CVA Format Case Study

wTABLE OF CONTENTSI. Introduction 3a. Overview of the case 3 b. Objective of the study 4c. Scope and Limitation of the study 5II. Health History 5III. Developmental Data 7IV. Medical Management 10 a. Medical orders with rationale 10b. Drug Study 13c. Laboratory results 17 V. Anatomy and Physiology with Pathophysiology 19 VI. Nursing Assessment 23VII. Nursing Management 26a. Ideal Nursing Management (NCP) 26b. Actual Nursing Management (SOAPIE) 28 VIII. Referrals and Follow-up 32IX. Evaluation and Implications 32X. Bibliography 33

I. INTRODUCTIONA.OVERVIEW:

Cerebrovascular diseaseis a group of brain dysfunctions related to disease of the blood vessels supplying the brain.Hypertensionis the most important cause; it damages the blood vessel lining, endothelium, exposing the underlying collagen where platelets aggregate to initiate a repairing process which is not always complete and perfect. Sustained hypertension permanently changes the architecture of the blood vessels making them narrow, stiff, deformed, uneven and more vulnerable to fluctuations in blood pressure.A fall in blood pressure during sleep can then lead to a marked reduction in blood flow in the narrowed blood vessels causingischemic strokein the morning. Conversely, a sudden rise in blood pressure due to excitation during the daytime can cause tearing of the blood vessels resulting in intracranial hemorrhage. Cerebrovascular disease primarily affects people who are elderly or have a history of diabetes, smoking, or ischemic heart disease. The results of cerebrovascular disease can include astroke, or occasionally ahemorrhagic stroke.Ischemiaor other blood vessel dysfunctions can affect the person during a cerebrovascular incident.Atransient ischemic attack(TIA) leaves little to no permanent damage within the brain. The symptoms of this include facial weakness, visual impairment, loss of coordination, or balance, a sudden headache, and mental confusion with unintelligible speech. Severe blockage of the arteries to the brain is known ascarotid stenosis.Carotid artery affects retina, cerebral hemisphere, or both. Retinal Transient blackouts; the sense of a shade pulled over the eyes. Cerebral Contralateral (opposite sided) paralysis of a single body part; paralysis of one side of the body; localized tingling, numbness; hemianopic visual loss; aphasia (loss of speech); rare loss of consciousness. Vertebrobasilar Bilateral visual disturbance including dim, gray, or blurred vision or temporary total blindness; diplopia (double vision). Labyrinth/medulla Vertigo; unsteadiness; nausea; vomiting. Brainstem Slurring dysarthria (tongue weakness causing impaired speech); dysphagia (difficulty swallowing); numbness, weakness; all four limb paresthesia; drop attacks from sudden loss of postural tone are basilar in origin; a vertebrobasilar artery occlusion episode causes symptoms to be induced by abrupt position changes.

Cerebrovascular disease can be divided intoembolism,aneurysms, and low flow states depending on its cause. Major modifiable risk factors includehypertension,smoking,obesity, anddiabetes.The most common forms of cerebrovascular disease arecerebral thrombosis(40% of cases) andcerebral embolism(30%), followed bycerebral hemorrhage(20%).[2]Cerebrovascular disease is primarily one of old age; the risk for developing it goes up significantly after 65. CVD tends to occur earlier than Alzheimer's Disease (which is rare before the age of 80). In some countries such as Japan, CVD is more common than AD. CVD occurs more rarely in younger people due to conditions such assyphilisthat lead to artery damage and strokes.

B.OBJECTIVES OF THE STUDYAfter 1 hour of case presentation, I should be able to achieve the following objectives: 1. Present a thorough general health assessment of the client which includes physical assessment and family history taking.2. Effectively discuss and elaborate actual signs and symptoms of disease exhibited by the client.3. Thoroughly discuss, explain, and elaborate the nature of the disease process.4. Efficiently provide appropriate and proper nursing diagnosis in line with the clients medical condition.5. Skillfully formulate nursing care plans for the different problems identified.6. Appropriately provide nursing interventions according to the standards of nursing practice.7. Effectively apply the learned concepts and theories of disease.8. Efficiently appraise the effectiveness and efficacy of nursing interventions rendered to the client.9. Impart the outcome of the rendered nursing interventions.10. Convey the significance of clients response to the rendered nursing interventions.11. Correctly provide concise and concrete information with regards to the patients disease condition.12. Appropriately provide appropriate environment for learning.

C.Scope and LimitationThe limitation of this Case Presentation focused on the patient whom the researcher had rendered care with, in Northern Mindanao Medical Center Hospital during their 4 days duty in the Medical ward. Also the study follow the required concept in their midterms which is the neural disturbances since they cant find it in the Medical ward, hence, this patient is chosen by the researcher for a case presentation. This case study encompasses the concepts of the circulatory system. The data presented in this case was primarily obtained from student nurse-patient interaction as well as with the significant other who partly served as informant and is based on the patients chart. The student nurse was able to render care to the patient during the 16 hours of duty on May 26, 2013. During the course of this 2 day nursing care, the student nurse assess patient thoroughly, plan nursing care, implement plan of care and give health teachings. The scope of this statistics is only limited to the occurrence of the cerebrovascular disease in Northern Mindanao which comprises about 75.5% of the total population.II. HEALTH HISTORYPATIENTS PROFILE Name:C.B

Address:Brgy. 4 Poblacion Talakag Bukidnon

Birthday:December 9, 1980

Birthplace: Bukidnon

Age: 32 years old

Nationality:Filipino

Religion:Catholic

Civil Status:Married

Occupation:None

Educational Attainment:High School Graduate

Family Income:Php 6000/month

Height:52

Weight: 70 kgs

Admitting Diagnosis:Cerebrovascular Disease

Attending Physician:Shielamar B. Flores MD

Past Health History:A. Heredo-familial DiseaseThe patients mother has a history of Goiter. On the other hand, his father has a history of heart disease

B. Diet and LifestyleThe patient exercise regularly but he is a chain smoker in which he can consume 10 sticks per day for almost 40 years duration. He is also into drinking alcohol, 2 bottles of beer occasionally. His diet contains high fat and sodium diet, which are chicharon, bulalo, and canned foods. He respond to stressful events by just verbalizing it to her wife.

C. History of admission.The patient was admitted at Camp Evangelista Station Hospital last 2005 diagnosed to have peptic ulcer, and last 2010 having been diagnosed with Hepatitis B and UTI.

Chief Complaint and History of Present IllnessA case of M.E ,56 yrs. old, female, Married, Pentecostal, Filipino and currently residing in Brgy.Besigan Cagayan de Oro City, Admitted for the 1st time in Northern Mindanao Medical Center with a chief complaint of Loss of Consciousness. 6 hrs prior to admission patient was noted with sudden onset of slurring of speech associated with several episodes of non-projectile vomiting. Patient then had Loss of Consciousness and was noted to have body weakness. Bp was noted to be elevated @ 200/140 mmHg. And Captopril 25mg SL was then given. Patient was then referred in Northern Mindanao Medical Center for further management.III. Developmental Data:TheoristTheoryStageResult and Justification

Sigmund FreudPsychosexual Development Theory - It is a theory of how our sexuality starts from a very young age.Genital Stage (Puberty-onwards): Libido reawakened as genital organs mature and focuses on relationships with members of the opposite sex.My patient was able to find a lifetime partner where they are happily living together with his 9 children.

TheoristTheoryStageResult and Justification

Erik Erikson

Psychosocial Development Theory - It describes 8 developmental stages through which a healthily developing human should pass from infancy to adulthood. In each stage the person confronts, and hopefully masters new challenges. Each stage builds on the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future.Generativity Vs. Stagnation.(Ages 40-65)Achieve the life goals established for oneself while considering the welfare of future generations.

My patient has her own salary to support for his children who are in school and he had already 5 children who are married and can support their own family. He has able to maintain healthy lifestyle and able to accept childs mates.


Robert Havighurst

Theory of Developmental Task- Learning is fundamental to life and in order to have a deeper insight on growth and development, one must understand it and recognize the premise that human being continues to learn throughout life. Happiness is being achieved when a particular task of a certain age is achieved by the person successfully but if not, failure occurs which is a feeling of unhappiness and disapproval from people surrounding the client.

(Ages 40-60)The following Tasks must be developed:Assisting teenage children to become responsible and happy adults, Achieving adult social and civic responsibility, Reaching and maintaining satisfactory performance in ones occupational career, Developing adult leisure time activities, Relating oneself to ones spouse as a person, To accept and adjust to the physiological changes of middle age, Adjusting to aging parents.

Five of the patients children are already married. He was there to guide them in their marriage life and helped them whenever there are problems. He depends on his income and works to earn money. His leisure activities are mainly watching TV and listening to radio. He also understands his current situation and is aware of the changes in his lifestyle. His wife and children were the one who takes care on him and has the responsibility on his current condition.


Jean Piaget

Theory of Cognitive Development -A comprehensive theory about the nature and development of human intelligence. It deals with the nature of knowledge itself and how humans come gradually to acquire it, construct it, and use it. Cognitive development is at the centre of human organism and language is contingent on cognitive development.Formal Operational Stage (Age 11-onwards).A person logically solves all types of problems; thinks scientifically; solves complex problems; cognitive structures mature.

My patient usually understands his situation but cannot directly identify solutions for his problems because he is paralyzed and unable to talk well due to CVA.

IV. MEDICAL MANAGEMENT A. DOCTORS ORDERNovember 20, 20121:10 am

November 22, 201211ooH





November 28, 20121440h

November 29, 20121342H

December 19, 2012O845H Please admit at the Medical Ward TPR every shift

NPO temporarily

I and O every shift and record

Labs: CBC, U/A, S/E, ECG 12 leads, Chest-xray PAL view, FBS, triglycerides, lipid profile, BUN, BUA, creatinine

Continue venoclysis plain NSS 1L to 20 drops/min

To follow plain NSS @ SR

Meds: Captopril 25 mg SL now then prn if the BP is 160/100 and above

Amlodipine 10 mg OD

O2 inhalation 2-3L/min with dyspnea (pm)

Refer to Dr.Jolo

Refer accordingly

IM NOTES For CT Scan brain plain Citicholine 500 mg I tab

Simvastatin 20 mg 1 tab OD H.S

Senna Concentrate 2 tab OD H.S prn for constipation Follow-up IVF with D5NM 1L @ SR Soft Diet

Please insert condom catheter

IVF to follow D5W iL @SR

May give paracetamol 500 1tab PRN for pain

IVF to follow D5LR iL @SR

IVF to follow D5NM iL @SR

Cephalexin 500 1 cap every 8 hours x 7 days

Terminate IVF when consumed

Pls follow up CT Scan result

For referral to neuro department with CT scan filter

Please carry out suggestions of neurologist

Refer to PT department for physiotherapy

Perindopril 5 mg 1 tab OD

Bisacodryl supp per rectum at HS if still no BM

May remove condom catheter

For repeat urinalysis

Encourage oral fluid intake For furher evaluation of his condition. To monitor any signs of deterioration of health status

Aspiration risk is greater, so as to avoid aspiration.

To monitor fluid loss

To monitor abnormalities in the blood, and fifferent enzymes and waste products of the body.

Venoclysis to supply blood vessels and prevent dehydration.

For hydration purposes

An ACE inhibitors help reduce blood pressure and also increased prostaglandin synthesis A calcium-channel blocker whichdilates blood vessel making the heart easier to pump blood.

To increase oxygen supply in the blood.

For further evaluation and treatment of disease condition.

For further evaluation and referral of the disease condition. To note any clot in the brain.

A CNS stimulant which increases blood supply and oxygen to the brain.

An anti-hyperlipidemic which reduces LDL cholesterol and triglycerides

Treats constipation

For fluid and eletrolye balance Easily digested help prevent aspiration

For patient to urinate without assistance due to stroke

For fluid and electrolyte balance

Analgesics use as temporary relief for pain associated in headache

For fluid and electrolyte balance

Hypertonic solutions help in fluid and electrolyte balance

A cephalosporin help decrease bacterial cells

To prevent complications

For referral and treatment of disease process

To determine if there are any abnormalities in the brain

For better management of the disease

For muscle and body rehabilitation

For prevention of stroke.

Constipation relief

To prevent infection

To determine any unusual result in his urine

For hydration purposes

B. Drug Study

Name of DrugClassification Dose/ frequencyMechanism of ActionsSpecific IndicationContraindicationSide effectsNsg Precautions

AmlodipineCalcium channel blocker

10mg OD PO

Inhibits influx of calcium through the cell membrane, resulting in a depression of automaticity and conduction velocity in cardiac muscle.Treatment for essential hypertension.allergy to amlodipine

CNS:Dizziness,light headedness, fatigue, lethargy1. Monitor vital signs, CBC, and ECG.2. Instructed to avoid grape fruit juice3. Can be taken with or without meals4. Note and report chest pain, SOB and dizziness

Name of DrugClassification Dose/ frequencyMechanism of ActionsSpecific IndicationContraindicationSide effectsNsg Precautions

CiticholineCNS stimulant500 mg OD POIncreases oxygen supply and blood to the brain.Citicholine in CVA, stimulates brain functionAny allergy or hypersensitivity to the drug

headache, dizziness, nausea and vomiting, abdominal cramps1. May reduce dosage with impaired renal function,2. May take with meals3. Monitor vital signs, CBC4. Monitor mental status.

Name of DrugClassificationDose/ frequencyMechanism of ActionsSpecific IndicationContraindicationSide effectsNsg Precautions

Captopril ACE inhibitor25 mg SL when BP is 160/100 or above POInhibits angiotension-converting enzyme resulting in decreased plasma angiotensin II, which leads to decreased vasopressor activity and decreased aldosterone secretion.

Management of hypertensionHypersensitivity to captopril, other ACE inhibitor or any componentRash, gastric irritation, headache, dizziness, fatigue, malaise, dry mouth, N&V1. Take 1 hour before meals, 2.Report fever, chest pain, skin rash and irregular heartbeat3. Withhold potassium-sparing diuretics


Senna concentrate

Laxative

2tabs OD

promotes incorporation of water into stool, resulting in softer fecal mass.to soften the stool Abdominal pain Nausea and vomiting

common side effects mild cramps Advise patient that laxative should only be used for short therapy Encouraged patient to use other forms of bowel regulation, such as increasing bulk in the diet and increasing fluid intake and increasing mobility


SimvastatinAntilipidemics

200mg 1tab OD HS

inhibits HMG-COA reductase, an early step in cholesterol biosynthesisin hyperlipidemia: an adjunct to diet to reduce elevated total LDLactive liver disease or unexplained persistent elevations of serum transaminases porphyria

Constipation, Dyspepsia, Flatulence, Headache

1.Instruct patient to take drug with the evening meal2.Use drug only after diet


perindoprilanti-hypertensive: 500mg 1tab ODinhibits ACE activity, thereby preventing conversion of angiotensin 1 to 2, a potent vasoconstrictor.

prevention of stroke recurrence in combination with indapamide in patients with a history of CVA.

in patients hypersensitivity to drug or other ACE inhibitorPalpitation, Edema, Chest pain, Abnormal ECG

1.Use cautiously in patient with a history of angioedema unrelated to ACE inhibitor therapy2.Also use cautiously in pt. with impaired renal function


Bisacodyl

Mucokenitics/ expectorants

1tab supp per rectumIncreases peristalsis and motor activity of the small intestines by acting directly on the smooth muscle.

Constipation relief of avacuation in hemorrhoids prep for barium enema, pre and post op.

Hypersensitivity to drugsNausea,Vomiting, Abdominal pain, Ulcerative lesions of colon

1.Monitor frequency and character of stool2.Swallow the tablet whole3.Do not crush or chew the drug


Cephalexincephalosporins

500 mg, every 8 hours, POInterferes with the final step in cell wall formation, resulting in unstable cell membranes that undergo lysis. Also, cell division and growth are inhibited.GU infections and respiratory infectionHypersensitivity to drugsDiarrhea, nausea and vomiting, abdominal pain, dizziness, skin rash, fever

1. Refrigerate suspension after reconstitution2. May reduce dosage with impaired renal function,3. May take with meals4. Consume 2-3 L/day of fluids to prevent dehydration.

.

c. LABORATORY RESULTSName: Gulle, EubertoNovember 25, 2012Age: 55 years oldURINALYSISColor: YellowWBC: 0-2/hpfTransparency: clearRBC: (-)/hpfSugar: NegativeAlbumin: Negative Amorphous urates: FewSpecific Gravity: 1.015pH: 6.0

CT SCAN REPORTGULLE, EUBERTONovember 27, 2012Interpretation: Plain CT Scan of the brain with serial axial views disclose the following findings.There is a hypodense focus at the left frontal lobe measuring around 7.6 cms in widest diameter. There is another one at the right occipital lobe measuring around 2.2 cms. There are tiny hypodensities in the superior left fronto parietal lobes.There is no abnormal attenuation of the cerebellum and brain stem.The ventricles are not dilated.The midline structures are intact.Petro mastoids, sinuses, orbits and sellar areas are unremarkable.

Impression:CONSIDER ACUTE TO SUB-ACUTE INFARCTS, LEFT FRONTO PARIETAL LOBES AND RIGHT OCCIPITAL LOBE.

Gulle, EubertoNovember 22, 2012

CHEST X-RAYCardiothroracic ratio 60.58. Both lungs are clear. Trachea, diaphragm, and bronchus are unremarkable.Impression: Moderate Cardiomegaly

HEMATOLOGYWBC: 13, 700/cumm above normal which suggests infection.Hemoglobin: 13.8 gm % - normal findingsHematocrit: 45.3 vol % - normal findingsPlatelet count: 277, 000/cumm normal findingsDifferential countNeutrophil: 77 above normal findings which suggest bacterial infectionLymphocytes: 18 below normal which suggests viral infectionEosinophil: 05 normal findings

V. ANATOMY AND PHYSIOLOGY with ACTUAL PATHOPHYSIOLOGY

OverviewNothing in the world can compare with the human brain. This mysterious three-pound organ controls all necessary functions of the body, receives and interprets information from the outside world, and embodies the essence of the mind and soul. Intelligence, creativity, emotion, and memories are a few of the many things governed by the brain.The brain receives information through our five senses: sight, smell, touch, taste, and hearing - often many at one time. It assembles the messages in a way that has meaning for us, and can store that information in our memory. The brain controls our thoughts, memory and speech, movement of the arms and legs, and the function of many organs within our body. It also determines how we respond to stressful situations (such as taking a test, losing a job, or suffering an illness) by regulating our heart and breathing rate.Nervous systemThe nervous system is divided into central and peripheral systems. The central nervous system (CNS) is composed of the brain and spinal cord. The peripheral nervous system (PNS) is composed of spinal nerves that branch from the spinal cord and cranial nerves that branch from the brain. The PNS includes the autonomic nervous system, which controls vital functions such as breathing, digestion, heart rate, and secretion of hormones.SkullThe purpose of the bony skull is to protect the brain from injury. The skull is formed from 8 bones that fuse together along suture lines. These bones include the frontal, parietal (2), temporal (2), sphenoid, occipital and ethmoid (Fig. 1). The face is formed from 14 paired bones including the maxilla , zygoma, nasal, palatine, lacrimal, inferior nasal conchae, mandible, and vomer. Inside the skull are three distinct areas: anterior fossa, middle fossa, and posterior fossa (Fig. 2). Doctors sometimes refer to a tumors location by these terms, e.g., middle fossa meningioma.Similar to cables coming out the back of a computer, all the arteries, veins and nerves exit the base of the skull through holes, called foramina. The big hole in the middle (foramen magnum) is where the spinal cord exits.BrainThe brain is composed of the cerebrum, cerebellum, and brainstem (Fig. 3). Thecerebrumis the largest part of the brain and is composed of right and left hemispheres. It performs higher functions like interpreting touch, vision and hearing, as well as speech, reasoning, emotions, learning, and fine control of movement. Thecerebellumis located under the cerebrum. Its function is to coordinate muscle movements, maintain posture, and balance. Thebrainstemincludes the midbrain, pons, and medulla. It acts as a relay center connecting the cerebrum and cerebellum to the spinal cord. It performs many automatic functions such as breathing, heart rate, body temperature, wake and sleep cycles, digestion, sneezing, coughing, vomiting, and swallowing. Ten of the twelve cranial nerves originate in the brainstem.The surface of the cerebrum has a folded appearance called the cortex. The cortex contains about 70% of the 100 billion nerve cells. The nerve cell bodies color the cortex grey-brown giving it its name gray matter (Fig. 4). Beneath the cortex are long connecting fibers between neurons, called axons, which make up the white matter.Right brain left brainThe right and left hemispheres of the brain are joined by a bundle of fibers called the corpus callosum that delivers messages from one side to the other. Each hemisphere controls the opposite side of the body. If a brain tumor is located on the right side of the brain, your left arm or leg may be weak or paralyzed.Not all functions of the hemispheres are shared. In general, the left hemisphere controls speech, comprehension, arithmetic, and writing. The right hemisphere controls creativity, spatial ability, artistic, and musical skills. The left hemisphere is dominant in hand use and language in about 92% of people.Lobes of the brainThe cerebral hemispheres have distinct fissures, which divide the brain into lobes. Each hemisphere has 4 lobes: frontal, temporal, parietal, and occipital (Fig 3). Each lobe may be divided, once again, into areas that serve very specific functions. Its important to understand that each lobe of the brain does not function alone. There are very complex relationships between the lobes of the brain and between the right and left hemispheres.Frontal lobe Personality, behavior, emotions Judgment, planning, problem solving Speech: speaking and writing (Brocas area) Body movement (motor strip) Intelligence, concentration, self awarenessParietal lobe Interprets language, words Sense of touch, pain, temperature (sensory strip) Interprets signals from vision, hearing, motor, sensory and memory Spatial and visual perceptionOccipital lobe Interprets vision (color, light, movement)Temporal lobe Understanding language (Wernickes area) Memory Hearing Sequencing and organizationDeep structuresHypothalamus -is located in the floor of the third ventricle and is the master control of the autonomic system. It plays a role in controlling behaviors such as hunger, thirst, sleep, and sexual response. It also regulates body temperature, blood pressure, emotions, and secretion of hormones.Pituitary gland- lies in a small pocket of bone at the skull base called the sella turcica. The pituitary gland is connected to the hypothalamus of the brain by the pituitary stalk. Known as the master gland, it controls other endocrine glands in the body. It secretes hormones that control sexual development, promote bone and muscle growth, respond to stress, and fight disease.Pineal gland- is located behind the third ventricle. It helps regulate the bodys internal clock and circadian rhythms by secreting melatonin. It has some role in sexual development.Thalamus- serves as a relay station for almost all information that comes and goes to the cortex (Fig. 5). It plays a role in pain sensation, attention, alertness and memory.Basal ganglia- includes the caudate, putamen and globus pallidus. These nuclei work with the cerebellum to coordinate fine motions, such as fingertip movements.Limbic system- is the center of our emotions, learning, and memory. Included in this system are the cingulate gyri, hypothalamus, amygdala (emotional reactions) and hippocampus (memory)HUMAN BRAIN WITH STROKEA stroke occurs if the flow of oxygen-rich blood to a portion of the brain is blocked. Without oxygen, brain cells start to die after a few minutes. Sudden bleeding in the brain also can cause a stroke if it damages brain cells.If brain cells die or are damaged because of a stroke, symptoms occur in the parts of the body that these brain cells control. Examples of stroke symptoms include sudden weakness; paralysis or numbness of the face, arms, or legs (paralysis is an inability to move); trouble speaking or understanding speech; and trouble seeing.

ACTUAL PATHOPHYSIOLOGY OF CEREBROVASCULAR DISEASECerebrovascular accidentorstroke (also calledbrain attack) results from sudden interruption of blood supply to the brain, which precipitates neurologic dysfunction lasting longer than 24 hours.REDISPOSING FACTORPRECIPITATING FACTORGood PrognosisPARALYSISBrain Tissue Necrosis

Vices (alcohol and smoking)DietStressHeredityHypertensionHyperlipidimia

VASOCONSTRICTION

Cerebral IschemiaBlockage of the blood vessels

Cell Death Decreased Oxygen Supply

Lack of oxygen supply and nutrients supply

Intracerebral HemorrhageHypoxia

Altered Cerebral Metabolism

Right Lower and upper extremities

Embolic StrokeAneurysm RuptureCytotoxic EdemaLocal AcidosisDecreased Cerebral Perfusion

VI. NURSING ASSESSMENT (SYSTEM REVIEW AND NSG. ASSESSMENT II)NURSING SYSTEM REVIEW CHARTNAME of PATIENT: Mr. E.GDate: December 12 , 2012- 10:00 amArea:Medical Ward - CESHPulse: 85bpm RR: 22cpmBP: 150/90mmHgTemp: 370CHeight: 150cmWeight:68 kgs

EENT:[x] Impaired Vision [ ] Blind [ ] Pain [ ] Reddened[ ] Drainage [ ] Gums [ ] Hard of Hearing dry lips, partial lower dentures

[ ] Deaf [ ] Burning [ ] Edema [ ] Lesion[x] Teeth [ ] No Problem[x] Assess Eyes, Ears Nose, and Throat for Abnormalities.

RESPIRATORY SYSTEM:[ ] Asymmetric [ ] Tachypnea [ ] Apnea [ ] Rales[] Cough [ ] Barrel Chest [ ] Bradypnea[] Shallow [ ] Rhonchi [ ] Sputum [ ] DiminishedHemiparesis

[ ] Dyspnea [ ] Orthopnea [ ] Labored [ ] Wheezing[ ] Pain [ ] Cyanotic [ ] No Problem[x] Assess Resp. Rate, Rhythm, Depth, Pattern, Breath Sounds and Comfort.

CARDIO VASCULAR:Normoactive bowel sounds

[ ] Arrhythmia [ ] Tachycardia [ ] Numbness [ ] Diminished Pulses [ ] Edema[ ] Fatigue [ x ] Irregular[ ] Bradycardia [ ] Murmur [ ] Tingling [ ] Absent Pulses[ ] Pain [] No Problem[x] Assess Heart Sounds, Rate, Rhythm, Pulse, Blood Pressure, Circulation, Fluid Retention, and Comfort.

GASTRO - INTESTINAL TRACT:[ ] Obese [ ] Distention [ ] Mass [ ] Dysphagia [ ] Rigidly [ ] Pain [] No Problem[x] Assess Abdomen, Bowel Habits, Swallowing,Bowel Sounds and Comfort.

GENITO - URINARY AND GYNE:Decreased muscle tone, limited ROM

[ ] Pain [ ] Urine Color[ ] Vaginal Bleeding [ ] Hematuria [ ] Discharge [ ] Nocturia[x] No Problem[x]Assess Urine Frequency, Control, Color, Odor, Comfort, Gyne-Bleeding and Discharge.Dry skin

NEURO:[x ] Paralysis [ ] Stuporus [ ] Unsteady [ ] Seizures[ ] Lethargic [ ] Comatose [ ] Vertigo [ ] Tremors[ ] Confused [ x] Vision [ ] Grip [] No Problem[x] Assess Motor Function, Sensation, LOC, Strength, Grip, Gait, Coordination, Orientation and Speech.

MUSCULOSKELETAL and SKIN:[ ] Appliance [x ] Stiffness [ ] Itching [ ] Petechiae [ ] Hot [ ] Drainage [ ] Prosthesis [ ] Swelling [ ] Lesion [ ] Poor Turgor [ ] Cool [ ] Deformity [] Wound [ ] Rash [ ] Skin Color [ ] Flushed [ ] Atrophy [ ] Pain [ ] Ecchymosis [ ] Diaphoretic[ ] Moist [ ] No Problem[x] Assess Mobility, Motion, Gait, Alignment, Joint Function, Skin Color, Texture, Turgor, and Integrity.

Place an (X) in the area of abnormality. Indicate the location of the problem in the figure if appropriate, using (X).

NURSING ASSESSMENT IISUBJECTIVEOBJECTIVE

COMMUNICATIONComments:Okay naman akong panan-aw as vb. By the patient.

[ ] hearing loss [ ] visual changes[x ]denied[ ] glasses [ ]languages[ ] contact lens [ ] hearing aide R LPupil size: 4mm [ ] speech difficultiesReaction: Pupil Equally Round Reactive to Light and Accommodation

OXYGENATION:Comments:Okay raman akong pagginhawa dilinaman sad ko mag lisud og ginhawa as vb. By the patient..

[]dyspnea [x]smoking historyyes[] cough[ ]sputum[x]denied

Resp. [x]regular [ ]irregularDescribe: bronchovesicular breath sounds heard over lungs; RR;20cpm

R:bronchovesicular sounds auscultated L:bronchovesicular sounds auscultated

CIRCULATION:Comments:Dili na nako mafeel ang sakit sa pikas nako nga tiil, as verbalized by the patient.

[ ]chest pain [ ] leg pain[ ] numbness of extremities[x] denied

Heart rhythm [x] regular [ ] irregularAnkle Edema: noneCarotid Radial Dorsal PedisFemoralR 85bpm 84bpm 84bpm refusedL 85bpm 84bpm 84bpm refusedComments: all pulses are palpable*if applicable: not applicable

NUTRITION:Comments: okay raman akong pagkaon,as vb by the patient .

Diet: Soft diet[ ] N [ ] V Character:[ ] recent change in weight and appetite[ ] swallowing difficulty[x]denied

[x]dentures [ ]none

Full partial with patientUpper [ ] [x] [ ]Lower [ ] [x] [ ]

ELIMINATION:Usual bowel pattern [ ] urinary frequencyOnce a day 1-2 times a day

[]constipation [ ]urgencyRemedies: [ ]dysuriaPapaya, pineapple [ ] hematuriaDate of last BM [ ] incontinence Dec. 18, 2012 [ ]polyuria[ ] diarrhea character [ x ] foley in placeNone [ ] deniedComments: Patient bowel sounds is normoactive.

Bowel sounds:Normoactive bowelSounds (8/mins.) Abdominal Distention Present [ ] yes [x] No Urine (color,consistency, odor) yellow,moderate in amount, aromatic *if foley balloon catheter foley in place draining well

MGT. OF HEALTH & ILLNESS:[x] alcohol []denied(Amount, frequency): oo mag-inom ko ug manigarilyo, as verbalized by the patient..[] SBE: Last Pap smear: N/ALMP: N/ABriefly, describe the patients ability to follow treatments (diet, meds, etc.) for chronic health problems (if present).N/A

SKIN INTEGRITY:Comments: Wala man koy gibati na katol-katol sa akong pamanit, as verbalized by the patient.

[x] Dry [ ] Itching [ ] other [ ] denied

[x] dry [ ]cold [ ] pale[ ] flushed [x]warm [ ] moist [ ]cyanotic*rashes, ulcers, decubitus (describe size, location, drainage) none

ACTIVITY/SAFETY:[ ] convulsionComments: dili nako malihok akong tuo nga lawas as verbalized by the patient.

[ ] dizziness[x] limited motionof joints[ ] ambulate[ ] bathe self[ ] other [ ] denied[ ] LOC and Orientation: Patient is alert but is disoriented to time, place and space.[ ] Gait [ ] walker [ ] care [] others[ ] steady [x] unsteadySensory and motor losses in face or extremitiesnone[ ] ROM limitations: Patient is having difficulty to move right upper and lower extremities due to paralysis.

COMFORT/SLEEP/AWAKE:[ ] painComments: Katarong man ko og tulog as verbalized by the patient.

(location) frequencyremedies)[ ] nocturia[] sleep difficulties[x] denied[ ] facial grimace[ ] guarding[ ] other signs of pain[x] side rail release form signed (60 + years)

COPING:Occupation: NoneMembers of household: *9 membersMost supportive person: Edith GulleObserved non-verbal behavior: none.Person (Phone Number): none

VII. NURSING MANAGEMENTA.IDEAL NURSING INTERVENTIONS

Nursing Diagnosis

Nursing Interventions:

Rationale

Activity Intolerance related to right side body weakness

1. Assess patients level of functioning using the functional mobility scale

2. Encourage bed exercises

3. Provide emotional support and encouragement.

4. Turn and position patient at least every hours

5. Involve patient in cure related to planning and decision making To determine patients capabilities

Prepares patient for late activities but also offers hope ascends of optimism about recovery.

To help improve patients self-concept and motivation to perform

Turning helps prevent skin breakdown by relieving pressure

To improve compliance

Nursing Diagnosis


Rationale

Self care deficit related to decrease strength1.Observe, document and report patients functional and perceptional or cognitive ability daily

2. Perform the prescribed treatment for the underlying condition. Monitor patients progress and report favorable and adverse responses

3. Provide assistive devices at each meal as needed

4. Encourage patient to do as much for self as possible, giving simple instructions one at a time

5. Consult with physician with physical/occupational therapist

Careful observation helps you adjust nursing actions to meet patients needs

Applying therapy consistently aids patients independence

This allow patient to do as much as possible for self

To aid comprehension

Provides expert assistive for developing therapy plan and identifying special equipment.

Nursing Diagnosis


Rationale

Ineffective Tissue Perfusion related to interruption to blood flow

1.Elevate head of bed and maintain head/neck in midline or neutral position

2. Keep environment and patient quiet, space nursing interventions3. Maintain adequate nutrition

4. Administer diuretics such as mannitol as ordered

5. Administer supplemental oxygen as indicated

To promote circulation/venous drainage This measures reduce intracranial pressure

To promote tissue healing, oxygenation and metabolism Mobilizes excess fluid oliguric renal failure or edema and prevents ICP Reduces hypoxia which can cause cerebral vasodilation and increase pressure/edema formation

B. ACTUAL NURSING CARE PLAN

SDili nako malihok ako tuo nga tiil og kamot as verbalized by the patient.

O>weakness in the lower and upper right extremities>cant perform ADLs >limited range of motion>slowed movements

AImpaired physical mobility related to hemiparesis Right

PLong term: At the end of 2weeks of nursing interventions, patient will be able to move freely without assistanceShort term: At the end of 1 day nursing interventions, patient can move slowly with assistance

I>Assess affected area >Instructed patient to perform deep breathing and coughing exercises.>Placed patient in semi-fowlers position>Encouraged passive ROM on the affected area and active ROM exercises on the affected area >Encouraged adequate rest periods.>Encouraged frequent turning on to the sidesCollaborative:>Consult Physical therapist for rehabilitation

E Goals partially met.

SKapoy pa ako gibati di man pud ko makalihok ug tarong as verbalized by the patient.

O>PR: 56 bpm

>BP: 150/100 mmHg

>fatigue

AActivity Intolerance related to immobility and weakness

PLong Term: At the end of 8 hours of nursing interventions, patient will report measurable increase in activity intolerance.Short term: At the end of 30 minutes of nursing interventions, patient will demonstrate a decrease in physiological signs of intolerance

I>Assess patients ability to perform normal tasks noting reports of weakness, fatigue and difficulty accomplishing tasks>Elevate head of the bed as tolerated>Recommend quiet atmosphere; bed rest if indicated.>Suggest patient change position slowly; monitor for dizziness>Plan activity progression with patient, provide assistance with activities

ELong Term: At the end of 8 hours of nursing interventions, patient was able to report increase in activity intolerance. Thus, goal met.

Short Term: At the end of 30 minutes of nursing interventions, patient was able to demonstrate a decrease in physiological signs of intolerance. Thus, goal met.

STaas gihapon usahay ako BP as verbalized by the patient.

OBP: 130/100 mmHgStressInactivity

ADecreased cardiac output related to malignant hypertension as manifested by decreased volume

PLong term: At the end of 5 days nursing interventions patient will be able to maintain adequate cardiac output and cardiac indexShort term: At the end of 6 hours nursing interventions patient will be able to have no elevation in blood pressure above normal limits and will maintain blood pressure.

I>BP monitored every 1-2 hours> Encouraged position changes every 2 hours> Encouraged patient to decreased intake of caffeine, cola and chocolates>Instructed to limit foods rich in salt and fats like, chicharon, canned foods etc.>Instructed to modify lifestyle like exercise, avoiding stress, avoid alcoholic drinks and stop smoking

ELong term: After 5 days of nsg. Interventions the patient was able to maintain adequate cardiac output and cardiac index.Short term: After 6 hours of nsg. Interventions the clientwas able to maintain BP to normal limits.

12

HEALTH TEACHINGS

MEDICATIONS

Encouraged to comply all medications

Encouraged to take medication on right timing with right dosage.

EXERCISE Encouraged SO to do passive and active range of motion for 30 minutes to promote circulation Gradually encouraged to do normal daily activities

TREATMENT Taught the importance of proper hygiene Encouraged SO to do warm compresses n he affected part Instructed the importance of adequate rest periods and sleep periods. Instructed to avoid smoking Instructed lifestyle modifications.

OUTPATIENT(check-up) Advised to have followed up check-up on at the outpatient department, @ CESH to check for any complications 1 week upon discharge.

DIET Encouraged to avoid high fat, high salt diet such as pork, beef, fried foods, balut, and instructed to take green leafy vegetables such as kang kong, cabbage, and etc. Encouraged to eat foods high in fiber like pineapple, papaya, cereals, pechay, and etc. Encouraged adequate fluid intake.

VIII. REFERRALS AND FOLLOW-UPThe Clients recovery greatly depends on the interventions provided by the health care team and the willingness of the patient to understand and participate in the management of the illness. As a student nurse it doesnt end in the hospital premises. Discharge instructions must be given to the client and family to ensure compliance of drug regimen and comprehension of instructions.For more or better promotion and restoration of the patients health status, the patient should be referred to a nearby and accessible health care facility or hospital and for further assessment, consultation and management; the patient is referred to CESH.Instructions were also made regarding the clients follow- up medical check- up scheduled 1 week after discharge @ Camp Evangelista Station Hospital outpatient department .This is to monitor and ensure the clients recovery and improvement of health status.

IX. EVALUATION AND IMPLICATIONS At the end of the study the researcher was able to attain the goals that have set from the start of this study. Thorough gathering of data by means of physical assessment was met and through the gathered data I was able to identify some health problems and I was able to skillfully formulate nursing care plan that I had applied to our patient in actual. By means of reviewing, discussing and elaborating the affected anatomy and physiology of the body enables me to create interventions that could alleviate pain and any discomforts experienced by the patient. With the help of the patient's family, I was able to explore part of the patient's personality that also helps me in creating interventions appropriate for him. Cerebrovascular accidentorstroke (also calledbrain attack) results from sudden interruption of blood supply to the brain, which precipitates neurologic dysfunction lasting longer than 24 hours. This condition is preventable by means of healthy lifestyle, diet modifications, exercise and regular check ups. We all know that this disease is life threatening thats why in order to prevent this we should be careful and responsible of what we do.Lastly, the researcher was also grateful for having the opportunity to have the case study for she, not only gain knowledge but also enhanced her skills in the field of nursing by means of planning interventions and rendering care to the patient. The researcher was hoping that the readers would be more conscious and be more careful in taking care of their health to prevent conditions to persist.X. BIBLIOGRAPHYBOOKS The Lippincott Manual of Nursing 8th edition, Lippincott Williams & Wilkins Medical-Surgical, Brunner and Suddart 11th Ed., Respiratory Function and Gas Exchange/pneumonia, pp 1347-1355, 1347-1348 NURSES POCKET GUIDE. Diagnoses, Prioritized Interventions, and Rationales by Marilynn E. Doenges , Mary Frances Moorhouse, and Alice C. Murr, Kozier, B. et al. Fundamentals of Nursing Concepts. Process and Practices. 11th edition. Upper Saddle, New Jersey, 2007. Mosbys Drug Guide for Nurses, 8th edition Nursing Care Plans, Nursing Diagnosis and Intervention 6th Edition, by Gulanick /Myers Psychiatric Nursing, made Incredibly Easy, Lippincott Williams & Wilkins pp. 58

INTERNET www.medicinenet.com/Bronchopneumonia/article.htm www.who.int/topics/bronchopneumonia www.nursingcribs.com www.drugs.com www.youtube.com www.google.com

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