Case Pres - Version 2

7/29/2019 Case Pres - Version 2

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GOOD DAY!



T/C Cerebroscular Accident Probable

Infarct Right, Diabetes

Mellitus Type 2



I. INTRODUCTION



BACKGROUND OF THE STUDYThere are 18.2 million people in the United States

who have diabetes mellitus (DM). The prevalence of thismedical disorder increases with age. Half of all casesoccur in people over the age of 55, and it is estimatedthat 18% of the United States population over the age of

60 have DM. Patients with DM are more prone todevelop vascular diseases, including strokes. In additionto being a deadly disorder in diabetics, stroke is adisabling disorder. Most stroke survivors are left with

some physical and/or cognitive deficits. Stroke is theleading cause of permanent disability in the UnitedStates and it is the second leading cause of cognitivedecline. Thus healthcare providers who care for patientswith DM should be knowledgeable about the inter-



relationship between DM and stroke, as well asinterventions that can minimize their patients’ risk of

primary and secondary stroke. In this article we willdiscuss epidemiologic relationships between DM andstroke, effects of DM on outcome from stroke, andstroke prevention strategies for the diabetic patient.

(Nader Antonios, MD and Scott Silliman, MD. DiabetesMellitus and Stroke.http://www.dcmsonline.org)

A person with diabetes is at higher risk thanothers for stroke and other cardiovascular diseases. Aswith many of the health problems associated withdiabetes, higher-than-normal blood glucose (bloodsugar) levels are factors.(www.ask.com)



A. RATIONALE FOR

CHOOSING THE CASEThe case was studied for the following reasons:1. To have critical thinking skills necessary for

providing safe and effective nursing care.

2. To have a comprehensive assessment andimplement care base on our knowledge andskills of the condition

3. To familiarize ourselves with effective inter-

personal skills to emphasized health promotionand illness prevention.4. To impart the learning experience from direct

patient care.



B. OBJECTIVES OF THE

STUDYThe presenters aim to recognize theactual and probable health problems of

the client in relation to his healthpractices as an individual andunderstand fully the process of the

occurrence of this disease throughapplying the theoretical frameworks andthe nursing processes.



Specific ObjectivesAfter the completion of the study, a nurse shallbe able to:

1.To thoroughly assess the clinical manifestations of

patient with CVA based on the patient’s history.2.To formulate comprehensive nursing diagnosis for

a client with CVA.

3.To formulate a plan of care for patients with CVA.4.To formulate appropriate nursing interventions that

can be applied for a patient with CVA.

5.To evaluate the plan of care for a patient with CVA



II. ASSESSMENT



A. Client Profile NAME: J.M.

AGE: 50 years old

GENDER: Male

ADDRESS: Mandaluyong City

BIRTH DATE: October 28, 1961

NATIONALITY: Filipino

RELIGION: Roman Catholic CIVIL STATUS: Married

OCCUPATION: Retired taxi driver (2004-2011)

HEALTH CARE FINANCING: Fortune Health Insurance

ADMISSION DATE: August 13,2012 ADMISSION TIME: 11:55 AM

ADMITTING PHYSICIAN: Dr. Estacion

ADMITTING DIAGNOSIS: T/C Cerebrovascular Accident ProbableInfarct Right Diabetes Mellitus Type 2

FINAL DIAGNOSIS:



B. Chief Complaint“Nanghihina ang kaliwang bahagi ng katawan ko tapos di

ako makapagsalita ng ayos” as verbalized by the patient.

C. History of Present IllnessFew hours prior to admission, patient is having a left sided

body weakness associated with numbness. According to him, hesuddenly fell from his seat and couldn’t talk straight.

D. Past Medical HistoryLast 2011, he stated that he undergone an amputation ofhis left big toe because of diabetes and was prescribed with some

medications for 3months:> Apidra (fast acting, mealtime insulin)>Lantus (long-acting insulin)



E. Personal HistoryLast 2002, the patient had a boils/abscess on his

back. He’s been wondering why it doesn’t heal andagonizing the pain for months. So he consulted a doctorand then tried to obtain a blood glucose test and theyfound out that the blood glucose level is high and

diagnosed to have Type 2 Diabetes Mellitus. Client wasnot aware of the signs and symptoms of diabetes since hebelieve that he is healthy. He was prescribed by hisdoctor an antibiotic only for the faster healing of hisboils/abscess. He stated that he also tried controlling hisfood intake by avoiding sugar rich and cholesterol richfood. But he failed to do regular exercise since he is a

taxi driver andwasn’t

able to manage his diet. And last2011, he got a blister on his left big toe and doesn’t heal



E. Personal Historyagain until it became a wound. Then he consulted a

doctor and advised him that his left big toe should beamputated before the wound increase its size since he isdiabetic.

Visual problems were verbalized by the patient. Duringhis childhood when he was 10 years old, he stated thathe was bumped by a car and was hospitalized. Thepatient wasn’t able to recall his childhood illnesses.



F. Family History of Illness



Family History of Illness

interpretationThe figure is a 3rd generation family

history of illness. Patient’s grandfather on

both side died of old age. His grandmotheron the father side died of cancer of theglands and grandmother on the mother side

died because of DM complications. Hisfather was a heavy drinker and died with aliver cirrhosis disease and his mother passedaway because of kidney disease.



G. Gordon’s Functional AssessmentHealth Perception and Management

efore Hospitalization During Hospitalization Client verbalizes that he has

been pampered starting when

his left big toe was amputatedthis year because of diabetes.

Last year, he and his wife

decided that he should stop from

working because he easily getstired. Whenever he feels sick he

treated it immediately by taking

OTC drugs for headache.

Client stated that he obediently

follow all the orders of the

doctors. He believes that doctors,nurses and other medical

members will help him for faster

recovery.



G. Gordon’s Functional AssessmentNutritional – Metabolic

Before Hospitalization During Hospitalization Client stated that he eats

everything he wants and sees.

Often failed to follow his DMdiet. He eats 3 times a day with

3 cups of rice per meal. She

drinks 6-8glasses of water a

day.

Client stated that he has

difficulty eating since his left

side of the body is weak andhe can’t chew and swallow his

food properly. Still on DM diet



G. Gordon’s Functional Assessment24 Hour Diet Recall

Meal Food Quantity Breakfast Suman 2 pieces

Water 1 glass (240 ml)

Lunch Rice ¾ cupPakbit 1 serving

Dinner Rice ½ cup

Adobong manok 1 serving



G. Gordon’s Functional AssessmentElimination

Before Hospitalization During hospitalization

Client verbalizes that he

defecates three times a week formed and brown in color. He

voids 6-8 times a day with

yellowish in color.

Client stated that he defecates

once a day since admissionwith a semi-formed stool and

brown in color. He voids 4-5

times with yellowish color and

needs assistance when voiding.



G. Gordon’s Functional AssessmentActivity – Exercise


Client verbalizes that he lacks

exercise ever since he became

a taxi driver. He also added

that he easily gets tired with

shortness of breath.

Still he was not able to carry

out any other activities.



G. Gordon’s Functional AssessmentSleep – Rest


Client normally gets 6 hours

of continuous sleep. He stated

that he can consumed 4 cups

of coffee and it doesn’t affect

his sleeping pattern. He does

have difficulty in breathingwhen lying and he snores. He

sleeps in prone position.

He claimed that

hospitalization affect his

sleeping pattern. He sleeps in a

semi fowler’s position. He

stated that he doesn’t feels

rested after sleeping becauseof the environment.



G. Gordon’s Functional AssessmentCognitive – Perceptual


The client can remember

remote, immediate, and recent

memory when being asked. He

has no hearing problems. He is

able to follow instructions and

answer questions accordingly.But he has attention deficit

when being asked.

The client is aware about his

present situation but not that

knowledgeable about the

disease condition when being

asked. He also verbalized

decreased sensation anddoesn’t feel pain easily.



G. Gordon’s Functional AssessmentSelf –Perception – Self – Concept


Client claimed that he was

already satisfied with life prior

to hospitalization although he

is experiencing some signs and

symptoms.

He stated that his self esteem is

low because of his

hospitalization and his disease.



G. Gordon’s Functional AssessmentRole – Relationship


Client lives with his wife and four

children. Even before hospitalization

he stated that he is already unable tosupport his family in financial needs

since he decided and his wife to stop

working and just stay at home. His

wife is a public teacher and he feels

a bit sad because he can’t help in

financial needs. He and his wife

make the decision in the family. They

have open communication with each

other.

The client presently feels the

support of his family and he is

happy about it.



G. Gordon’s Functional AssessmentSexuality – Reproductive


The patient has 4 sons and he

also stated that they didn’t

practice family planning. Prior

to hospitalization, the client

verbalized impotence by

having lessened sensationduring intimacy.

He claimed that he lost his

sexual interest due to the

physical changes that he is

experiencing.



G. Gordon’s Functional AssessmentCoping – Stress – Tolerance


When he is tired, he sleeps for

him to rest and not to stress

himself. He stated that he is

not ill tempered and a happy

person.

Though he is in stressful state

because of his hospitalization

he just calm himself and take

his bed rest.



G. Gordon’s Functional AssessmentValue – Belief


Prior to hospitalization, client

admitted that he doesn’t go to

church.

When he was hospitalized, he

still prays and asks for God’s

protection despite of whathappened to him.



H. Physical ExaminationGeneral Survey

Client is lying on bed, has a proportionate body built.Hygiene and grooming is unkempt and has acetonebreath. He has no signs of distress, cooperative, and a bitdifficulty in speaking but understandable.

Vital signs

His temperature is 36.4 °C axillary, blood pressure takenin supine position is 140/100 mmHg, Radial Pulse Rate

is 84 beats per minute , weak and Respiratory rate is 26cycles per minute in cheyne-stokes respiration.



H. Physical ExaminationSkin

His skin is brown in color, rough and has poor skinturgor. Symmetry of color is uniform. Edema +2 ispresent on both feet, moderate pitting and indentationsubsides rapidly. Skin is moist and warm to touch.

Hair

His hair is evenly distributed, thick curly hair withflaking.

NailsHis nails are convex in curvature and angle withgrooves texture, nail bed color is pallor with intact

surrounding tissue. Capillary refill is delayed.



H. Physical ExaminationSkull and face

His head is normocephalic and has negative masses.Asymmetrical facial gestures and facial movements.

Eye Structures and Visual Acuity

His eyebrows and eyelashes are evenly distributed,symmetrical eyelids with intact skin and 18 involuntaryblinks. He has pale conjunctiva, anicteric sclera, smoothand clear cornea. Pupils is black, Pupils, Equal, Round,

React to Light and Acommodation. Peripheral vision isintact, coordinated extraocular movement but hasdifficulty in reading newsprint.



H. Physical ExaminationEars and Hearing

His external pinnae is uniform color with skin,symmetrical and firm. Ear canal has wet cerumen. It isnot tender and has no gross abnormalities. His externalear canal has no discharges. He has sluggish hearingacuity.

Nose and Sinuses

He has symmetrical nasolabial fold. His septum is in

midline, non-deviated and has no perforation. Itsmucosa is pinkish and has no discharges. It is bothpatent. He has symmetrical gross smell. Sinuses are nottender.



H. Physical ExaminationMouth and Oropharynx

His lips are pale, dry and have no lesions. His tongue isdeviated with white coating. He has incomplete set ofteeth with a missing lower 1st premolar. There are nodentures, braces and retainers. Gums are red, palate,oropharynx and tonsils is light pink. Uvula is in midline.Gag reflex is intact.

Neck

His movement is coordinated with limited range ofmotion and unequal muscle strength. Lymph nodes arenot palpable. Trachea is in midline, thyroid glands andjugular veins are not visible and carotid pulse is

symmetrical. There are neither neck masses nor rigidity.



H. Physical ExaminationThorax and Lungs

His inspiration/expiration ratio is 1:2, cheyne-strokesbreathing pattern. He has positive use of accessorymuscles and difficulty of breathing with abnormalsound on the left lower lung field. Shape is symmetrical,aligned spine, skin is smooth. Positive for crackles on theleft lower lung field.

Heart

He has normo dynamic precordium. There are neitherthrills nor heaves. Point of maximal impulse (PMI) andapical beat is located at the 5th intercostals space (ICS)left mid clavicular line (LMCL).



H. Physical ExaminationBreast and Axilla

His breasts are symmetrical in size and shape. There isno gynecomastia. It has no lesions. It is smooth and non-tender. There are no retractions, dimplings and edema.

AbdomenHis abdomen is generally smooth. It is symmetricallyglobular and has no lesions. Bowel sounds arenormoactive and heard 12 times/minute. It is

tymphanitic upon percussion. There is no fluid wave.Genito-Urinary System

Client refused to have his genitalia examined. There is

no dysuria and oliguria.



H. Physical ExaminationUpper and Lower Extremities

Muscle strength is unequal, tenderness in bones andjoints deformities.



H. Physical ExaminationDate

Diagnostic

Test Indication Normal Values

Actual

Values

Clinical

Interpretation

8/13/12 Complete Blood

Count

(CBC)

CBC is orderedto determine

presence of

bleeding,

anemia and

evaluate fluid

volume

balance

Hemoglobin 140-180gm/L

93 Hemoglobin,Hematocrit and RBC

is decreased indicates

Anemia which can be

due to destruction of

blood cells internally

because of the

viscosity of the blood.

Diabetes mellitus

decreases RBC life-

span. Decreased in

haemoglobin

decreases the amount

of oxygen-carryingprotein causes to

have difficulty in

breathing which

manifest in the client.

WBC is within the

normal value.

Hematocrit 0.40-0.54 0.29

RBC 4.3-

6.2x106/µL

3.1

WBC 4.1-

10.9x103/µ

L

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Case Pres - Version 2