,
therapy.for pain
of excitation
pectoris
of pathologic
the final
and swelling,
diarrhea,
hypotensio
contraction
and
hypersecretor step of acid
appetite loss.
dyspepsia.M
coupling and
vasospastic n,
y condition: to production.
-Monitor hepatic
usculoskeleta
palpitations
subsequent
angina
maintain
enzymes.
-Monitor intake and
l-muscle
GI: gingival
contraction
healing of
Assess
output ratios and
cramps,
hyperplasia
erosive
knowledge/teach
daily
myalgia,
, nausea
esophagitis.
appropriate
use of this
weight. Assess
for
back
or leg
DERM:
Short term
medication,
signs of CHF
pain.
flushing
(peripheral edema,
treatment
interventions
to
Respiratoryrales/crackles,
of active
reduce
side effects, 63
cough, upper
weight
benign gastric
anddyspnea,
other symptoms
respiratory
gain and jugular
ulcer
to report
infection
venous distention
Mechanism
of action
Indication
Mannito
l
Increases
osmotic
pressure of
plasma in
glomerular
filtrate,
inhibiting
tubular
reabsorption
of water and
electrolytes
(including
sodium and
potassium).
These actions
enhance
water flow
from various
tissues and
ultimately
decrease
intracranial
and
intraocular
pressures
Test dose
for marked
oliguria or
suspected
inadequate
renal
function,
prevent
acute renal
failure
during
cardiovasc
ular and
other
surgeries,
acute renal
failure, to
reduce
intracranial
pressure
and brain
mass,
reduce
intraocular
pressure,
to promote
dieresis in
drug
toxicity,
irrigation
during
transurethr
al resection
of prostate.
Osmitr Osmotic
ol
Diuretic
Side
Effects/
Adverse
Reaction
CNS:
dizziness,
headache,
seizures
CV: chest
pain,
hypotension,
hypertension,
tachycardia,
thrombophlebi
tis, heart
failure,
vascular
overload
EENT: blurred
vision, rhinitis
GI: nausea,
vomiting,
diarrhea, dry
mouth
GU: polyuria,
urinary
retention,
osmotic
nephrosis
Metabolic:
dehydration,
water
intoxication,
hypernatremia
, hyponatremi
a,
hypovolemia,
hypokalemia,h
Time
and
Dosag
e
50ml
IVTT
every
6 hrs
Nursing
Responsibilities
-Monitor signs of
electrolyte
imbalance
64
65
66
things and sufficient knowledge about the patients conditions can be of great help and
they should know the preventive measures for prevention is always better than cure.
B. Patients Prognosis
Poor
Fair
Good
Duration
Justification
Patient has been
admitted
because of right
sided weakness
Onset
experienced his
chief complaint
Willingnes
the willingness
to take all
medications
after the
explanation of
the purpose of
the medicine.
67
Environm
The patient
ent
stayed in a ward
Diet
on salty and
fatty foods.
Computation:
Poor-
1x0=0
Fair-
2x3=6
Good-
3x2=6
12/5 = 2.4 (Fair Prognosis)
C. RECOMMENDATIONS
Giving importance to the health of ourselves and maintaining a healthy lifestyle
as individuals, is highly required to maintain a good and healthy life. It is because
ignoring the health condition could greatly affect life especially when certain conditions
or diseases would develop.
68
It is very important that every person should give importance to his/her health. A
person should promote healthy lifestyle changes that include adequate nutrition, clean
environment, and free from stress. For our patient, it is important to eliminate those
factors that can trigger to his condition.
With this we recommend the following:
1.
2.
3.
4.
5.
6.
7.
We were able to appreciate more the essence of utilizing the nursing process in
the care, service and management of our patient. This case study improves not only our
70
knowledge but also with our skills concerning on providing care for our patient with such
diseases and we can be able to share our learning regarding this study to the significant
people. In addition, it enhances our analysis, research, knowledge and skills on the field
of nursing. It was indeed a hard job on conducting this study yet, it gave a great impact
in our career regarding how useful it is in our chosen profession.
XI.
BIBLIOGRAPHY
Books
71
Medical - Surgical Nursing 7th ed. by Black Joyce M. and Jane Hokanson Hawks
Medical Surgical Nursing 7th ed. Copyright 2008 by Lewis, et.al. Nurses
pocket guide, 12th ed. by Doenges, Marilynn, et.al.
http://www.healthline.com/health/cerebrovascular-accident#Overview1 Date
72
http://www.worldlifeexpectancy.com/philippines-strokeDate of Retrieval:
73