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Cerebro Vascular

Accident

Submitted to:

Submitted by:

July , 2012

TABLE OF CONTENTS


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Page

I. Introduction 1-2

a. Overview of the Case 3

b. Objective of the study 3c. Scope and Limitation of the study 3

II. Profile of the patient 4

III. Developmental Data 5-7

IV. Health History 7

a. Family and Personal health history

b. History of Present Illness

V. Nursing assessment 8-10

(System Review & Nursing Assessment II)

VI. Anatomy & Physiology 11-13

VII. Pathophysiology 14

VIII. Medical Management 15-16

a. Medical Orders and Rationale

b. Laboratory Results

c. Drug study

IX. Nursing Management 17-19

X. Referrals and Follow-up 20

XI. Evaluation and Implications 21

XII. Bibliography 22


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I. INTRODUCTION

Cerebrovascular accident: The sudden death of some brain cells due to lack of oxygen

when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain. A

CVA is also referred to as a stroke. Symptoms of a stroke depend on the area of the brainaffected. The most common symptom is weakness or paralysis of one side of the body with

partial or complete loss of voluntary movement or sensation in a leg or arm. There can be

speech problems and weak face muscles, causing drooling. Numbness or tingling is very

common. A stroke involving the base of the brain can affect balance, vision, and swallowing,

breathing and even unconsciousness. Stroke is a medical emergency. Anyone suspected of

having a stroke should be taken immediately to a medical facility for diagnosis and treatment.

The causes of stroke: An artery to the brain may be blocked by a clot (thrombosis) which

typically occurs in a blood vessel that has previously been narrowed due to atherosclerosis

("hardening of the artery"). When a blood clot or a piece of an atherosclerotic plaque (a

cholesterol and calcium deposit on the wall of the artery) breaks loose, it can travel through the

circulation and lodge in an artery of the brain, plugging it up and stopping the flow of blood; this

is referred to as an embolic stroke. A blood clot can form in a chamber of the heart when the

heart beats irregularly, as in atrial fibrillation; such clots usually stay attached to the inner lining

of the heart but they may break off, travel through the blood stream, form a plug (embolus)in a

brain artery and cause a stroke. The diagnosis of stroke involves a medical history and a

physical examination.

This case study will give us a thorough understanding on what cerebrovascular

accident/stroke is all about, on what nursing intervention could be possibly be done to the

patient, recommended plan of care , and the management of the patients condition in the signs

and symptoms that may occur. This case study is about patient R.A, male, 47 years old, was

admitted at Sabal Hospital. All gathered data and inputs about the patient will be shown in this

study.


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A. Scope and Limitation

The study focuses on patient A.R., who was diagnosed with Cerebrovascular Accident,

which also includes the patients basic information and assessments. This involves the ideal and

actual nursing management appropriate for patient A.R, the drug study of the medication given

and the health teaching given to the patient.

This study also covers the personal profile and background of patient A.R. The

information is obtained from the client himself and from his significant others. Other relevant

information is kept confidential for his privacy.

B. Objective of the Study

The purpose of this study is to provide a deeper theoretical and practical knowledge to

the readers as well as the researchers, to help improve their understanding regarding the

cerebrovascular accident. This as well improves patients understanding regarding his condition

through the assessment, nursing interventions, and evaluation which helps in providing quality

care to the patients.

This also aims to provide a framework of study regarding the subject that can serve as

the reference of future studies and research.

C. Significance of the Study

This study provides a thorough knowledge to the researcher, regarding on the patients

condition which is cerebrovascular accident and as well as helps the patient with this condition

through proper assessment, providing appropriate interventions to alleviate from their sufferings,

through providing health teachings that would help them increase their knowledge to lessen

their anxiety. This study also helps to evaluate if the patients goals were achieved, and if there

were significant improvement to the patient with the interventions that has been given. This also

helps researchers to fully understand the patients condition and checks or monitor changes in

the patients health whether it might be improving or not.


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II. PATIENTS PROFILE

Name: A. R.

Date of Birth: August 19, 1965

Age: 43 years oldSex: male

Civil Status: Single

Height: 54

Weight: 161kg

Religion: Roman Catholic

Nationality: Filipino

Address: Balingasag

Occupation: Debt Collector

Monthly Income: 7,000/month

Educational Attainment: Fourth Year High School

Fathers name: C.A.

Occupation: Government employee

Monthly income: 5,000 Php/ month

Mothers name: J.A.

Occupation: Highschool teacher

Monthly income: 3,000 Php/ month


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III. DEVELOPMENTAL DATA

Eriksons Psychosocial Development (Generativity vs. Stagnation) - MIDDLE ADULTHOOD

This stage of Psychosocial Development is more concern of guiding the next generation.

As to our patient, who is a loving father to his children, and an affectionate, devoted husband to

his wife, this is what concerns him more. To guide his sons and daughters be a good citizen, to

be successful and an achiever. Thats what a father and as a parent wants for his children as

he said. Raising his family and working toward the betterment of their lives and the society do

gave him a sense of generativity- a sense of productivity and accomplishment in his life. Seeing

his family in good state, made him satisfied. No regrets or compunction!

As to the other developmental stages of our patient, he belongs on the genital stage(Erogenous Zone: Maturing Sexual Interests). The final stage on Freuds Psychosexual

Development. He was been able to develop a strong sexual interest into his opposite sex (his

wife). His main goal now is to establish a balance between the various life areas not only on his

needs, but to his family.

With the balance that he had between various life areas, he then able to achieve the last

stage on Piagets Developmental Stage; formal operational stage. On this stage our patient can

now think logically about abstract propositions and test hypotheses systemtically, becomes

concerned with the hypothetical, the future, and ideological problems that happens around him.

IV. Health History

a. Family and Personal health history

b. History of Present Illness


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EENT:

[] Impaired vision [ ] blind

[ ] pain redden [ ] drainage

[ ] gums [ ] hard of hearing [ ] deaf

[ ] burning [ ] edema [ ] lesion teeth

[ ] assess eyes ears nose

[ ] throat for abnormality [x] no problem

RESP:

[ ] Asymmetric [x] tachypnea [ ] barrel

chest

[ ] apnea [ ] rales [x] cough

[ ] bradypnea [ ] shallow [] rhonchi

[] sputum [ ] diminished [] dyspnea

[] orthopnea [ ] labored [] wheezing

[] pain [ ] cyanotic

[] assess resp. rate, rhythm, depth,

pattern,

breath sounds, comfort [ ] no problem

CARDIOVASCULAR:

[ ] arrhythmia [] tachycardia [ ]numbness

[ ] diminished pulses [x] edema [x] fatigue

[ ] irregular [ ] bradycardia [] murmur

[ ] tingling [ ] absent pulses [ ] pain

V. Nursing AssessmentNURSING ASSSESSMENT (System Review Chart)

Name: Date:BP: 110/80mmHg T: 35.5C PR: 90bpm Height: 57 Weight:unrecall

Drowsiness

Right eye blurring vision

Dyspnea and tachypnea

Scrotal edema

Fatigue

Bilateral pitting edema

Drowsiness


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NURSING ASSESSMENT II

SUBJECTIVE OBJECTIVE

COMMUNICATION:[ ] hearing difficulty

[ ] visual changes

[x ] denied

Comments:Blurredlangi

yang right

sidsaiyangmata as

verbalized by his wife

[ ] glasses [ ] languages

[ ] contact lenses [ ] hearing difficulties due to

age

[ ] speech difficulties

Pupil size:R:3 mmL:3mm

Reaction: PERRLA (Pupil Equally Round and

Reactive to Light Accommodation)

OXYGENATIO

[ ] dyspnea

[ ] smoking history

[ ] cough

[ ] sputum

[X] denied

Comments:

galisudsiyaugginahawa

as verbalized by his wife

Resp. []regular [ x] irregular

Describe:rapid shallow breathing

R: _symmetric in lung expansion__

L: _symmetric in lung expansion__

CIRCULATION:

[x] chest pain

[ ] leg pain

[ ] numbness of

extremities

[ ] denied

Comments:

usahaygasakitiyahangdu

ghan as verbalized by his

wife

Heart Rhythm [ ] regular [x] irregularAnkle Edema: (+) bilateral pittting edema

Pulse Car Rad. DP Fem

R + 90bpm - not

assessed_

L + 90bpm - not

assessed____

Comments: Pulse on all sites are palpable .

NUTRITION:

Diet: rice, isda,

gulayugprutas

Character

[ ] recent change in

weight

Comment:

walamaiproblemasaiyan

gkaon as verbalized by

his wife.

[ ] dentures [ x ]none

FullPartialWith patient

Upper [ x ] [ ] [ ]


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[ ] swallowing

Difficulty

[x ] denied

Lower [ x ] [ ] [ ]

ELIMINATION:

Usual bowel pattern:

zero

[x] constipation

remedy

Date of last BM

December 11, 2011

[ ] diarrhea

______None________

[x] urinary frequency

Fully bag catheter

[ ] urgency

[ ] dysuria

[ ] hematuria

[ ] incontinence

[ ] polyuria

[ ] foley in place

[x ] denied

Comments: decreased

peristaltic sound noted.With normal color of

urine and consistency

noted

Bowel sounds

:Audible Normo-active bowel sounds

Abdominal Distention

Present [ ] yes [x] no

Urine* (color,

consistency, odor)

Clear ,yellowish in

color and aromatic in

color

MGT. OF HEALTH & ILLNESS:

[ ] alcohol [ ] denied

(amount/frequency)unrecall

[ ] SBE: N/A Last Pap Smear: N/A

LMP: N/A

Briefly describe the patients ability to follow

treatments (diet, meds, etc.) for chronic health

problems (if present).

Patient was able to follow the treatment plan

with the help by his significant others


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SUBJECTIVE OBJECTIVE

SKIN INTEGRITY:

[ ] dry

[ ] other

[x] denied

Comments: wala man

siyaproblemasaiyangpanit.

Walapudsiyay allergy. As

verbalized by his wife

[ ] dry [x] cold [ ] pale

[ ] flushed [ ] warm

[ ] moist [ ] cyanotic [ ] others

*rashes, ulcers, decubitus (describe size,

location, drainage: _no any rashes,

ulcerations, decubitus noted

ACTIVITY/ SAFETY:

[ ] convulsion

[ ] dizziness

[ ] limited motion of

Joints

Limitation in

Ability to

[ ] ambulate

[ ] bathe self

[ ] other

[ x] denied

Comments:katulogonlangsiya

permi.

Sunoddilipudsiyamakalakaw-

lakawkaytungodsaiyandtiilnana

nghupong. As verbalized by

his wife.

[ ] LOC and orientation Patient is drowsy

upon the assessment

Gait: [ ] walker [ ] cane [ ] other

[ ] steady [ ] unsteady

[ ] sensory and motor losses in face or

extremities : frowning of face and trying

to moved his body

[x] ROM limitations: patient respond and

limited motion of the lower extremities.

COMFORT/SLEEP/

AWAKE:

[ ] pain

(location,frequency

remedies)

[ ] nocturia

[ ] sleep difficulties

[x ] denied

Comments: usahaymakamata-

matasiya kung gabie as

verbalized his wife

[ ] facial grimaces

[ ] guarding

[ ] other signs of pain : ___none____

COPING:

Occupation: none

Members of household: 4 members in their house.

Most supportive person: wife

Observed non-verbal behavior: Client was

shy and unable to answer questions..

Phone number that can be reached

anytime: not given


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VI. Anatomy and Physiology

Basic Anatomy and Physiology of the

Human Brain

This chapter contains some basic background on the anatomy and physiology of the human

brain relevant to this project. The final section focuses on the neonatal brain and some common

pathologies.

Figure 24 Cerebrospinal Fluid. (Reproduced from [Marieb 1991]).


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Cerebrospinal fluid

Cerebrospinal fluid(CSF) is a watery liquid similar in composition to blood plasma. It is formed

in the choroid plexusesand circulates through the ventricles into the subarachnoidspace, where

it is returned to the dural venous sinuses by the arachnoid villi. The prime purpose of the CSF is

to support and cushion the brain and help nourish it. Figure 24 illustrates the flow of CSF

through the central nervous system.

Major regions of the brain and their functions

The major regions of the brain (Figure 25) are the cerebral hemispheres, diencephalon,

brain stemand cerebellum.

Figure 25 Major Regions of the Brain. (Reproduced from [Marieb 1991]).


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Cerebral hemispheres

The cerebralhemispheres (Figure 26), located on the most superior part of the brain,

are separated by the longitudinal fissure. They make up approximately 83% of total brain mass,

and are collectively referred to as the cerebrum. The cerebral cortexconstitutes a 2-4 mm thick

grey matter surface layer and, because of its many convolutions, accounts for about 40% of

total brain mass. It is responsible for conscious behaviour and contains three different functional

areas: the motor areas, sensory areasand association areas. Located internally are the white

matter, responsible for communication between cerebral areas and between the cerebral cortex

and lower regions of the CNS, as well as the basal nuclei(or

basal ganglia), involved in controlling muscular movement.

Cerebral Cortex

Ventral View ( From bottom)

The outermost layer of the cerebral hemisphere which is composed of gray

matter. Cortices are asymmetrical. Both hemispheres are able to analyze sensory data,

perform memory functions, learn new information, form thoughts and make decisions.

Left Hemisphere Sequential Analysis: systematic, logical interpretation of information.

Interpretation and production of symbolic information:language, mathematics,

abstraction and reasoning. Memory stored in a language format. Right Hemisphere

Holistic Functioning: processing multi-sensory input simultaneously to provide "holistic"

picture of one's environment. Visual spatial skills. Holistic functions such as dancing and

gymnastics are coordinated by the right hemisphere. Memory is stored in auditory,

visual and spatial modalities.

Diencephalon


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The diencephalon is located centrally within the forebrain. It consists of the

thalamus,hypothalamusand epithalamus, which together enclose the third ventricle. The

thalamus acts as a grouping and relay station for sensory inputs ascending to the

sensory cortex and association areas. It also mediates motor activities, cortical arousal

and memories. The hypothalamus, by controlling the autonomic (involuntary) nervous

system, is responsible for maintaining the bodys homeostatic balance. Moreover it

forms a part of the limbicsystem, the emotional brain. The epithalamus consists of the

pineal glandand the CSF-producing choroid plexus.

Figure 26 Major Regions of the cerebral hemispheres. (Reproduced from [Marieb 1991]).


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Brain stem

The brain stem is similarly structured as the spinal cord: it consists of grey matter

surrounded by white matter fibre tracts. Its major regions are the midbrain, pons and

medullaoblongata. The midbrain, which surrounds the cerebral aqueduct, provides fibre

pathways between higher and lower brain centres, contains visual and auditory reflex and

subcortical motor centres. The pons is mainly a conduction region, but its nuclei also contribute

to the regulation of respiration and cranial nerves. The medulla oblongata takes an important

role as an autonomic reflex centre involved in maintaining body homeostasis. In particular,

nuclei in the medulla regulate respiratory rhythm, heart rate, blood pressure and several cranial

nerves. Moreover, it provides conduction pathways between the inferior spinal cord and higher

brain centres.

Cerebellum

The cerebellum, which is located dorsal to the pons and medulla, accounts for about

11% of total brain mass. Like the cerebrum, it has a thin outer cortex of grey matter, internal

white matter, and small, deeply situated, paired masses (nuclei) of grey matter. The cerebellum

processes impulses received from the cerebral motor cortex, various brain stem nuclei and

sensory receptors in order to appropriately control skeletal muscle contraction, thus giving

smooth, coordinated movements.

The cerebral circulatory system

Blood is transported through the body via a continuous system ofblood vessels. Arteries

carry oxygenated blood away from the heart into capillariessupplying tissue cells. Veinscollect

the blood from the capillary bed and carry it back to the heart. The main purpose ofblood flow

through body tissues is to deliver oxygen and nutrients to and waste from thecells, exchange

gas in the lungs, absorb nutrients from the digestive tract, and help formingurine in the kidneys.

All the circulation besides the heart and the pulmonary circulation iscalled the systemic

circulation.Since it is the ultimate aim of this research project to image cerebral oxygenation

andhaemodynamics some aspects of the cerebral circulatory system are described below.


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Figure 27 Major cerebral arteries and the circle of Willis. (Reproduced

from [Marieb 1991]).

Blood supply to the brain

Figure 27 shows an overview of the arterial system supplying the brain. The major arteries are

the vertebraland internal carotid arteries. The two posteriorand single anteriorcommunicating

arteries form the circle of Willis, which equalises blood pressures in the brains anterior and

posterior regions, and protects the brain from damage should one of the arteries become

occluded. However, there is little communication between smaller arteries on the brains

surface. Hence occlusion of these arteries usually results in localised tissue damage.


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VII. PATHOPHYSIOLOGY

Stroke, or cerebral vascular accident (CVA), is a condition that is caused by a

lack of oxygen to the brain leading to reversible or irreversible paralysis (Stroke,

2007). A CVA is induced by an obstruction in blood flow to the brain causing hypoxia tothe effected brain tissue which quickly leads to neuronal cell death if left untreated

(Corwin, 2008). Due to cell death there is a great deal of inflammation, production of

oxygen free radicals and oedema which worsens the condition (Corwin, 2008). Acidosis

is a side effect of hypoxia which causes further injury by activating the acid-sensing

neuronal ion channels (Corwin, 2008). Brain damage ensues and usually peaks 24-72

hours after onset (Corwin, 2008). When classifying a cerebrovascular accident there are

two main categories: ischemic and haemorrhagic (Corwin, 2008).

Transient ischemic attacks are also thought to be caused by thrombi, however,

the difference is that these strokes resolve within 24 hours of onset (McCance&Huether,

2006). There is a very high probability of reoccurrence in these patients if left untreated

(McCance&Huether, 2006). Like thrombotic strokes TIAs are usually caused by

atherosclerosis (Corwin, 2008). It has been hypothesized that TIAs occur when the

atherosclerotic vessel spasms cutting off oxygen supply to the distal tissue, or there is

an increased demand for oxygen which can not be met due to the partially occluded

vessel (Corwin, 2008).

Haemorrhagic stroke accounts for roughly 15% of all strokes (Brown & Edwards,

2005). The stroke occurs when there is a larges accumulation of blood causing the

surrounding brain tissue to be displaced and compressed, often causing blood to leak

into the ventricles (McCance&Huether, 2006). There are large haemorrhages, which

may be several centimeters, or small haemorrhages that may only be one to two

centimeters in diameter (McCance&Huether, 2006). There may only be a slit, referred

to as a petechial haemorrhage which is a very small pinhead size bleed

(McCance&Huether, 2006). The main contributing factor to this type of stroke is

hypertention (McCance&Huether, 2006).


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DIAGRAM

Hypertension Hyperlipidemia

Shearing force Fatty disposition into arterial wall

Damage of arterial endothelial layer

Inflammatory response & intramuscular clotting

Atheromatous aorta Thrombus Formation

LVH Narrowing of the lumen

Embolic occlusion in myocardial arteryDisrupted brain cell metabolism

Accumulation of H2O, Ca, NA CAD

ICP

Localized acidosis and free radicalFormation

Cell injury

CVA

Prognosis

Predisposing Factors:

Gender

Age

Precipitating Factors:

Lifestyle

Uncontrolled HTN Diet

S: SxBP, dyspnea,

Angina, edema,

Dizziness,swollenNeck vein,Palpitations,mentalconfusion

S: SxChest pain,Dyspnea,dizziness,unusual fatigue,ECG changes,dysrrhythmias


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If Treated If untreated

References:

Pathophysiology (Adaptation and Alteration in Function) 4th edition by Barbara, Bullock.

Essentials of Anatomy and Physiology 6th edition by Seeley.

Coma

Cerebral death

Loss of neural feedbackmechanism

Cessation of physiologicfunctions

Multi-organ failure

DEATH

Return of normalperfusion

Decreased Edema

Improved function


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VIII. MEDICAL MANAGEMENT

a. Medical Orders and Rationale


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b. Laboratory Results

HEMATOLOGY REPORT

TEST RESULT REFERENCERANGE7-18-12

WBC High WBC count often means that an infection

is present in the body, while a low number canmean that a specific disease or drug hasimpaired the bone marrows ability to producenew cells.

8.08 x 10 ^ g/l 3.8-10.8 x 10 ^g/l

RBC Decreased RBC is usually in anemia of any

cause with the possible exception ofthalassemia minor, where a mild or borderlineanemia is seen with a high or borderline-highRBC. Increased RBC is seen in erythrocytotoxic

state.

4.90 4.2-5.6

Hgb Decreased in various anemias, pregnancy,

severe or prolonged hemorrhage withexcessive fluid intake. Increased inpolycythemia, chronic obstructive pulmonarydisease failure of oxygenation because of CHFand normally in people living at high altitudes.

151 g/dl 140-160 g/dl

Hct Decreased in sever anemias, anemia in

pregnancy, acute massive loss. Increased inerythrocytosis of any cause and in dehydrationor hemoconcentration associated with shock.

0.44 % .40-.54 %

Mean corpuscular volume Decreased in ion deficiency, thalassemia,

anemia of chronic diseas and lead poisoning.Increased in folate deficiency, B12 deficiencyand hypothyroidism

91 fl 80-100 fl

Mean corpuscular hemoglobin Levels below 27pg suggest conditions such as

anemia and iron deficiency. Levels above 33pgsuggest possible thyroid issues.

31 27-33


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Mean corpuscular Hgb concentration Decreased MCHC values are seen in conditions

where the hemoglobin is abnormally dilutedinside the red cells such as in iron deficiencyanemia and in thalassemia. Increased MCHCcalues are seen in conditions where the

Hgb is abnormally concentrated inside thered cells, such as in burn patients andhereditary spherocytosis, a relative rarecongenital disorder.

34 g/dl 32-36 g/dl

Differential count

Lymphocytes Increased with infections mononucleosis, viral

and some bacterial infections and hepatitis.Decreased in aplastic anemia, SLE andimmunodeficiencyAIDs

0.25 0.20-0.40

Neutrophils Increased with acute infections, trauma, orsurgery, leukemia, malignant disease andnecrosis. Decreased with viral infections, bonemarrow suspension and primary bone marrowdisease.

0.68 % .48-.73 %

Monocytes Increased with viral infections, parasitic disease,

collagen and hemolytic disorders. Decreasedwith use of corticosteroids, RA and HIV infection

0.06 .00-.10

Eosinophils Increased in allergies, parasitic disease,

collagen disease, and subacute infections.Decreased with stress and use of meds.

0.01 0.00-0.08

Basophils Increase in acute leukemia and following

surgery or trauma. Decreased with allergicreactions, stress, parasitic disease and use ofcorticosteroids

0.0 0.00-0.20

Platelet

Both increases and decreases can point toabnormal conditions of excess bleeding orclotting.

256 x 10 ^ g/l 150-400 x 10 ^g/l


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TEST RESULT REFERENCERANGE

Blood sugar (Fbs, Rbs, 2HPP) Increased in DM, nephritis,

hypothyroidism and infections.

Decreased in hyperinsulinism,hyperthyroidism and hepatic damage.

82.9 70-115 mg/dl

CT Scan Report

Brain Plain CT Scan

Multiple axial tomographic sections of the brain without contrast were obtained

revealing the following:

There is a 3.5x3.2x4.8 oms. Wedge shaped hypodensity in the right

temporoparietal lobe with small hyperdensity which maybe artificial inorigin.

Ventricles, sulci, and cisteins are intact.

There is no midline shift

No extra-axial fluid collection seen.

Posterior fossa, sella, orbits, petromastoids, paranasal sinuses and bony

calvarium are unremarkable.

Impression:

Acute infarct with probable hemorrhagic conversion, right temporo-parietal lobes.


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c. Drug study


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IX. NURSING MANAGEMENT

NURSING CARE PLAN

Name of Patient: Rowel Arbellera

Cues Nursing Diagnosis Objectives Nursing Intervention Rationale Evaluation

Left side

weakness

Impaired physical

mobility related toleft hemiparesis,

loss of balance and

coordination,

spasticity, and brain

injury

Improve patients

mobility and preventdeformities

1. Use foot

board atintervals

during the

flaccid

period

2. Apply

posterior

splint at

night

3. Change

position

every 2

hours

4. Elevate

affected arm5. Place a

pillow in the

axilla

1. To prevent

foot dropand heel

cords from

shortening

2. To prevent

flexion of

affected

extremities

3. To prevent

bed sores

4. To prevent

edema5. To prevent

adductions

of the

affected

shoulder

At the end of

performing variouskinds of nursing

intervention patient

achieves improved

mobility


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NURSING CARE PLAN



Left side

weakness

Deficient self-care

(hygiene, toileting,

transfers, feeding)

related to stroke

sequelae

Enhance

patients self-

care

1. Encourage patient to

carry out all self care

activities on the

unaffected side

2. Encourage patient toassist in personal

hygiene; select suitable

self-care activities that

can be carried out with

one hand

3. Provide emotional

support

4. Make sure that patient

is fully dressed during

ambulatory activities

5. Hep patient to set

realistic goal; add a new

task daily

1. To enhance

patients hygiene

status and

promote

independence2. To promote

mobilization of the

unaffected side

and to promote

comfort

3. To prevent fatigue

and

discouragement

4. To improve

patients morale

5. For patient to

know that theres

an improvement in

his status

At the end of

nursing

interventions

patients self-care

was enhanced


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NURSING CARE PLAN



Left side

weakness

Brain

Damage

Disturbed sensory

perceptions related

to brain damage

Manage sensory-

perceptual

difficulties

1. Approach

patient with

decreased

field of vision

on the sidewhere visual

perception is

intact

2. Teach

patient to

turn and look

in the

direction of

the defective

visual field

3. Increase

natural or

artificial

lighting in the

room

4. Remind

patient with

hemianopsia

of the other

side of the

body; place

extremities

1. For patient

to recognize

person and

objects

2. To

compensate

for the loss

of the vision

of the

affected side

3. To improve

vision

4. So that

patient can

see them.

At the end of

performing various

kinds of nursing

sensory-perceptual

difficulties wasmanage


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X. REFERRALS AND FOLLOW-UP (DISCHARGED PLAN)

The patient was advised to go home with instructions given to the family. They

were given home medications in which specific dosages and duration was specified to

prevent overdosing of drugs. The patient was also given a specific date of his follow-up

checkup in order to see the improvement of his condition or complications exist. Health

teachings was given with emphasis on; proper compliance to medication, proper

exercise, encouraged to make it a habit to visit in the nearest health centre or hospital

regularly, having calorie free diet, control intake of salt and fatty foods in order to have a

healthy life and prevent disease.

XI. Evaluation and Implications

Cerebrovascular accident is most known common disease nowadays especially

in middle and late adulthood. The cost of treatment is not limited to the cost of

hospitalization and medical laboratories. Rather, the cost is multiplied a hundredfold,

and becomes the burden of an entire family.

On our first day of our clinical duty the patient has already in a better condition

but still has body weakness in his left side of the body. His medication was properly

given and nursing interventions were implied due to his complaints. He was recovering

and his family has full of support to him.

On our second day of our clinical duty all laboratory results of the patient were

already done except for his 2-D echo result. Since he still has some weakness in his left

side of his body, passive range of motion was done and he felt better. Due meds were

given and bedside and morning care was done.

While on our third day of care to our patient, his condition was improving. He was

able to comply all his due meds but still waiting for his 2-D echo results. He was also

very talkative to us and to his family. Moreover, nursing interventions were applied and

health teachings were given. The family was further instructed to monitor their fathers


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condition and refer immediately to their physician in cases of recurring symptoms of

stroke.

At the end of the shift, the interventions and procedures done to the patient were

successful and the patient was able to participate actively to the treatment regimen.

XII. Bibliography

Documents

Group Cp Compiled