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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
Name of Patient: Rowel Arbellera
Cues Nursing Diagnosis Objectives Nursing Intervention Rationale Evaluation
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
Name of Patient: Rowel Arbellera
Cues Nursing Diagnosis Objectives Nursing Intervention Rationale Evaluation
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