Bsn3-2c UC-BCF CVA Case Study

8/13/2019 Bsn3-2c UC-BCF CVA Case Study

1/49

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

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

ACKNOWLEDGEMENT

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.

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

showed.

To the researchers 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


2/49


CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II Page 2

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 . . . . . . . . . .8-16

13 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 Electrolytesi. Circulatory Statusj. Respiratory Statusk. Temperature Statusl. Integumentary Statusm. Comfort Status

XI. DIAGNOSTIC PROCEDURES

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

XII. TREATMENT /MANAGEMENT

a) IV Fluids . . . . . . . . . .28b) Drugs . . . . . . . . . . .24-27

XIII. COMPREHENSIVE PATHOPHYSIOLOGY . . . . . . .29

XIV. 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 . . . . . . . . . .41

XVI. CONCLUSIONS AND RECOMMENDATIONS . . . . . .42

XVII. LIST OF REFERENCES . . . . . . . . .43


3/49



I. INTRODUCTIONThe 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 researchpractice 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.


4/49



II. STATEMENT OF OBJECTIVES

A. General ObjectivesThe 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 ObjectivesThis 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


5/49



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 patients 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 Lightbefore the symptoms manifested. His wife immediately placed

him on bed in a high Fowlers 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 sleepthat 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

Hesheredo-familial disease is hypertension and 1 died with heart attack in their family. During

his teenager, mid-adult years (mid 40s) and the recent years, he had been eating many fatty foods

such as fried chicken, fried fish and pinikpikanand 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 hasnt experienced any surgery. He also hasnt experienceblood 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 didnt ever try smoking in his entire life. He admitted that he drank alcohol

occasionally during her teenage years up to present.


6/49



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 2ndchild worked as a Mechanical Engineer in Switzerland for 1

year while the 3rdChild is working as a seaman in Abu Dhabi for almost 5 months.

According to SOs propositions, He do attends church in regular basis but has no known

devotion to Sto. Nio 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 Xs 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.


7/49



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 AM

Vital 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- 58 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 realityGeneral Survey:

Patient is lying on bed, awake, coherent, and afebrile with oxygen inhalation at 10 LPM viaface 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 FINDINGS

1. INTEGUMENTARY

A. SKIN

1. Skin color Pale


8/49



3. Presence of edema No edema

4. Existence of lesionsFreckles, 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 texture

Wrinkled

B. NAILS

1. 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 nails Intact epidermis

5. Blanch test result of capillary refill Delayed 4 seconds

2. HEAD

A. SKULL

1. Size, shpae and symmetry of the skull

Rounded (normecephalic and symmetrical, with frontal,

parietal, and occipital prominences); Smooth skullcontour

2. Presence of nodules, masses, and

depressionsSmooth, uniform consistence; absence of nodules or

masses

B. HAIR

1. Evenness of growth, thickness or thinness

of hairThin hairs not evenly distributed

2. Color Black with white hairs


9/49



C. 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, andfrequency of blinking)

Upper eyelids cover the small portion of the iris, cornea,

and sclera when eyes are open; eyelids meetcompletely 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 clarityWhite in color, clear, no yellowish discoloration; some

capillaries maybe visible

F. CORNEA

Clarity and textureNo irregularities on the surface; looks smooth; clear or

transarent

G. IRIS

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

H. PUPILS

1. Color, shape, and symmetry of sizeColor depends on the person's race; size ranges from 3-7

mm, and are equal in size; equally round


10/49



2. Light reaction and accommodationConstrict briskly/sluggishly when light is directed to the

eye, both directly and consensual

3. Ability to blinkAbsence of blink in the right eye

I. VISUAL ACUITY

1. Near visionDifficulty 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

glandNo edema or tenderness over lacrimal gland

K. EXTRAOCULAR MUSCLES

Eye alignment and coordinationBoth eyes coordinated, move in unison, with parallel

alignment

L. VISUAL FIELDS

Peripheral visual fieldsWhen looking straight ahead, client can see objects in

the periphery

4. EARS

A. AURICLES

1. Color, symmetry of size, and position

Color 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 resultSound is heard in both ears or is localized at the center of

the head


11/49



4. Rinne test resultAir-conducted (AC) hearing is greater than bone-

conducted (BC) hearing

5. NOSE

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

Symmetric and straight; no discharge or flaring; Uniformcolor

2. Presence of redness, swelling, growths

and discharge in the nasal cavitiesMucosa 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 cartilageNot tender; no lesions

6. SINUSES

Identification of the sinuses and for

tendernessNot tender

7. MOUTH

A. LIPS

Symmetry of contour color and texturePale 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


12/49



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 areasSmooth 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 NODES

A. NECK MUSCLES

Inspection of neck muscle and head

movement.

Muscles equal in size, coordinated head movement

without discomfort

A. LYMPH NODES


13/49



Identification of Lymph nodes and for

tendernessNot palpable

B. TRACHEA

Placement of the TracheaCentral 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 massesSkin intact; uniform temperature; chest wall intact; no

tenderness; no masses

4. Respiratory excursion assessment Full and symmetric chest expansion

5. Vocal fremitus palpationBilateral symmetry of vocal fremitus; Fremitus is heard

most clearly at the apex of the lungs

6. Posterior thorax percussion

Percussion 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


14/49



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

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

tenderness; no masses

3. Respiratory excursion assessmentFull symmetric excursion; thumbs normally separate 3 to 5

cm

4. Vocal Fremitus palpationBilateral symmetry of vocal fremitus; Fremitus is normally

decreased over heart and breast tissue.

5. Anterior thorax percussion

Percussion 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 palpation

Symmetric 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


15/49



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; nodischarge, except from pregnant or breast-feeding

females; inversion of one or both nipples that is present

from puberty

5. Axillary, subclavicular, and

supraclavicular lymph nodesNo tenderness, masses, or nodules

6. Masses, tenderness, and any discharge

from the nipplesNo 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 quadrantsNo tenderness; relaxed abdomen with smooth,

consistent tension

14. MUSCULOSKELETAL SYSTEM

A. MUSCLES

1. Muscle size and comparison on the other

sideProportionable to the body even in both sides

2. Contractures in the muscles and tendons No contractures


16/49



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-eriksons 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 didnt also regret

every moment of his life.

2. Environmental StatusMr. 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

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

4. Muscle tonicity Even and firm muscle tone

5. Muscle strength

60% muscle strength at the left side of the body. Whereas

the right side is poor on muscle strength due to right

sided body weaknessB. BONES

1. Normal structures and deformities in the

skeletonNo deformities

2. Areas of edema or tenderness in the

bonesAbsence 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


17/49



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 StatusThe 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 sight

Mr. X is positioned in High Fowlers position and askedto face the Snellens 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 Patients eyes are symmetrical and round Sclera is white in color Eyes are symmetrical in moving.

5. Motor StatusPrior 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. Xs gait was assessed using the head to toe method. Obviously, he cant 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


18/49



and medially as well as rotating in the same manner. He has difficulty bending his right elbow howeve

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 cant tilthis righ

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 StatusMr. X was put into NPO upon admission to facilitate test and for observation of his genera

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: 58ft/in

Weight: 75 Kg

BMI=30.00 Kg/m2


19/49



7-3 1030 600 1630 1630 1630

3-11 600 450 1050 1050 1050

Total: 2680 Total: 2680

August 7, 2013

Intake Output

Time Oral Parenteral Others Total Urine Drainage Others Total7-3 860 475 1335 600 600

3-11 1250 400 1650 1250 1250

Total: 1800 Total: 2985

8. Fluid and electrolytesPrior 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 StatusA. Pulse Rate

Data Time Pulse Rate

08/05/13 10 am 110 BPM

08/05/13 2 pm 115 BPM

08/06/13 10 am 115 BPM

08/06/13 2 pm 118 BPM

08/07/13 10 am 111 BPM

08/07/13 2 am 119 BPM

His 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 BP

08/05/13 10 am 180/100 mm Hg

08/05/13 2 pm 170/100 mm Hg

08/06/13 10 am 140/100 mm Hg

08/06/13 2 pm 120/100 mm Hg

08/07/13 10 am 150/100 mm Hg

08/07/13 2 am 140/100 mm Hg

His 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.


20/49



10. Respiratory Status

Data Time Respiratory Rate

08/05/13 10 am 26 CPM

08/05/13 2 pm 28 CPM

08/06/13 10 am 25 CPM

08/06/13 2 pm 29 CPM

08/07/13 10 pm 25 CPM

08/07/13 2 pm 27 CPM

His 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 Temperature

08/05/13 10 am 36.5 C

08/05/13 2 pm 36.8 C

08/05/13 10 am 37.0 C

08/05/13 2 pm 36.5 C

08/05/13 10 am 36.7 C

08/05/13 2 pm 36.8 C

Mr. Xs 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.


21/49



DIAGNOSTIC PROCEDURES:

1. HEMATOLOGY

Data: Complete Blood Count

Date of Examination: August 1, 2013 Time of Examination: 3:05 PM

Description: 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

RBC

Male 4.7-6.1 10/L

Female 4.2-5.9 10/L

WBC

Male

4.5-11.0 x109

/LFemale

HCT

Male 40.7%-50.3%

Female 36.1%-44.3%

PLT

Male 150,000 -450,000

x 10-6/LFemale

RBC-5.36x10/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 Count

Reference/ Normal Findings Findings Interpretation and Analysis

Neutrophil

Male

48-73 %Female

Lymphocytes

Male 20-45 %

Female

Monocytes

Male 00-10 %

Female

Eosinophils

Male 00-05 %

Female

Basophils

Male 00-02 %

Female

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


22/49



2. Blood Chemistry

Data: Serum Electrolytes


Description: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 CholesterolABNORMAL 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

3. Chest AP

Chest X- Ray Anteroposterior View


Description: - a chest radiograph, commonly called a chest X-ray (CXR) or chest film, is aprojection

radiograph of thechest 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 thethoracic cavity including thelungs,heart,andgreatvessels.Pneumonia andcongestive 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
http://en.wikipedia.org/wiki/Projectional_radiographyhttp://en.wikipedia.org/wiki/Projectional_radiographyhttp://en.wikipedia.org/wiki/Chesthttp://en.wikipedia.org/wiki/Thoracic_cavityhttp://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Hearthttp://en.wikipedia.org/wiki/Great_vesselhttp://en.wikipedia.org/wiki/Great_vesselhttp://en.wikipedia.org/wiki/Pneumoniahttp://en.wikipedia.org/wiki/Congestive_heart_failurehttp://en.wikipedia.org/wiki/Congestive_heart_failurehttp://en.wikipedia.org/wiki/Pneumoniahttp://en.wikipedia.org/wiki/Great_vesselhttp://en.wikipedia.org/wiki/Great_vesselhttp://en.wikipedia.org/wiki/Hearthttp://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Thoracic_cavityhttp://en.wikipedia.org/wiki/Chesthttp://en.wikipedia.org/wiki/Projectional_radiographyhttp://en.wikipedia.org/wiki/Projectional_radiography


23/49



Data:Urine


Description: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

FindingsResults Interpretation and Analysis

Physical ResultsColor Light

Yellow-

Amber

Transparency Slightly

hazy

Appearance Clear

Chemical Results

pH level 5-8 ph

Specific

Gravity1.010-1.030

Protein Negative

Glucose Negative

Albumin Negative

Microscopic Results

RBC 0

WBC 0

Epithelial

cells

0

Physical ResultsColor Amber

Transparency Slightly

hazy

Appearance Clear

Chemical Results

pH level 7.5 ph

Specific

gravity 1.010Protein Negative

Glucose Negative

Albumin Negative

Microscopic Results

RBC 0

WBC 0

Epithelial

cells0

Physical

Color- Normal

Transparency- Normal

Appearance- Normal

Chemical

pH level- Within normal range

Specific Gravity- Within normal range;

***Kidneys are able to concentrate urine

Protein- Normal

Glucose- Normal

Albumin- Normal finding, indicates normal

glomerular permeability and adequate

reabsorption function of the kidneys.

Microscopic

RBC- Normal

WBC- Normal

Epithelial Cells- Normal


24/49



5. Cranial- CT Scan


Description: - 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, brainTumors, 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


25/49




26/49



TREATMENT AND MANAGEMENT:

a. Drugs:

NAME OF THE

DRUGACTION

DOSAGE/

FREQUENC

Y

INDICATIONCONTRAINDICATI

ONADVERSE EFFECTS

NURSING

RESPONSIBILITIES

MANNITOL

Brand Name:

Osmitrol,

Resectisol

Classification:

Osmotic Diuretic

Increases osmotic

pressure of

plasma inglomerular

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

Indications

1. Increasedintracranial

pressure(IC

P)

2. Intraocularpressure

(IOP)

Active intracranial

bleeding (exceptduring

craniotomy),

anuria secondary

to severe renal

disease,

progressive heart

failure, pulmonary

congestion, renal

damage, or renal

dysfunction after

mannitol therapy

begins, severe

pulmonarycongestion or

pulmonary edema,

and severe

dehydration.

-Dehydration

-Headache

-Blurred vision

-Nausea and vomiting

-Volume expansion

-Chest pain

-Thirst

-Tachycardia

-

Assessment:

>Obtain patients

medical history.

>Assess patients

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 missany dose

>Instruct patient to take

only prescribed

medicines.

NAME OF THE

DRUGACTION

DOSAGE/

FREQUENCYINDICATION CONTRAINDICATION ADVERSE EFFECTS

NURSING

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


27/49



Amlodipine

Classification:

Calcium-

channel

Blockers

These

medications

block the

transport of

calcium into the

smooth muscle

cells lining thecoronary 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

NAME OF THE

DRUGACTION

DOSAGE/

FREQUENCYINDICATION CONTRAINDICATION ADVERSE EFFECTS

NURSING

RESPONSIBILITIES

Generic Name:

Citicoline

Classification:

CNS stimulant/

neurotonic

Increase blood

flow and oxygen

consumption in

the brain. It

increases the

neurotransmission

levels because it

favors the

synthesis andproduction

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 patients

medical history.

>Assess patients

condition

>Monitor Vital Signs

(BP, PR, RR)

>Assess for allergic

reactions like GIdisturbances.

Health teaching:

>Teach patient to gain

benefits & not to miss

any dose

>Instruct patient to

NAME OF THE

DRUG

ACTION DOSAGE/

FREQUENCY

INDICATION CONTRAINDICATION ADVERSE EFFECTS NURSING

RESPONSIBILITIES


28/49



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

Insomnia

hypersensitivity,

hypotension,

insomnia,

excitement

Assess cardiac status:

B/P, pulse, respiration,

ECG

Teach pt. do not break,

open, crush, or chew

sust rel caps


29/49



NAME OF DRUG INDICATIONSACTION

CONTRAINDICATION SIDE EFFECTS ADVERSE EFFECTSNURSING

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

preventinghypovolemic

shock or

hypotension

-Normal Saline is a

sterile,

nonpyrogenic

solution for fluid

and electrolyte

replenishment.

-It contains no

antimicrobialagents.

-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 cathe

and need tobe

replaced

d. Condition of

catheter dressing.

Check the level of th

IVF.

a.Correct solution,

medication and

volume.

b.Check and regulathe drop rate.

c.Change the IVF

solution if needed.


30/49



COMPREHENSIVE PATHOPHYSIOLOGY:

Predisposing Factors:

Age: 76 years old

Sex: Male

Family history of CVD

Precipitating Factors:

DIET: Increase lipid and fatty foods intake

Sedentary Lifestyle

Obesity:

BMI: 30.00 Wt: 75 kg Height: 58 ft/in

HPN II

HPN II

Dislodgement of Clot

Thrombotic Infarction

CVA Stroke

Motor Cortex Area Brocas 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


31/49



XIV. NURSING CARE PLANS

A. Prioritizations of Problems

Rank Nursing Problem

1 Self care deficit : hygiene, dressing and grooming related to

Neuromuscular impairmentsecondary to CVA

2 Impaired verbal communication related to alteration of motor speech

area of the brain as manifested by slurring of speech

3 Impaired Physical Mobility related to Musculoskeletal as manifested by

needs of fully assistance in ADLs

4 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 Prioritizations

Problem Justification

1. Self care deficit : hygiene,

dressing and grooming,

related to Neuromuscular

impairmentsecondary to

CVA

This is the first prioritized nursing diagnosis because the Orems

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 individuals ability or willingness to perform the activities

required caring for himself or herself.

2. Impaired verbalcommunication related to

alteration of motor speech

area of the brain as

manifested by slurring of

speech

- This is the second prioritized nursing diagnosis because thedisorder 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 Maslows hierarchy of needs, physiologic needs should

satisfy first, so that the client should satisfy this to satisfy his

physiologic needs. Maslows contended that until our basic

physiologic needs were met, human beings arent 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 persons ability to move and those

conditions that require restricted mobility as therapeutic


32/49



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 toneuromuscular 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 thatmake 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 5thprioritization due to

significant impact on aging to the skin and its ability to retainmoisture. 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 skins ability to retain moisture.


33/49



ASSESSMENT

EXPLANATION

OF THE

PROBLEM

PLANNINGNURSING

INTERVENTIONSRATIONALE EVALUATION

Subjective:

Simula nung

mastroke siya

di na niya

magawa kahitmga simpleng

pansariling

gawain. As

verbalized by

the SO

Objective:

>Unkempt,

soiled clothing

>Foul smellingodor

>with

unsatisfying

appearance

>with minimal

sweating

uncombed

hair

Hypertension

Occlusion

within vessels of

the brainparenchyma

Disruption of

blood supply in

the brain area

Tissue and cell

necrosis

Destruction of

Neuromuscular

junctions

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 carepractices.

> demonstrate

techniques/lifestyle

changes to meet

self care needs.

LONG-TERM GOAL:

After 3 days of

nursingintervention, the

patient was able

to maintain

neatness and

cleanliness.

INDEPENDENT:

>Assessed for

type and severity

of immobilityimpairment,

muscle

flaccidity,

spasticity and

coordination,

ability to walk, sit,

move in bed

perform

>Assessed

presence of

factors thataffects clients

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

regardingmobility and

ability to

perform

activities with

in limitations

without injury

or frustration

>Impairment

in these areas

can alterclients ability

for self-care.

>To promote

privacy.

>To reduce

energy

expenditure

>To ensure

easier

dressing and

comfort

> To protect

the patients

skin integrity

maintaining

his first line of

defenseagainst

sickness and

infection.

>Clothing

that is difficult

to get in and

out of may

compromise

a patients

ability to be

LONG TERM

OBJECTIVE:

Goal Met

After 4 hours ofnursing

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.


34/49



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.

continent

>Adequate

exercise

increases

muscle tone;

consistency in

daily routine

stimulates

bowelelimination.

>Appearance

affects how

the client sees

self. A

disheveled

appearance

conveys

sense of low

self worth,

whereas anattractive,

well put

together

appearance

conveys a

positive sense

of self to the

client as well

as to others.


35/49



ASSESSMENT

EXPLANATION

OF THE

PROBLEM

PLANNINGNURSING


Subjective:

hindi ko

maintindihan

ang sinasabi

niya asverbalized by

the SO.

Objective:

>Difficulty

when speaking

>Slurring of

speech

>Disorientation

to place andtime

>Irritable

> GCS= 10

>restlessness

noted

-GCS:

E= 4

V=2M=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 brains

Broccas area,

which is

primary

responsible for

communicatio

n through

facial

expressions and

speech. By

causingdamage to this

area, the

patients

communicatin

g skills are

greatly altered

and affected.

SHORT-TERM

GOAL:

>After 1 hour of

effective nursingintervention 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 byrepeating aloud.

>Facilitated

hearing and vision

examinations when

needed.

>Assisted client S/O

(s) to learn

therapeutic

communicationskills of

acknowledgement

.

>Provided

environmental

stimuli as needed.

>Maintained acalm unhurried

manner, provide

sufficient time for

client to respond.

>Used

confrontation skills,

>To determine

absence orpresence 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 withexpressive

aphasia may

talk more easily

when they are

rested, relaxed

to one person

at a time.

>To clarify

discrepancies

between verbal

SHORT-TERM

GOAL:

>After nursing

intervention the

patient was

able to

establish

method of

communicatio

n in which

needs can be

expressed.

LONG-TERM

GOAL:

Goal met after

3 days of

nursing

interventions,

the

client has

established

method of

communicatio

n in which

needs can be

expressed as

evidenced by :

>Salamat as

verbalized by

the client.>Established

eye contact

while

communicatin

g with others

>Used paper

and pen to

express needs


36/49



NURSING

DIAGNOSIS:

Impaired

verbal

communicatio

n related to

alteration ofmotor speech

area of the

brain as

manifested by

slurring of

speech

when appropriate,

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. Administermedications as

ordered:

- Citicoline 2 drops

BID / 1gm IV q8

and non-verbal

cues.

>Enhances

participation

and

commitment to

plan.


37/49



ASSESSMENTEXPLANATION OF

THE PROBLEMPLANNING

NURSING


Subjective:

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= 0/5

Legs:

L= 5/5R= 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

Deposition of

fatty materials on

vessel walls

Plaque formation

Narrowing of

atherosclerosis

plaque

Deprivation of

blood supply in

the brain

Cerebral

defects in the

motor area

Impairment of

gross and motor

function of the

brain

Impaired physical

mobility

SHORT TERM

OBJECTIVE:

After 5 hours of

nursing

intervention,

the patient will

be able to:

a) Participate

in performing

ADLs with

minimal

assistance from

others

b) Do active

and passive

ROM exercise

on the right side

of his body

within physical

limitations afterhours 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

nursingintervention,

the patient will

be able to:

a) Manifest an

improved

participation in

performing

ADLs with or

without

support.

b) Maintain

INDEPENDENT:

Dx:

1. Established

rapport to the

patient and SO.

2. Assessed and

determine factors

that contribute to

physical immobility

3. Determineddegree 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

-To gain the

pts & S.O.s

trust &

cooperation

during the nsg

care &

procedures.

-To identify

contributing

factors that

enable the

nurse to focus

on

appropriate

interventions

-To assessfunctional

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 tothe recovery

of the patient

-To reduce risk

of tissue

ischemia or

injury and to

prevent

pressure sores

LONG TERM

OBJECTIVE:

After 5 hours of

nursing

intervention,

goal was met

as evidenced

by:

a) Patient

participated in

performing

ADLs with

minimal

assistance

b) Patient

having an

active and

passive ROM

exercise within

physicallimitations 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


38/49



NURSING

DIAGNOSIS:

Impaired

Physical

Mobility relatedto

Musculoskeletal

as manifested

by needs full

assistance in

AD

functional

abilities of the

right side of 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

9. Massaged

pressure points

after each position

change

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 drinkingliquor, smoking,

improper exercise

and too much

fatty foods.

-To promote

circulation

and oxygen

distribution

-To promote

optimal level

of functioning

-To minimize

muscle

atrophy and

promote

circulation

-These factors

may affect

them in

developing

variousdiseases as

what like the

patient is

suffering now.

-It restores the

activity and

functions of

the brain. It

improves

neuromuscular

function.

ADLs with or

without support

b) Patient has

an improved

functional

abilities of the

right side of the

body

c) The patient

has an

increased

muscle strength

with a scale of:

Arms

L=5/5

R=2/5

Legs

L=5/5

R=2/5

d) The patient

is having level 3

physicalmobility and a

GCS scale of

E=4, V=4, M=5.


39/49



POTENTIAL NURSING CARE PLAN


THE PROBLEMPLANNING NURSING INTERVENTIONS RATIONALE EVALUATION

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.

SHORT TERM

OBJECTIVE:

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-

Fowlers 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 thesignificance of

precautionary measures

to prevent aspiration

>Involved client S/O in

determining activity

schedule

> To assess

if there is gag

reflex or

difficultyof swallowing.

> Impaired

swallowing

may cause

aspiration.

>To aid

breathing

and

promotes

lungexpansion.

> 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 imparthealth

teaching

> To promote

commitment

to plan,

maximizing

outcomes.

LONG TERM

OBJECTIVE:

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.


40/49




THE PROBLEMPLANNING

NURSING


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

f

Documents

Bsn3-2c UC-BCF CVA Case Study