190577365 bsn3-2c-uc-bcf-cva-case-study

BSN3- SECTION2-GROUP C NCM 103 1ST SEM SY 2013-2014

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The proponents of this case study would like to extend their warmest gratitude to all the people who made the success of this undertaking a reality.

First and foremost, to the Almighty Father, for His unceasing love and blessings; for giving us enough power and fortitude to face all the hardships in the making of this work. To Him be all glory and praise!

To our Clinical Instructors, Mrs. Josephine Minger RN MAN, Ms. April Anne Balanon RN MSN, Mr. Ken Fias-Ilon RN MAN, Mrs. Mediatrix Lee RN MAN and Dr. Josephine Rivera MD for their invaluable time, knowledge, effort and suggestions rendered to us and in securing information that made a valuable involvement to our case study.

To all doctors and staff nurses of Stroke Unit of Baguio General Hospital and Medical Center, for the openhanded assistance and services they showed and for giving us the opportunity to complete this endeavor.

CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II Page 1



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The researchers also greatly acknowledge Mr. X significant others, for cooperation and willingness she showed.

To the researcher’s loving parents for expressively and economically supporting the career the researchers have been taking and for their never ending support and understanding; for always being there to guide us and care for us after the long days of duties.

To our classmates, friends, mentors and colleagues, for giving us the inspiration to finish this seemingly impossible task.

To the group, we would like to recognize each other for our own radical efforts in order to complete this case study; for sticking together through thick and thin and for simply being there. With this, we are proud to say that we are indeed the mighty Group C.

Lastly, to each and everyone who helped realize this job into completion, may it be direct or indirect, no matter how minimal, the gratitude and pleasure for the achievement of this task is ours to share.

Thank You Very Much!!!! And God Bless You All!!!!!

The Researchers

TABLE OF CONTENTS

Pages

I. INTRODUCTION . . . . . . . . . .3II. STATEMENT OF OBJECTIVES . . . . . . . .4III. GENERAL PROFILE/INFORMATION . . . . . . .4IV. CHIEF COMPLAINT . . . . . . . . .5V. PRESENT HISTORY OF THE ILLNESS . . . . . . .5VI. PAST HISTORY OF THE ILLNESS . . . . . . . .5VII. SOCIAL AND ENVIRONMENTAL HISTORY . . . . . .6VIII. FAMILY HEALTH HISTORY. . . . . . . .6IX. HEALTH-PERCEPTION/HEALTH MANAGEMENT PATTERN . . . .

.7X. PHYSICAL EXAMINATION

Head to Toe . . . . . . . . . .8-1613 Areas of Assessment . . . . . . . .16-20

a. Psychosocial Status.b. Environmental Statusc. Mental and Emotional Statusd. Sensory Statuse. Motor Statusf. Nutritional Statusg. Elimination Statush. Fluid and Electrolytes



i. Circulatory Statusj. Respiratory Statusk. Temperature Statusl. Integumentary Statusm. Comfort Status

XI. DIAGNOSTIC PROCEDURESa. Hematology. . . . . . . . . . .21b. Blood Chemistry. . . . . . . . . .22c. Chest AP . . . . . . . . . .22d. Urinalysis. . . . . . . . . . .23e. Cranial CT-Scan . . . . . . . . .23

XII. TREATMENT /MANAGEMENTa) IV Fluids . . . . . . . . . .28b) Drugs . . . . . . . . . . .24-27

XIII. COMPREHENSIVE PATHOPHYSIOLOGY . . . . . . .29XIV. NURSING CARE PLANS

a) Prioritization of Problems . . . . . . . .30b) Basis of Prioritization . . . . . . . . .30c) Nursing Care Plans

1. Actual . . . . . . . . . .32-372. Potential . . . . . . . . .38-40

XV. DISCHARGE PLANS . . . . . . . . . .41XVI. CONCLUSIONS AND RECOMMENDATIONS. . . . . .42XVII. LIST OF REFERENCES . . . . . . . . .43

I. INTRODUCTION

The BSN3-Section 2-Group C was given the opportunity to have a hospital exposure last August 5-7, 2013 at 7-3 shift and on the said dates found a commendable case reasonable to be presented for the case study as agreed by the group.

This study hopefully would become one of the bases for innovation of the Philippine health care system especially in the Medical Surgical setting. The same study aims to be a means of research practice for the studied profession. Readers of the study are expectedly to be educated in the course of taking care of patients. This also targets to document the event which by the demand of time can be used for review or recall about the subject event. In our part, this is essential for our realization of the said experience and which would make us a subject of ourselves for improvement.

A Cerebrovascular Accident or stroke is infarction of a specific portion of the brain due to insufficient blood supply. It can occur from an occlusion of one of the major vessels feeding the brain, a partial or complete obstruction of a major intracranial vessel, or it can also be a hemorrhage within the brain. The blood vessels affected determines the area and extent of infarction.

There are risk factors prior to the recurrence of CVA such as hypertension, hypercholesterolemia, smoking, oral contraceptives use, emotional stress, obesity, family history of stroke and age. This condition may alter the original circulation of blood, then leads to stroke. In line with this, as we all know almost all of the illicit drugs, alcohol and nicotine found in cigarettes are one of the potent vasoconstrictor.

Stroke depends primarily on the location of the lesion or infracted tissue. If the brain stem is affected, blood pressure fluctuations altered respiratory patterns and cardiac dysrythmias are all possible.



Coma can follow stroke from various causes; strokes due to occlusal disease (thrombus, embolus) rarely caused sudden death. When sudden death thus occurs it is usually due to heart failure. Respiratory infection and brain stem failure are two primary causes of death with stroke.

According to the Philippine Nurses Association, the top 5 of the clinical disease entities frequently studied were Cerebrovascular Disease, infectious disease, neuromuscular diseases, epilepsy and demyelinating disease. For the past 10 years, there has been an increasing trend in the number of studies dealing with Cerebrovascular Disease.

The group chose Patient X as their subject primarily because his case posed as a very intricate case requiring due understanding and knowledge. The group recognizes their partial knowledge about CVA and the surgical procedures involved in such condition, thus making this case a good avenue to broaden the proponents’ knowledge about the disease and the surgical procedures involved.

Having awareness and gaining more knowledge about CVA would enhance our skills and attitudes in handling patients suffering from this disease.

This case serves as a challenge for us student-nurses to be committed and dedicated health professionals for in the next days, we will take care of the health of the citizens.

II. STATEMENT OF OBJECTIVES

A. General Objectives

The main goal of the group is to be able to present the case study of our chosen client that would provide a comprehensive discussion of the pathological mechanism of the disease to yield significant information for the case study.

B. Specific Objectives

This case analysis aims to:

a) Illustrate the pathophysiology of CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II and in relation to the signs and symptoms specially observed in the clients.

b) Discuss the medical intervention for the management of CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II.

c) Formulate appropriate nursing care plans suited for the client based on the assessment findings.

d) Identify care measures to be given to the patient and family to promote continuity of care and independence after discharge.

III. GENERAL PROFILE / INFORMATION

Name: X

Age: 74 years old

Sex: Male

Civil Status: Married



Hospital Number: 716217

Date of Birth: January 11, 1939

Place of Birth: Mankayan, Benguet

Nationality: Filipino

Address: Abatan, Buguias Benguet

Occupation: Retired Lawyer

Religious Affiliation: Roman Catholic

Admitting Diagnosis: HPN- II T/C CVA

Admitting Physician: Dr. Joel B. Bongotan MD

Final Diagnosis: CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II

Hospital: Baguio General Hospital and Medical Center

Hospital Area: Stroke Unit Medical Ward

Date Admitted: August 1, 2013

Time Admitted: 5:55 PM

Health Care Financing: PhilHealth and SSS

IV. CHIEF COMPLAINT

Nape pain (right side), right sided body weakness with dizziness

V. PRESENT HISTORY OF ILLNESS

This was the patient’s first admission in a hospital in his entire life as he can remember. Two days prior to admission at around 1:00 PM on July 29, 2013, the patient had sudden onset of dizziness causing him to fell down to the floor, fatigability, right sided body weakness where in his hand and feet movement became imprecise and speech became incomprehensible these happened while he is fetching a pale of water from a spring 30 feet away from their house. He was drinking an alcoholic beverage of 3 bottles of San Mig Light before the symptoms manifested. His wife immediately placed him on bed in a high Fowler’s position. She called her neighbor and brought 3 tablets of Neobloc 30 mg to the patient. The patient had taken the medication and relieved of his dizziness. He had a sound sleep that night. The morning after, he still experienced same symptoms meanwhile a midwife visited him and advised him to be admitted to a hospital and she also emphasized that it would be better to take the medication that is prescribed by the physician also to avoid other complications because Neobloc that was taken by the patient was unprescribed and was only recommended by their neighbor since he is also hypertensive. The SO was alarmed and decided to rush patient X at Buguias Emergency Hospital.

One day prior to admission, no noted improvement hence, opted to transfer to Baguio General Hospital and Medical Center for further management and was admitted on August 1, 2013 at around 5:55 PM.



VI. PAST HISTORY OF ILLNESS

He’s heredo-familial disease is hypertension and 1 died with heart attack in their family. During his teenager, mid-adult years (mid 40’s) and the recent years, he had been eating many fatty foods such as fried chicken, fried fish and “pinikpikan” and cholesterol rich foods such as fried egg. He also loves to eat salty foods. He also claimed that he had no known food and drug allergy nor experience any accidents or injuries.

He has no previous illness for the past six months. He did not recall having been admitted in a hospital in his life. He hasn’t experienced any surgery. He also hasn’t experience blood transfusion. Patient had no known food and drug allergies.

He was also an herbalist, believing in the effectiveness of herbs as a health treatment when having minor illness at home.

He claimed that he didn’t ever try smoking in his entire life. He admitted that he drank alcohol occasionally during her teenage years up to present.

VII. SOCIAL AND ENVIRONMENT HISTORY

Patient X is a College graduate in the course of Law in University of the Cordilleras; he took his bar exam and passed. He worked as a lawyer for almost 10 years in Baguio City. He is married to a High school teacher major in English at the age of 28. His family used to reside at Buguias Benguet. He lives together with his wife and grandchildren. They had their children grown there and their ethnic affiliation is Kankana-ey. Each one of them had finished their studies and now working abroad. Their 1st Child is an architecture in Iran for 4 years, the 2nd child worked as a Mechanical Engineer in Switzerland for 1 year while the 3rd Child is working as a seaman in Abu Dhabi for almost 5 months.

According to SO’s propositions, He do attends church in regular basis but has no known devotion to “Sto. Niño maybe.” Noticeably, he as a father was bonded significantly to his 3 sons, when they were still a children they used to be in his bedside. She added that he is really close to his grandchildren and feels in deep sadness whenever one of them leaves for attending school here in Baguio. They usually visit him during sembreak, summer, holidays and special occasions.

They used to live in a 3 storey house and is made of concrete and has 5 bedrooms, one bathroom, a kitchen, and a living room which is just enough or adequate for their living space. The location of the house is away to any possible accident hazards. The house appears to be durable and able to resist typhoons. Every member of the family has their own bedrooms. Mr. and Mrs. X share bedrooms while the siblings have their own rooms. The Laundry area outside the house, kitchen sink cabinet and the garbage cans are the resting sites of vectors of disease such as flies, mosquitoes and cockroaches present in the house. Their foods are stored in closed door cabinets and the refrigerator. Their water supply comes from spring. The water coming from the spring is used for washing, cleaning, and bathing and for drinking purposes. Their bathroom is near the kitchen and is kept clean everyday by his wife. Their way of disposing garbage is through a closed compost pit only for the biodegradable while for the plastic trashes they used to burn it. They have three garbage cans inside the house, one is in the kitchen, the other, is in



the bathroom and lastly, near the bedroom. Their neighborhood is not congested, there is still room for trees and plants to grow and place to play and hang-out. They have their own telephone line and every family has their own cell phones. They also have a family van for their transportation facility.

VIII. FAMILY HEALTH HISTORY

According to the SO, Patient X’s father side only has a Hypertension and 1 died with heart attack in their family.

XI. HEALTH – PERCEPTION / HEALTH MANAGEMENT PATTERN

Presently, the family is in good condition.The family members’ undergone complete immunization when they are still young. Mr. X makes

sure that his family will not lead to any diseases. He is very sensitive to the health of his sons when they were still young.

He eats three times a day. His food preferences are more often meat, fruits, vegetables and less sea foods. The members of the family (except his wife) have the habit of drinking liquors occasionally. His healthy lifestyle practices is walking, badminton, stretching which takes 6-10 minutes and eating fruits most specifically oranges. Because he is too old, he did not exercise everyday. He has enough of sleep about 8 hours a day he feel complete when he has sufficient rest a day. Resting and listening to radio drama serves as his relaxation and stress management activities.

X. PHYSICAL ASSESSMENT

A. Head to toe Assessment

Date Assessed: August 7, 2013, 8:15 AMVital Signs:• BP: 140/100 mmHg• PR: 92 BPM• RR: 23 CPM• T: 36.8 °C

General Appearance:• Proportionate varies to body built, height, and weight in relation to the client's age, lifestyle,

and health.Height- 5’8” Weight- 75 kgs

• Minor body odor and foul breathe odor relative to self care deficit.• Cooperative; quantity and quality of speech are slightly understandable; exhibits thought

through association of body gestures in communicating.• Relevance and organization of thoughts logically sequence and makes sense of reality

General Survey: Patient is lying on bed, awake, coherent, and afebrile with oxygen inhalation at 10 LPM via face

mask with ongoing IVF of PNSS 1L x 20 gtts/minute at 500 cc level hooked at left metacarpal



vein patent and infusing well; intact NGT; With intact and patent IFC connected to a urine bag draining to amber colored urine;

Needs full assistance to ADL and with signs of distress noted. Used adult diaper for defecation.

AREAS ASSESSED ACTUAL FINDINGS1. INTEGUMENTARYA. SKIN

1. Skin color Pale

3. Presence of edema No edema

4. Existence of lesions Freckles, some birthmarks, some flat and raised nevi, no abrasions or other lesions

5. Skin moisture Dry

6. Skin temperature Uniform; within normal range

7. Skin turgor Sagged

8. Skin textureWrinkled

B. NAILS1. Fingernail plate shape (its curvature and angle) Convex curvature; angle of nail plate about 160°

2. Fingernail and toenail bed color Pallor

3. Fingernail and toenail texture Smooth texture

4. Presence of tissues surrounding nailsIntact epidermis



5. Blanch test result of capillary refillDelayed 4 seconds

2. HEAD

A. SKULL

1. Size, shpae and symmetry of the skullRounded (normecephalic and symmetrical, with frontal, parietal, and occipital prominences); Smooth skull contour

2. Presence of nodules, masses, and depressions Smooth, uniform consistence; absence of nodules or

masses

B. HAIR

1. Evenness of growth, thickness or thinness of hair Thin hairs not evenly distributed

2. Color Black with white hairsC. FACE

Facial features, symmetry of facial movements

slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds

3. EYES

A. EYEBROWS

Hair distribution, alignment, skin quality and movement

Symmetrical and in line with each other, black and evenly distributed

B. EYELASHES

Evenness of distribution and direction of curl Evenly distributed and turned outward

C. EYELIDS

Surface characteristics and position (in relation to the cornea, ability to blink, and frequency of blinking)

Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are open; eyelids meet completely when the eyes are closed; symmetrical

D. CONJUNCTIVA



1. Color, texture, and tine presence of lesions in the bulbar conjunctiva

Pale in color, with presence of small capillaries; moist; no foreigh bodies; no ulcers

2. Color, texture, and the presence of lesions in the palbebral conjunctiva

Pale in color, with presence of small capillaries; moist; no foreigh bodies; no ulcers

E. SCLERA

Color and clarity White in color, clear, no yellowish discoloration; some capillaries maybe visible

F. CORNEA

Clarity and texture No irregularities on the surface; looks smooth; clear or transarent

G. IRIS

Shape and color Anterior chamber is transparent; no noted visible materials; color depends on the person's race

H. PUPILS

1. Color, shape, and symmetry of size Color depends on the person's race; size ranges from 3-7 mm, and are equal in size; equally round

2. Light reaction and accommodation Constrict briskly/sluggishly when light is directed to the eye, both directly and consensual

3. Ability to blink Absence of blink in the right eye

I. VISUAL ACUITY

1. Near vision Difficulty in reading newspaper not unless using his eye glass.

2. Distance vision 9/20' vision on Snellen chart

J. LACRIMAL GLAND

Palpability and tenderness of the lacrimal gland No edema or tenderness over lacrimal gland



K. EXTRAOCULAR MUSCLES

Eye alignment and coordination Both eyes coordinated, move in unison, with parallel alignment

L. VISUAL FIELDS

Peripheral visual fields When looking straight ahead, client can see objects in the periphery

4. EARS

A. AURICLES

1. Color, symmetry of size, and positionColor same as facial skin; symmetrical; auricle aligned with outer canthus of eye, about 10 degrees from vertical

2. Texture, elasticity and areas of tenderness

Mobile, firm, and not tender, pinna recoils after it is folded

B. HEARING ACUITY TESTS

1. Client's response to normal voice tones Normal voice tones audible

2. Watch tick test result Able to hear ticking in both ears

3. Weber's test result Sound is heard in both ears or is localized at the center of the head

4. Rinne test result Air-conducted (AC) hearing is greater than bone-conducted (BC) hearing

5. NOSE

1. Any deviations in shape, size, or color and flaring or discharge from the nares

Symmetric and straight; no discharge or flaring; Uniform color

2. Presence of redness, swelling, growths and discharge in the nasal cavities Mucosa pink; clear, watery discharge; no lesions



3. Nasal septum (between the nasal chambers) Nasal septum intact and in midline

4. Patency of both nasal cavities Air moves freely as the client breathes through the nares

5. Tenderness, masses, and displacements of bone and cartilage Not tender; no lesions

6. SINUSES

Identification of the sinuses and for tenderness Not tender

7. MOUTH

A. LIPS

Symmetry of contour color and texture Pale in color, dry, rough in texture due to cracking; symmetry of contour, ability to purse lips

B. BUCCAL MUCOSA

Color, moisture, texture and the presence of lesions

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

C. TEETH

Color, number and condition and presence of dentures

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

D. GUMS

Color and condition Pink gums; no retraction

E. TONGUE/FLOOR OF THE MOUTH

1. Color and texture of the mouth floor and frenulum

Pink color; moist; slightly rough; thin whitish coating; moves freely; no tenderness



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

Central position; pink color; smooth tongue base with prominent veins

3. Any nodules, lumps, or excoriated areas Smooth with no palbable nodules, lumps, or excoriated areas

F. PALATES and UVULA

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

Light pink, smooth, soft palate; lighter pink hard palate, more irregular texture

2. Position of the uvula and mobility (while examining the palates) Positioned in midline of soft palate

G. OROPHARYNX and TONSILS

1. Color and texture Pink and smooth posterior wall

2. Size, color, and discharge of the tonsils Pink and smooth; no discharge; of normal size

3. Gag reflex Dificiency

8.. NECK and LYMPH NODESA. NECK MUSCLES

Inspection of neck muscle and head movement.

Muscles equal in size, coordinated head movement without discomfort

A. LYMPH NODES

Identification of Lymph nodes and for tenderness Not palpable

B. TRACHEA



Placement of the Trachea Central placement in midline of neck; spaces are equal on both sides

C. THYROID GLAND

1. Symmetry and visible masses Not visible on inspection

2. Smoothness and areas of enlargement, masses or nodules Lobes may not be palpated

9. THORAX

A. POSTERIOR THORAX

1. Shape, symmetry, and comparison of anteroposterior thorax to transverse diamter

Anteroposterior to transverse diameter in ratio 1:2; Chest symmetric

2. Spinal alignment Spine vertically aligned

3. Temperature, tenderness, and masses Skin intact; uniform temperature; chest wall intact; no tenderness; no masses

4. Respiratory excursion assessment Full and symmetric chest expansion

5. Vocal fremitus palpation Bilateral symmetry of vocal fremitus; Fremitus is heard most clearly at the apex of the lungs

6. Posterior thorax percussionPercussion notes resonate except over scapula; Lowest point of resonance is at the diaphragm; percussion on a rib normally elicits dullness

7. Posterior thorax auscultation Vesicular and bronchovesicular breath sounds

B. ANTERIOR THORAX

1. Breathing patterns Quiet, rhythmic, and increase respiratory rate



2. Temperature, tenderness, masses Skin intact; uniform temperature; chest wall intact; no tenderness; no masses

3. Respiratory excursion assessment Full symmetric excursion; thumbs normally separate 3 to 5 cm

4. Vocal Fremitus palpation Bilateral symmetry of vocal fremitus; Fremitus is normally decreased over heart and breast tissue.

5. Anterior thorax percussionPercussion notes resonate down to the sixth rib at the level of the diaphragm but are flat over areas of heavy muscle and bone, dull on areas over heart and the liver, and tympanic over the underlying stomach

6. Trachea auscultation Bronchial and tubular breath sounds

7. Anterior thorax auscultation Bronchovesicular and vesicular breath sound

10. CAROTID ARTERIES

1. Carotid artery palpationSymmetric pulse volumes; full pulsations, thrusting quality; quality remains same when the client breathes, turns head, and changes from sitting to supine position; elastic arterial wall

2. Carotid arteries auscultation No sound heard on auscultation

11. JUGULAR VEINS

Jugular veins inspection No sound heard on auscultation

12. BREAST and AXILLAE

1. Breast's size symmetry, and contour or shape

Rounded Shape; slightly unequal in size; generally symmetric

2. Localized discolorations or hyperpigmentation, retraction or dimpling, localized hypervascular areas, swelling or edema in the skin of the breast

Skin uniform in color; skin smooth and intact; no major discolorations

3. Areola's size, shape, symmetry color, discharge, and lesions

Round or oval and bilaterally the same; color varies widely, from light pink to dark brown; irregular placement of sebaceous glands on the surface of the areola irregular placement of sebaceous glands on the surface of the areola



4. Nipple's size, shape, position, color, discharge, and lesions

Round, everted, and equal in size; similar in color; soft and smooth; both nipples point in the same direction; no discharge, except from pregnant or breast-feeding females; inversion of one or both nipples that is present from puberty

5. Axillary, subclavicular, and supraclavicular lymph nodes No tenderness, masses, or nodules

6. Masses, tenderness, and any discharge from the nipples No tenderness, masses, or nodules, or nipple discharge

13. ABDOMEN

1. Abdominal contour Flat rounded (convex), or scaphoid (concave)

2. Enlargement of liver of spleen No evidence of enlargement of liver or spleen

3. Symmetry of contour Symmetric Contour

4. Abdominal movements associated with respirations, peristalsis or aortic pulsations

Symmetric movements caused by respiration; visible peristalsis in very lean people; aortic pulsations in thin persons at epigastric area

5. Bowel sounds, vascular sounds, and peritoneal friction rubs

Audible bowel sounds; Absence of arterial bruits; absence of friction rub

6. Several abdominal areas of the four quadrants

Tympany over the stomach and gas-filled bowels; dullness, especially over the liver and spleen, or a full bladder

7. Light palpation in the four quadrants No tenderness; relaxed abdomen with smooth, consistent tension

14. MUSCULOSKELETAL SYSTEM

A. MUSCLES

1. Muscle size and comparison on the other side Proportionable to the body even in both sides

2. Contractures in the muscles and tendons No contractures

3. Fasciculations and tremors in the muscles No fasciculation and tremors



4. Muscle tonicity Even and firm muscle tone

5. Muscle strength60% muscle strength at the left side of the body. Whereas the right side is poor on muscle strength due to right sided body weakness

B. BONES1. Normal structures and deformities in the skeleton No deformities

2. Areas of edema or tenderness in the bones Absence of edema or tenderness in bones

C. JOINTS

1. Joint swelling No joint swelling, no warmth, redness

2. Tenderness, smoothness of movement, swelling, crepitation and presence of nodules

No tenderness, swelling and nodules: smooth movements: minimal crepitus may be present but there should be no pronounced crepitation

B. 13 Areas Assessment***The mode in communicating between students and patient is through the help of the SO since they both know how to understand sign language.

1. Psychosocial Status

According to Erik-erikson’s 8 stages of development the client is under the Ego integrity vs. Despair (65 to death). This stage occurs during late adulthood from age 65 through the end of life. According to him, he did fulfill his career and was able to raise their children well, he didn’t also regret every moment of his life.

2. Environmental Status

Mr. X used to live in a 3 storey house and is made of concrete and has 5 bedrooms, one bathroom, a kitchen, and a living room which is just enough or adequate for their living space. The location of the house is away to any possible accident hazards. The house appears to be durable and able to resist typhoons. Every member of the family has their own bedrooms. Mr. and Mrs. X share bedrooms while the siblings have their own rooms. The Laundry area outside the house, kitchen sink cabinet and the garbage cans are the resting sites of vectors of disease such as flies, mosquitoes and cockroaches present in the house. Their foods are stored in closed door cabinets and the refrigerator. Their water supply comes from spring. The water coming from the spring is used for washing, cleaning, and bathing and for drinking purposes. They have their own bathroom and toilet. Their bathroom is near the kitchen and is kept clean everyday by his wife. Their way of disposing garbage is through a closed compost pit only for the biodegradable while for the plastic trashes they used to burn it. They have three garbage cans inside the house, one is in the kitchen, the other, is in the bathroom and lastly, near the bedroom. Their neighborhood is not congested, there is still room for trees and plants to grow and a place to play and



hangout. They have their own telephone line and every family has their own cell phones. They also have a family van for their transportation facility.

3. Mental and Emotional Status

The patient responds to stimuli by means of rubbing his sternum for him to wake up. The patient needs to be oriented with the time and date though he is aware that he is currently admitted in the hospital. He is responsive (through gestures), coherent, and can relate to conversations. He even smiles with jokes and wave his hands when someone he used to see visited him. He is aware regarding his condition. His hospitalization merely affected his status. He is able to write his name without difficulty since he is left handed and he could differentiate the objects shown to him (i.e. differentiating banana from an apple.) Through sign language and hand gestures. His ability to read and write matches his educational level. The patient was also able to respond to questions asked of him and was able to identify objects presented to him. The patient was able to evaluate and act appropriately in situations requiring his judgment.

4. Sensory Status

Sense of sightMr. X is positioned in High Fowler’s position and asked to face the Snellen’s chart at the distance of

20 feet occluding the other eye. The client had 9/20 visual acuity on the right eye, the same with the left.

With the use of penlight the following were observed:

Pupils constrict when struck by light Patient’s eyes are symmetrical and round Sclera is white in color Eyes are symmetrical in moving.

5. Motor Status

Prior to admission, Mr. X was able to do daily routines without difficulty such as walking from one place to another, sit and change position in bed without difficulties.

During admission, Mr. X’s gait was assessed using the head to toe method. Obviously, he can’t able to stand on his own and balance himself since the patient is in total bed rest. He complains difficulty when turning him from side to side however; he states that he likes to move rather than flat in bed for a longer period of time.

Assessment of the range of motion of the patient was done through instructions which include the ability of the patient to bend his shoulder apart. He has difficulty in moving his right shoulder laterally and medially as well as rotating in the same manner. He has difficulty bending his right elbow however at the left elbow it can and farther apart or rotate it laterally to face upward and extending beyond the neutral position.



The patient can also flex and extend his left knee of his ankle and left foot, so he can’t tilt his right foot inward and move it toward and away the midline of his body. His neck is symmetrical with his head in central position. Movements through a full range of motion can be done with several discomforts.

6. Nutritional Status

Mr. X was put into NPO upon admission to facilitate test and for observation of his general condition. With intubation, a Nasogastric tube was also inserted thus allowing the patient to take only liquid foods. After the patient was extubated he was then allowed to take soft foods minimally to practice her to go back to a full diet but still during this moment, he still has NGT feedings so as to his medications. His BMI is 30.00 Kg/m2(Obese)

Obtained BMI BMI Ranges ----Kg/m2

Height: 5’’8 ft/inWeight: 75 KgBMI=30.00 Kg/m2

<18.5(Underweight)18.5-24.9(Normal)25-29.9 (Overweight)30.0-39.9(Obese)

7. Elimination Status

Before admission, he usually urinates for about 3-4 times a day and defecates twice or thrice.During admission, the urine output approximately ranges from 600-1350 cc per shift characterized

by amber in light yellow in color. He defecates regularly 2-3 times a day using the adult diaper and the characteristics of his stool are slightly yellow in color, sticky and foul odor.

August 5, 2013

Intake Output

Time Oral Parenteral

Others

Total Urine Drainage

Others Total

7-3 830 550 1380 1350 13503-11 1030 700 1730 600 600

Total: 3100 Total: 1950

August 6, 2013

Intake Output


Others


Others Total

7-3 1030 600 1630 1630 16303-11 600 450 1050 1050 1050 Total: 2680 Total: 2680

August 7, 2013


5/5

5/5

0/5

0/5


Intake Output


Others


Others Total

7-3 860 475 1335 600 6003-11 1250 400 1650 1250 1250 Total: 1800 Total: 2985

8. Fluid and electrolytes

Prior to admission, Mr. X drinks 2 glasses of water every after meal. He usually drinks a cup of coffee during breakfast and during afternoon snack. According to the SO, he drinks carbonated drinks rarely and drinks alcoholic beverages occasionally.

During admission, through NGT feeding he was able to drink water and take his medication after we pound and dissolved it in water. Mr. X was ordered to have an ongoing IVF of PNNS 1 L and regulated at 20 gtts/min. He has no restriction on his fluid intake. There was no edema present but there is dry skin noted. He was able to urinate 3-4 times within the shift by following the bladder training.

9. Circulatory Status

A. Pulse Rate

Data Time Pulse Rate08/05/13 10 am 110 BPM08/05/13 2 pm 115 BPM08/06/13 10 am 115 BPM08/06/13 2 pm 118 BPM08/07/13 10 am 111 BPM08/07/13 2 am 119 BPMHis pulse was obtained from radial artery. The pulse rate ranges from 110-135 BPM which is above the normal range of 60-100 BPM hence it is classified as Tachycardia. His capillary refills returns within 4 seconds and it was taken from left forefinger. Pulse scale is 2 + which is easily palpable.

B. Blood Pressure

Data Time BP08/05/13 10 am 180/100 mm Hg08/05/13 2 pm 170/100 mm Hg08/06/13 10 am 140/100 mm Hg08/06/13 2 pm 120/100 mm Hg08/07/13 10 am 150/100 mm Hg08/07/13 2 am 140/100 mm HgHis BP was obtained from brachial artery. His BP ranges from 120-180/100 mm Hg and is classified as Stage 2 HPN ranging from 140-150/100-110 mm Hg.

10. Respiratory Status

Data Time Respiratory Rate08/05/13 10 am 26 CPM08/05/13 2 pm 28 CPM08/06/13 10 am 25 CPM08/06/13 2 pm 29 CPM



08/07/13 10 pm 25 CPM08/07/13 2 pm 27 CPMHis respiratory status ranges from 25-29, which is above the normal range of 16-20 CPM thus, it is classified as Tachypnea. Nasal Flaring noted at times. When auscultated, his breath sounds are normal, no cough but have difficulty in breathing is noted. His SPO2 is ranging from 97 to 99%.

11. Temperature Status

Data Time Temperature08/05/13 10 am 36.5 °C08/05/13 2 pm 36.8 °C08/05/13 10 am 37.0 °C08/05/13 2 pm 36.5 °C08/05/13 10 am 36.7 °C08/05/13 2 pm 36.8 °CMr. X’s temperature was obtained by the use of axillary thermometer placed on his axilla. His temperature status is normal, ranges from 36.5-37.0 °C.

12. Integumentary Status

Skin is pale in color, with the presence of edema, freckles and some birthmarks are noted. Skin moisture is dry, afebrile, sagged in turgor, skin texture is wrinkled. Fingernail and toenail are pallor, convex curvature and angle of the nail plate is about 160°, smooth in texture, capillary refill is delayed for 4 seconds. Thin hairs not evenly distributed and black in color with white hairs

13. Comfort Status

Before admission, Mr. X usually sleeps between 8:00PM – 9:00PM and wakes up around 5:00AM and naps every afternoon.

Now that he is admitted, he could hardly sleep because of his condition. His vital signs need to be monitored hourly. He sleeps irregularly because of the occurrence of sudden chestpain during the night, uncomfortable, irritability and restlessness.



DIAGNOSTIC PROCEDURES:1. HEMATOLOGY

Data: Complete Blood CountDate of Examination: August 1, 2013 Time of Examination: 3:05 PMDescription: A complete blood count is usually a series of tests in which the numbers of red blood cells and platelets in a given volume of blood are counted. The CBC also measures the hemoglobin content and the packaged cell volume (hematocrit) of the red blood cells, assesses the size and the shape of red blood cell, and determines the types and percentages of the white blood cells.Significance: Provides valuable information about the blood and blood forming tissues, as well as other body system. Abnormal results can indicate the presence of a variety of conditions sometimes before the patient experiences symptoms of disease.

Reference/ Normal Findings Findings Interpretation and Analysis

RBCMale 4.7-6.1 10¹²/LFemale 4.2-5.9 10¹²/L

WBCMale 4.5-11.0

x10 9 /LFemale

HCTMale 40.7%-50.3%Female 36.1%-44.3%

PLTMale 150,000 -

450,000 x 10-6/L

Female

RBC-5.36x10¹²/L

WBC-5.9x109/L

HCT-49.0%

PLT-162x10-6/L

RBC- Within NORMAL range

WBC- Within NORMAL range

HCT- Within NORMAL range

PLT- Within NORMAL range

***

Data: Differential CountReference/ Normal Findings Findings Interpretation and AnalysisNeutrophilMale

48-73 %Female

LymphocytesMale 20-45 %Female

MonocytesMale 00-10 %Female

EosinophilsMale 00-05 %Female

Basophils

Neutrophil - 49 %

Lymphocytes – 39%

Monocytes – 09%

Eosinophils – 1%

Basophils- 0%

Neutrophil - Within NORMAL range

Lymphocytes - Within NORMAL range

Monocytes - Within NORMAL range

Eosinophils - Within NORMAL range

Basophils- Within NORMAL range



Male 00-02 %Female



3. Chest APChest X- Ray Anteroposterior View

Date of Examination: August 1, 2013 Time of Examination: 4:40 PMDescription: - a chest radiograph, commonly called a chest X-ray (CXR) or chest film, is a projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are among the most common films taken, being diagnostic of many conditions.Significance: Chest radiographs are used to diagnose many conditions involving the chest wall, including its bones, and also structures contained within the thoracic cavity including the lungs, heart, and great vessels. Pneumonia and congestive heart failure are very commonly diagnosed by chest radiograph.Reference/ Normal Findings: Results are considered normal if the organs and structures being examined are normal in appearance.Results:-Haziness is noted in the left paracardiac area.-Heart is enlarged.-Aorta isclerotic.-Diaphragm in normal in position and contour.-Included bones are intact.

Impression: Cardiomegaly Atherosclerotic aorta

2. Blood ChemistryData: Serum Electrolytes

Date of Examination: August 1, 2013 Time of Examination: 03:15 PMDescription: Electrolyte tests are performed from routine blood tests. Electrolyte tests are typically conducted on blood plasma or serum, urine, and diarrheal fluids.Significance: Serum electrolytes are taken in order to know whether the patient has electrolyte imbalance (excess or deficit in the plasma level of a specific ion). It is important to keep a balance of electrolytes in the body, because they affect the amount of water in our body, blood acidity (pH), muscle action, and other important processes.

Reference/ Normal Findings Actual Results Interpretation and Analysis

Constituents

Results

Glucose (Fasting)

3.85-6.05

mmol/L

Total Cholesterol

3.9-5.1 mmol/L

Blood Urea Nitrogen

1.7-9.3 mmol/L

Serum Creatinine

53-106 mmol/L

Constituents

Results

Glucose (Fasting)

4.56 mmol/L

Total Cholesterol

8.3 mmol/L

Blood Urea Nitrogen

4.9 mmol/L

Serum Creatinine

55 mmol/L

Glucose (Fasting)- Within NORMAL range

Total Cholesterol – ABNORMAL HIGH; Too much cholesterol in the blood, however, can cause deposits of cholesterol inside arteries. These plaques can narrow the artery enough to block blood flow. This process known as atherosclerosis commonly occurs in the coronary arteries which nourish the heart. For this case, an increase in the Total Cholesterol is just a proof supporting the atherosclerotic aorta.

Blood Urea Nitrogen - Within NORMAL range

Serum Creatinine - Within NORMAL range


http://en.wikipedia.org/wiki/Congestive_heart_failure

http://en.wikipedia.org/wiki/Pneumonia

http://en.wikipedia.org/wiki/Great_vessel

http://en.wikipedia.org/wiki/Heart

http://en.wikipedia.org/wiki/Lung

http://en.wikipedia.org/wiki/Thoracic_cavity

http://en.wikipedia.org/wiki/Chest

http://en.wikipedia.org/wiki/Projectional_radiography

http://en.wikipedia.org/wiki/Projectional_radiography





Data: UrineDate of Examination: August 1, 2013 Time of Examination: 4:09 PMDescription: Urinalysis is a diagnostic physical, chemical, and microscopic examination of urine sample (specimen). Specimens can be obtained by normal emptying of the bladder (voiding) or by a hospital procedure called catheterization.Significance: It is a useful screening tool for diseases such as urinary tract infections, renal disease, and other disease of the body which result in the formation of compounds that can be detected in the urine at abnormal levels.

Reference/ Normal Findings Results Interpretation and Analysis

Physical Results

Color Light Yellow- Amber

Transparency

Slightly hazy

Appearance Clear

Chemical

Results

pH level 5-8 phSpecific Gravity

1.010-1.030

Protein NegativeGlucose NegativeAlbumin Negative

Microscopic

Results

RBC 0WBC 0

Epithelial cells

0

Physical Results

Color Amber

Transparency

Slightly hazy

Appearance Clear

Chemical

Results

pH level 7.5 phSpecific gravity 1.010Protein NegativeGlucose NegativeAlbumin Negative

Microscopic

Results

RBC 0WBC 0

Epithelial cells

0

PhysicalColor- NormalTransparency- NormalAppearance- Normal

ChemicalpH level- Within normal rangeSpecific Gravity- Within normal range; ***Kidneys are able to concentrate urine

Protein- NormalGlucose- NormalAlbumin- Normal finding, indicates normal glomerular permeability and adequate reabsorption function of the kidneys.

MicroscopicRBC- NormalWBC- NormalEpithelial Cells- Normal


5. Cranial- CT ScanDate of Examination: August 1, 2013 Time of Examination: 4:30 PMDescription: - is a medical imaging method employing tomography. Digital geometry processing is used to generate a three-dimensional image of the inside of an object from a large series of two dimensional x-ray images taken around a single axis of rotation.Significance: CT Scanning of the head is typically used to detect: Bleeding, brain injury and skin fractures, brain Tumors, blood clot or Bleeding, enlarged brain cavities, etc...Reference/ Normal Findings: Results are considered normal if the organs and structures being examined are normal in appearance.Results:-There is an ill defined curvilinear hypodensity noted on the posterior and anterior limb of the left external capsule.-Likewise a well marginated area of low density is seen on the right occipital lobe with adjacent dilatation of the right occipital horn.-The thalami, centrum semi-ovale, and pineal body are not usual.-The pons, medulla, cerebellum and CPA area are undisturbed.-The sella, parasellar regions, petromastoids and basophenorals are intact.-Cranial vault is intact.

Impression: Acute vessel infarct, Left external capsule Gliosis, Right occipital lobe





TREATMENT AND MANAGEMENT:

a. Drugs:

NAME OF THE DRUG ACTION

DOSAGE/ FREQUENCY

INDICATION CONTRAINDICATION ADVERSE EFFECTS NURSING

RESPONSIBILITIES

MANNITOLBrand Name: Osmitrol, Resectisol

Classification: Osmotic Diuretic

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.

100 cc every 4 hours

Indications1. Increased

intracranial pressure (ICP)

2. Intraocular pressure (IOP)

Active intracranial bleeding (except during craniotomy), anuria secondary to severe renal disease, progressive heart failure, pulmonary congestion, renal damage, or renal dysfunction after mannitol therapy begins, severe pulmonary congestion or pulmonary edema, and severe dehydration.

-Dehydration-Headache-Blurred vision-Nausea and vomiting-Volume expansion-Chest pain-Thirst-Tachycardia-

Assessment: >Obtain patient’s medical history.>Assess patient’s condition>Monitor Vital Signs (BP, PR, RR)>Assess for allergic reactions like GI disturbances.

Planning:>Direct IV administration should be very slowly to prevent episodes of hypotension.

Health teaching:>Teach patient to gain benefits & not to miss any dose>Instruct patient to take only prescribed medicines.


DOSAGE/ FREQUENCY

INDICATION CONTRAINDICATION

ADVERSE EFFECTS

NURSING RESPONSIBILITIES


http://nursingcrib.com/pathophysiology/increased-intracranial-pressure/




Amlodipine

Classification:Calcium-channel Blockers

These medications block the transport of calcium into the smooth muscle cells lining the coronary arteries and other arteries of the body.

5mg OD Treat high blood pressure or chest pain.

Sick sinus syndrome, 2nd- or 3rd-degree heart block, hypertension less than 90 mm Hg systolic, hypersensitivity

Headache and edema (swelling) of the lower extremities, dizziness, flushing, fatigue, nausea, and palpitations

>Assess cardiac status: B/P, pulse, respiration, ECG>Teach pt. do not break, open, crush, or chew sust rel caps


DOSAGE/ FREQUENCY

INDICATION CONTRAINDICATION

ADVERSE EFFECTS

NURSING RESPONSIBILITIES

Generic Name: Citicoline

Classification:CNS stimulant/ neurotonic

Increase blood flow and oxygen consumption in the brain. It increases theneurotransmission levels because it favors the synthesis and production speed of dopamine in the striatum, acting then as a dopaminergic agonist thru the inhibition of tyrosine-hydroxylase

1 gm IV every 12 hours

Treatment of cerebrovascular accident in acute and recovery phase.It was indicated for the patient to accelerate the recovery of consciousness and helps the patient to overcome motor deficit.

Hypertonia of the parasympathetic nervous system

Headache, nausea, vomiting, diarrhea, shock, hypersensitivity, hypotension, insomnia,

Assessment: >Obtain patient’s medical history.>Assess patient’s condition>Monitor Vital Signs (BP, PR, RR)>Assess for allergic reactions like GI disturbances.

Health teaching:>Teach patient to gain benefits & not to miss any dose

>Instruct patient to

NAME OF THE DRUG

ACTION DOSAGE/ FREQUEN

INDICATION CONTRAINDICATION ADVERSE NURSING

RESPONSIBILITIES



CY EFFECTS

LOSARTAN

Brand Name: Lozargard

Classification: Angiotensin II blocker

Selectively blocks the binding Angiotensin II to receptor sites in many tissues, especially the vascular smoot h muscles and adrenal glands. This prevents the vasoconstriction and aldosterone –secreting effects of angiotensin II on these tissues.

35 mg BID Treatment for Hypertension.Reduction of Cardio-Vascular morbidity and mortality in hypertensive patients.

Hyperkalemia

Hypertonia of the parasympathetic nervous system

Fever and Insomniahypersensitivity, hypotension, insomnia, excitement

Assess cardiac status: B/P, pulse, respiration, ECGTeach pt. do not break, open, crush, or chew sust rel caps



NAME OF DRUG INDICATIONS ACTIONCONTRAINDICATION

SIDE EFFECTS

ADVERSE EFFECTS

NURSING MANAGEMENT

Brand name: Plain NSS

Other name: 0.9% Sodium Chloride Solution

Form: IV fluid

Route:

Dose:1000 ml @25 gtts/min

Frequency:

CLASSICFICATION: Isotonic Intravenous Solution

Used because it has little to no effect on the tissues and Make the person feel hydrated preventing hypovolemic shock or hypotension

-Normal Saline is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment.

-It contains no antimicrobial agents.

-The pH is 5.0 (4.5 to 7.0).

-It contains 9 g/L Sodium Chloride with an osmolarity of 308 mOsmol/L.

-It contains 154 mEq/L Sodium and Chloride.

-Heart failure

-Pulmonary edema

-Renal impairment

-Sodium retention

-hypotension -febrile response,

-infection at the site of injection,

-venous thrombosis or phlebitis extending from the site of injection,

-extravasation,

-and hypervolemia.

Monitor patient frequently or:

a. Signs of infiltration /sluggish flow

b.signs of phlebitis/infection

c. well time of catheter and need tobe replaced

d. Condition of catheter dressing.

Check the level of the IVF.

a.Correct solution, medication and volume.

b.Check and regulate the drop rate.

c.Change the IVF solution if needed.



COMPREHENSIVE PATHOPHYSIOLOGY:


Predisposing Factors:

Age: 76 years oldSex: MaleFamily history of CVD

Precipitating Factors:

DIET: Increase lipid and fatty foods intakeSedentary LifestyleObesity:BMI: 30.00 Wt: 75 kg Height: 5’’8 ft/inHPN II

HPN II

Dislodgement of Clot

Thrombotic Infarction

CVA Stroke

Motor Cortex Area Broca’s Area Postereoinferior Artery

Right Sided Body Weakness

Impaired Physical Mobility

Risk for Impaired Skin Integrity

Slurred Speech

Impaired Verbal Communication

Decrease Gag Reflex

Dysphagia

Risk for AspirationImpaired Verbal Communication


XIV. NURSING CARE PLANSA. Prioritizations of Problems

Rank Nursing Problem1 Self care deficit : hygiene, dressing and grooming related to

Neuromuscular impairment secondary to CVA2 Impaired verbal communication related to alteration of motor

speech area of the brain as manifested by slurring of speech3 Impaired Physical Mobility related to Musculoskeletal as manifested

by needs of fully assistance in ADL’s4 Risk for Aspiration Related To Impaired Swallowing 5 Risk for Impaired Skin Integrity related to Prolonged Bed rest

Secondary to Impaired Mobility

B. Basis of PrioritizationsProblem Justification

1. Self care deficit : hygiene, dressing and grooming, related to Neuromuscular impairment secondary to CVA

This is the first prioritized nursing diagnosis because the Orem’s self-care deficit theory explains not only when nursing is needed but also how people can be assisted through five methods of helping: acting or doing for, guiding, teaching, supporting, and pr0viding an environment that promotes health. Medical conditions that could lead to self care deficit are as follows: cerebrovascular accident, stroke, multiple sclerosis, renal dialysis, rheumatoid arthritis, and a lot more. In addition, the deficit may be the result of transient limitations, such as those one might experience while recuperating from surgery; or the result of progressive deterioration that erodes the individual’s ability or willingness to perform the activities required caring for himself or herself.

2. Impaired verbal communication related to alteration of motor speech area of the brain as manifested by slurring of speech

- This is the second prioritized nursing diagnosis because the disorder impairs the expression and understanding of language. So as we nurses prioritize this problem to improve a person's ability to communicate by helping him or her to use remaining language abilities, restore language abilities as much as possible, compensate for language problems, and learn other methods of communicating.

3. Impaired Physical Mobility related to Musculoskeletal as manifested by needs fully assistance

This is the third prioritized nursing diagnosis because according to Maslow’s hierarchy of needs, physiologic needs should satisfy first, so that the client should satisfy this to satisfy his physiologic needs. Maslow’s contended that until our basic physiologic needs were met, human beings aren’t really able to focus on meeting their higher order needs such as safety, love, esteem and self actualization. Physical mobility is necessary for the health and well-being of all persons ,but is especially important in older adults because a variety of factors impinge upon mobility with aging. Hogue(1964)identified mobility as the most important functional ability that determines the degree of independence and health care needs among older persons .CVA directly affecting mobility includes acute or chronic conditions that affect the muscular, skeletal or neurological systems and limit the person’s ability to move and those conditions that require restricted mobility as therapeutic regime. Impaired physical mobility a nursing diagnosis approved by the North American



Nursing Diagnosis Association defined as the state in which an individual has a limitation in independent, purposeful physical movement of the body or of one or more extremities. Related factors arising from within the person include pain or fear of discomfort, anxiety or depression and physical limitations due to neuromuscular or musculoskeletal impairment. External factors include enforced rest for therapeutic purposes, as in the case of immobilization of a fractured limb. The human body is designed for motion; hence, any restriction of movement will take its toll on every major anatomic system.

4. Risk for Aspiration Related To Impaired Swallowing

This nursing diagnosis will received 4th prioritization because this may ability to swallow. Slightly less saliva is produced. As a result, food is softened (macerated) less well and is drier before it is swallowed. The muscles in the jaws and throat may weaken slightly, making chewing and swallowing less efficient. Also, older people are more likely to have conditions that make chewing and swallowing difficult. For example, they are more likely to have loose teeth or to wear dentures.With aging, the contractions that move food through the esophagus become weaker. This change is very slight and usually has little effect on moving food to the stomach. But if older people try to eat while lying down or lie down just after eating, food may not easily move to the stomach. If reflux develops, the aging esophagus may be slower to move refluxed stomach acid back into the stomach. Some older people have a hiatus hernia, which may contribute to reflux.

5. Impaired Skin Integrity related to Prolonged Bed rest Secondary to Impaired Mobility

The nursing diagnosis received the 5th prioritization due to significant impact on aging to the skin and its ability to retain moisture. Changes in aging skin (eg, decreases in production of lipids, desquamation rate, and dermal proteins; changes in lipid composition; and prolonged epidermal turnover) decrease the skin’s ability to retain moisture.



ASSESSMENT

EXPLANATION OF THE PROBLEM

PLANNINGNURSING

INTERVENTIONS

RATIONALE EVALUATION

Subjective:“ Simula nung mastroke siya di na niya magawa kahit mga simpleng pansariling gawain.” As verbalized by the SO

Objective:

>Unkempt, soiled clothing

>Foul smelling odor

>with unsatisfying appearance

>with minimal sweatinguncombed hair

Hypertensionˇ

Occlusion within vessels of the brain parenchyma

ˇDisruption of blood supply in the brain

areaˇ

Tissue and cell necrosis

ˇDestruction of Neuromuscula

r junctionsˇ

Interruption in transportation

of electrical impulses to

the neuromuscular

receptors

SHORT TERM OBJECTIVE:

After 4 hours of nursing interventions, the patient will be able >to identify personal resource that can provide assistance;> to verbalize knowledge of health care practices.> demonstrate techniques/lifestyle changes to meet self care needs.

LONG-TERM GOAL:

After 3 days of nursing intervention, the patient was able to maintain neatness and cleanliness.

INDEPENDENT:

>Assessed for type and severity of immobility impairment, muscle flaccidity, spasticity and coordination, ability to walk, sit, move in bed perform

>Assessed presence of factors that affects client’s capacity for self care.

> Provided privacy during dressing

> Provided frequent assistance as needed with dressing

> Provided loosed clothing

>Changed the diaper as soon as patient defecated.

> Assisted in removing and replacing necessary clothing

>Provides data regarding mobility and ability to perform activities with in limitations without injury or frustration

>Impairment in these areas can alter client’s ability for self-care.

>To promote privacy.

>To reduce energy expenditure

>To ensure easier dressing and comfort

> To protect the patient’s skin integrity maintaining his first line of defense against sickness and infection.

>Clothing that is difficult to get in and out of may compromise a patient’s

LONG TERM OBJECTIVE:

Goal Met After 4 hours of nursing interventions, the patient was able >to identify personal resource that can provide assistance;> to verbalize knowledge of health care practices.> demonstrate techniques/lifestyle changes to meet self care needs.

LONG-TERM GOAL:

After 3 days of nursing intervention, goal was met as evidenced by the patient maintained neatness and cleanliness.



NURSING DIAGNOSIS:Self care deficit : hygiene, dressing and grooming, related to Neuromuscular impairment secondary to CVA

>Increased daily activity level as client progresses.

>Emphasized personal appearance, encouraged dressing in clean clothes.

ability to be continent

>Adequate exercise increases muscle tone; consistency in daily routine stimulates bowel elimination.

>Appearance affects how the client sees self. A disheveled appearance conveys sense of low self worth, whereas an attractive, well put together appearance conveys a positive sense of self to the client as well as to others.



ASSESSMENT

EXPLANATION OF THE PROBLEM

PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective:“hindi ko maintindihan ang sinasabi niya” as verbalized by the SO.

Objective:

>Difficulty when speaking

>Slurring of speech

>Disorientation to place and time

>Irritable

> GCS= 10>restlessness noted-GCS: E= 4 V=2 M=5

A CVD, which may be caused by, hemorrhage, thrombus, embolism or vasospasm, can result in a local area of cell death, called infarct. It is caused by a lack of blood supply which is then surrounded by an area of cells that are secondarily affected. Since symptoms depend on the location of the stroke and size of the infarct, it could involve the brain’s Brocca’s area, which is primary responsible for communication through facial expressions and speech. By causing damage to this area, the patient’s communicating skills are greatly altered and affected.

SHORT-TERM GOAL:

>After 1 hour of effective nursing intervention the patient will relate findings of decreased frustration with communication.

LONG-TERM GOAL:

After 3 days of nursing interventions, the client will establish method of communication in which needs can be expressed.

INDEPENDENT:

1 Dx:>Assessed level of impairment.

>Noted speech patterns and manner of communicating including gestures.>Validated client message by repeating aloud.

>Facilitated hearing and vision examinations when needed.

>Assisted client S/O (s) to learn therapeutic communication skills of acknowledgement.

>Provided environmental stimuli as needed.

>Maintained a calm unhurried manner, provide sufficient time for client to respond.

>Used confrontation skills, when appropriate,

>To determine absence or presence of impairment.>To evaluate the degree of impairment.

>To assess client to establish of means of communication to express needs, ideas and questions.

>To improve communication.

>Improves general communication.

>To maintain contact with reality/ lessen anxiety that may worsen problem.

>Individuals with expressive aphasia may talk more easily when they are rested, relaxed to one person at a time.

>To clarify discrepancies between

SHORT-TERM GOAL:

>After nursing intervention the patient was able to establish method of communication in which needs can be expressed.

LONG-TERM GOAL:Goal met after 3 days of nursing interventions, theclient has established method of communication in which needs can be expressed as evidenced by :

>“Salamat” as verbalized by the client.>Established eye contact while communicating with others>Used paper and pen to express needs



NURSING DIAGNOSIS:Impaired verbal communication related to alteration of motor speech area of the brain as manifested by slurring of speech

within an established nurse-client relationship.

>Involves family/ so in plan of care as possible.Tx:10. Encouraged the patient and S.O.’s to avoid sedentary lifestyle such as drinking liquor, smoking, improper exercise and too much fatty foods.

COLLABORATIVE:1. Administer medications as ordered:- Citicoline 2 drops BID / 1gm IV q8

verbal and non-verbal cues.

>Enhances participation and commitment to plan.

ASSESSMENTEXPLANATION

OF THE PROBLEM

PLANNINGNURSING

INTERVENTIONS

RATIONALE EVALUATION

Subjective:Deposition of


INDEPENDENT:Dx:




“Hindi daw siya gaanong makagalaw sa kanang bahagi ng katawan” as verbalized by the SO.

Objective:-Weak in appearance-↓ in muscle strength:Arms: L= 5/5 R= 0/5Legs: L= 5/5 R= 0/5-GCS: E= 4 V= 2 M=5

-Unable to carry out activities without assistance such as changing clothes.-Limited ROM on the right hand and foot(only able to carry out passive ROM on this area)-Impaired ability to turn side to side; needs fully assistance-Level 3 physical mobility

fatty materials on vessel walls

Plaque

formation

Narrowing of atherosclerosis

plaque

Deprivation of blood supply in

the brain

Cerebraldefects in the

motor area

Impairment of gross and motor function of the

brain

Impaired physical mobility

After 5 hours of nursing intervention, the patient will be able to:a) Participate in performing ADL’s with minimal assistance from othersb) Do active and passive ROM exercise on the right side of his body within physical limitations after hours of sleep.

SO will be able to:a) Verbalize understanding of the situation /risk factors, individual therapeutic regimen and safety measures.

b) Demonstrate techniques/ behaviors that will enable safe repositioning

LONG-TERM OBJECTIVE:After 3 days of nursing intervention, the patient will be able to:a) Manifest an improved participation in performing ADL’s with or without support.b) Maintain functional abilities of the right side of

1. Established rapport to the patient and SO.

2. Assessed and determine factors that contribute to physical immobility

3. Determined degree of immobility & muscle strength

Tx:

4. Assisted patient in comfortable position

5. Provided support on affected body parts such as pillow

6. Provided safety precautions by raising up the side rails.

7. Provided environment free from noise and disturbances

8. Changed position every 2 hours and possibly more often if placed on the affected part

9. Massaged pressure points after each position change

-To gain the pt’s & S.O.’s trust & cooperation during the nsg care & procedures.

-To identify contributing factors that enable the nurse to focus on appropriate interventions

-To assess functional ability

-To promote optimal level of functioning

-To maintain position of function and reduce discomfort

-To prevent injury and fall

-To have a good atmosphere conducive to the recovery of the patient

-To reduce risk of tissue ischemia or injury and to prevent pressure sores

-To promote circulation and oxygen distribution

-To promote

After 5 hours of nursing intervention, goal was met as evidenced by:a) Patient participated in performing ADL’s with minimal assistanceb) Patient having an active and passive ROM exercise within physical limitations after hours of sleep

SO was able to:a) Verbalized understanding of the situation /risk factors, individual therapeutic regimen and safety measures.

b) Demonstrated techniques/ behaviors that will enable safe repositioning

LONG-TERM OBJECTIVE:After 3 days of nursing intervention, goal was met as evidenced by: a) Patient has an improved participation in performing ADL’s with or without support.b) Patient has



NURSING DIAGNOSIS:Impaired Physical Mobility related to Musculoskeletal as manifested by needs full assistance in AD

the body. c) Manifest an increase in muscle strength of both arms and legs of the patient.d) Improved physical mobility from level 3 to level 2 and improved GCS

10. Assisted in performing ADL

11. Assisted in performing ROM exercise after hours of sleep & within physical limitations.

Edx:12. Encouraged the pt and S.O.’s to avoid a sedentary lifestyle such as drinking liquor, smoking, improper exercise and too much fatty foods.

optimal level of functioning

-To minimize muscle atrophy and promote circulation

-These factors may affect them in developing various diseases as what like the patient is suffering now.

-It restores the activity and functions of the brain. It improves neuromuscular function.

an improved functional abilities of the right side of the bodyc) The patient has an increased muscle strength with a scale of:Arms L=5/5 R=2/5Legs L=5/5 R=2/5d) The patient is having level 3 physical mobility and a GCS scale of E=4, V=4, M=5.

POTENTIAL NURSING CARE PLAN

ASSESSME EXPLANATION PLANNING NURSING RATIONALE EVALUATIO



NT OF THE PROBLEM INTERVENTIONS N

Subjective:“Hindi siya makakain sa pagnguya, naka NGT siya at doon nila pinapasok ang pagkain niya”

Objective:-decrease ability to swallow

NURSING DIAGNOSIS:Risk for Aspiration Related To Impaired Swallowing

>(the misdirection of oropharyngeal secretions or gastric contents into the larynx and lower respiratory tract) is common in older adults with dysphagia and can lead to aspiration pneumonia. The older adult with one of these conditions is at even greater risk for aspiration because the dysphagia is superimposed on the slowed swallowing rate associated with normal aging.

>When there is a blockage of vertebrobasilar artery there will be Cranial nerves affectations. CN V, VII, IX, XII blockage may result to dysphagia or difficulty of swallowing which thereby having high risk for aspiration.


After 6 hours of nursing intervention, the patient will be able to demonstrate measures to prevent aspiration.

LONG-TERM GOAL:

After 3 days of nursing intervention, the patient will be free from risks for aspiration.

DX:>Assessed level of consciousness of surroundings, and cognitive impairment

> Assessed swallowing reflex or gag reflex

>Auscultated lung sounds to determine presence of secretions

TX:>Suctioned mouth secretions as needed

>Elevated to Semi-Fowler’s position when feeding via NGT

>Placed on lateral position or changed the position.EDX:> Educated SO about the importance of oral suctioning.

>Informed SO about the significance of precautionary measures to prevent aspiration

>Involved client S/O in determining activity schedule

> To assess if there is gag reflex or difficulty of swallowing.

> Impaired swallowing may cause aspiration.

>To aid breathing and promotes lung expansion.

> To reduce secretions present in the mouth

>Reduces the risk of aspiration by allowing secretions to drain.

>To prevent blockage on the passage of food.

>To impart health teaching

>To impart health teaching

> To promote commitment to plan, maximizing outcomes.


After 6 hours of nursing intervention, goal was met as evidenced by he was able to demonstrate measures to prevent aspiration.

LONG-TERM GOAL:

After 3 days of nursing intervention, goal was met as evidenced by: patient is free from risks for aspiration.

ASSESSMEN EXPLANATION PLANNING NURSING RATIONALE EVALUATION



T OF THE PROBLEM INTERVENTIONS

Subjective: “Namumula yung sa may pwetan niya. Siguro dahil sa matagal niyang pagkakahiga” as verbalized by the SO

Objective:-intact skin with presence of reddish few unruptured blisters in bony prominent area-Reddened skin surface in the buttocks-blisters is 3mm in diameter-Prolonged bed rest

Pressure on soft tissues between

bony prominences

↓Compresses capillaries &

occludes blood flow↓

Pressure not relieved

↓Microthrombi

formation↓

+ occlusion in capillaries & blood flow

↓Formation of

blister↓

Rupture of blister

↓+ open wound

>Immobility, which leads to pressure, shear, and friction, is the factor most likely to put an individual at risk for altered skin integrity. Advanced age; the normal loss of elasticity; inadequate nutrition; environmental moisture, especially from incontinence; and vascular insufficiency potentiate the effects of pressure and hasten the development of skin breakdown. Groups of persons with the highest risk for altered skin integrity are the

SHORT TERM OBJECTIVE:After 8 hours of nursing intervention, the patient will be able to:a) Reduce risk of further impairment of skin integrityb) SO will demonstrate understanding & skill in care of the wound

LONG-TERM GOAL:

After 3 days of nursing intervention, the patient will be able to:

Experience healing of blisters/regain skin integrity

Absence of Reddened skin in the bony prominences.

Reduce risk for infection

INDEPENDENTDx:1. Assessed skin, skin color, turgor and sensation. Described and measured blister and observed changes

2. Assessed between folds of skin, remove anti embolic stockings or devices & use a mirror to see the heels. Also assess under oxygen tubing especially on the ears & the cheek, beneath splints and under medical devices.

3. Noted objective data of blisters

Tx:4. Repositioned every 2 hours.

5. Elevated heels off the bed by using pillows or heel elevation botts.

6. Maintain head of bed @ the lowest elevation, , reposition to 30 degree lateral position. Used seat cushions & assess sacral

-Establishes comparative baseline provides opportunity for timely intervention

-Pressure ulcers under medical devices are commonly overlooked.

-Reassessment of blisters, sooner if ulcer shows manifestations of deterioration. Analyses of the trends in healing are important step in assessment.

-To disperse pressure over time or decreasing the tissue load

-Heel covers do not relieve pressure, but they can reduce friction.

-To prevent further occurrence of pressure ulcer.

LONG TERM OBJECTIVE:After 8 hours of nursing intervention, goal was met as evidenced by:a) Have reduced risk of further impairment of skin integrityb) SO demonstrates understanding & skill in care of the wound

LONG-TERM GOAL:

After 3 days of nursing intervention, goal was met as evidenced by:

Has experienced healing of blisters/regain skin integrity

Free from reddened skin in the bony prominences.

Has reduced risk for infection



NURSING DIAGNOSIS:Risk for Impaired Skin Integrity related to Prolonged Bed rest Secondary to Impaired Mobility

spinal cord injured, those who are confined to bed or wheelchair for prolonged periods of time, those with edema, and those who have altered sensation that triggers the normal protective weight shifting. Pressure relief and pressure reduction devices for the prevention of skin breakdown include a wide range of surfaces, specialty beds and mattresses ,and other devices.

ulcers daily.

Edx:7. Instructed SO

to maintain clean, dry clothes, preferably cotton fabric (any T-shirt).

8. Demonstrated good skin hygiene, e.g., wash thoroughly and pat dry carefully.

9. Emphasized importance of adequate nutrition and fluid intake.

10. Demonstrated to the SO on how to make a guava decoction to apply to the wound as alternative disinfectant.

-Skin friction caused by stiff or rough clothes leads to irritation of fragile skin and increases risk for infection.

-Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to fragile skin.

-Improved nutrition and hydration will improve skin condition.

-Providing the family with an alternative solution assists them in optimal healing with less expensive resources.



XIV. DISCHARGE PLANS

Criteria Health Teachings

A. Diet Patient was instructed to maintain the low salt and low fat diet. The low salt diet is designed to induce a loss of sodium and water from the body or avoid sodium retention. A 2000 mg low sodium diet is sufficient to control blood pressure. A low fat diet help lose weight to decrease risk of having CVA again.

The patient is encouraged to lessen cholesterol and fatty food intake such as egg, bulalo and fried food, minimize salt intake 2 grams per day, increase serving of fruits and vegetables such as cabbage, carrots, banana, apple, orange, malunggay etc. and increase serving of carbohydrates to 2 serving of rice.

B. Activities Patient is instructed that he should do active and passive range of motion exercise at the unaffected area. Do simple exercises such as moving forward and backward of hands with intervals alternately, stretching, breast walking in the morning at home for 20-30 mins and deep breathing to prevent recurrence of the disease.

C. Medications Encouraged the patient and significant others to follow the medication that was prescribed in order to help maintain its good health condition. The following are prescribed by the doctor for home medications. And should take her medicine at the right time, right dose and right frequency. Insist physical therapy 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.

D. Spirituality Allowed the patient and the family to pray if possible all the time to God and encourage them to have faith in God to provide optimistic approach toward his condition.

E. Others The patient with her SO was advised to have a follow-up check-up, as indicated by the physician after discharge to the OPD at the nearest hospital. Instructed to call and seek physician help if BP does not lower within normal level with continuance of drug intake and report any chest pain immediately.Encourage to turn side every 2 hours with assistance of significant others as needed, relaxation technique and avoid being fatigue by adequate resting between work and instructed to avoid getting quickly upon arising on bed and sit on bed first before standing.



CONCLUSIONS AND RECOMMENDATIONS:A. Conclusions:

In summary content and analysis of the study, the researchers were able to drive the following conclusions. The patient’s sedentary lifestyle greatly affects and aggravates the conditions itself. With the diet of high in fats and salty foods, this can cause hypertension and lipid deposition in the major vessel of the brain. On the latter part of this fat and lipid deposition is atherosclerosis. With the lifestyle of alcohol drinking and cigarette smoking, the patient’s susceptibility to this condition is increased. Alcohol and nicotine found in cigarettes are potent vasoconstrictor.

As part of the nursing duties and responsibilities, health teachings like diet and lifestyle modification must be rendered to promote health. Certain restrictions should be emphasized and the threats of these if not followed.

Furthermore the group imparted the important information as health teachings that would be useful to patient’s understanding of care regimen and nature of her health condition and enhanced skills & knowledge as health care provider in the clinical setting.

The group also had enhanced their primary nursing skills in this rotation. Teamwork was established and camaraderie developed between peers. Also through working together with this CP the group built friendship that made our work easier and smoother.

Moreover, the significant other and the patient had acquired priceless information about the patient’s disease condition which is a plus factor in changing her negative lifestyle that could lead to a healthier living.

Lastly, the group has developed a better working relationship with one another, especially through this challenges and demanding strength of our student life.

Over-all the case study was enjoying and satisfying.

B. Recommendations

As this study proceeds, few lessons were learned and things discovered. One of the basic is education and awareness. This is believed to be the primary of all, for it all started from “self.”

For this, we strongly suggest to strengthen and intensively increase the provision of basic health education as well as imparting it to the different sectors starting from the most basic unit of the community. This knowledge campaign would surely help the eradication of unawareness and promotion of health motives.

LIST OF REFERENCES:



o Smeltzer, Medical-Surgical Nursing, 11th Edition, U.S.A.: Lippincott Wilkins and Williams, pages 1670-1672, 1882-1184

o Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005

o Einbach, Medical-Surgical Nursing, 2009; U.S.A.: Price Publshing, pages 500-501o Smeltzer, Bare, Hinkle, and Cheever; Brunner and Suddarth’s TEXTBOOK OF MEDICAL-

SURGICAL NURSING; 11th ed. 2008

o Wolters Kluwer and Lippincott Williams and Wilkins; PATHOPHYSIOLOGY MADE INCREADIBLY VISUAL; 2008

o Marieb, E. et al: ESSENTIALS OF ANATOMY AND PHYSIOLOGY, 6th edition, Addison-Wesley Publishing Company Inc., America; 2005

o Deluane and Landner et al: FUNDAMENTALS OF NURSING: Standards and Practice, 3rd

edition, Delmar learning, a division of Thomson Learning; 2006

o Giddens and Langford et al: MOSBY’S NURSING PDQ, Elsevier PTE LTD Health Science Asia, 2004

o Doenges, M. et al: NURSING CARE PLAN, 6th edition, F.A Davis Company, Philadelphia; 2005

o Gulanink and Myers et al NURSING CARE PLANS: Diagnosis and Interventions, 6th edition, 3 Killiney Road #08-01 Winsland House Singapore 239519, 2007

o Doenges, Moorhouse, Murr, et al: NURSE’S POCKET GUIDE: Diagnoses, Prioritized interventions, and rationales, 11th edition, F.A. Davis Company Philadelphia, Pennsylvania, 2008

o Smith T. et al: THE HUMAN BODY: An Illustrated Guide to its Structure, Function and Disorders, Dorling Kindersley Limited, London. 2000

o Mosby E. et al: Pocket Dictionary of Medicine, Nursing and Health Professions, 5th ed, 3 Killiney Road #08-01 Winsland House I Singapore 239519, 2006

o Lippincott, William and Wilkins, et al: NURSING DRUG HANDBOOK, 23rd edition, Wolters Kluwer Company, Philadelphia; 2005

o Spratto and Woods et al: NURSE’S DRUG HANDBOOK: The information standard for prescription drugs and nursing considerations, 2008 edition, Delmar learning, a division of Thomson Learning, 2008

o Clayton, Stock and Harroun, et al: BASIC PHARMACOLOGY FOR NURSES, 14th edition, Mosby an imprint of Elsevier Inc. 2007







Education

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