A CASE STUDY ON

CEREBROVASCULAR ACCIDENT WITH LEFT

HEMIPARESIS

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 brain affected. 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

The causes of stroke: An artery to the brain may be blocked by a clot (thrombosis) which typicallyoccurs 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 atria 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. A cerebral hemorrhage (bleeding in the brain), as from an aneurysm (a widening and weakening) of a blood vessel in the brain, also causes stroke.

The diagnosis of stroke involves a medical history and a physical examination. Tests are done to search for treatable causes of a stroke and help prevent further brain damage. A CAT scan (a special X-ray study) of the brain is often done to show bleeding into the brain; this is treated differently than a stroke caused by lack of blood supply. A CAT scan also can rule out some other conditions that may mimic a stroke. A sound wave of the heart (echocardiogram) may be done to look for a source of blood clots in the heart. Narrowing of the carotid artery (the main artery that supplies blood to each side of the brain) in the neck can be seen with a sound wave test called a carotid ultrasound. Blood tests are done to look for signs of inflammation which can suggest inflamed arteries. Certain blood proteins are tested that can increase the chance of stroke by thickening the blood.

Treatment of a stroke: Early use of anticoagulants to minimize blood clotting has value in some patients. Treatment of blood pressure that is too high or too low may be necessary. (Lowering elevated blood pressure into the normal range is no longer recommended during the first few days following a stroke since this may further reduce blood flow through narrowed arteries and make the stroke worse.) The blood sugar glucose in diabetics is often quite high after a stroke; controlling the glucose level may minimize the size of a stroke. Drugs that can dissolve blood clots may be useful in stroke treatment. Oxygen is given as needed. New medications that can help oxygen-starved brain cells survive while circulation is reestablished are being developed.

Rehabilitation: When a patient is no longer acutely ill after a stroke, the aim turns to maximizing the patient's functional abilities. This can be done in an inpatient rehabilitation hospital or in a special area of a general hospital and in a nursing facility. The rehabilitation process can involve speech therapy to relearn talking and swallowing, occupational therapy for regaining dexterity of the arms and hands, physical therapy for improving strength and walking, etc. The goal is for the patient to resume as many of their pre-stroke activities as possible.

According to the World Health Organization, 15 million people worldwide will suffer from stroke this year. Five million will die and another five million will be permanently disabled. Stroke is the third leading cause of death in the United States. Over 143,579 people die each year from stroke in the United States. In the Philippines, stroke affects 486 out of 100,000 Filipinos or roughly half a million Filipinos, according to Dr. Navarro in his study published in The Philippine Journal of Neurology. Nearly three-quarters of all strokes occur in people over the age of 65. The risk of having a stroke more than doubles each decade after the age of 55. Among adults age 20 and older, the prevalence of stroke in 2005 was 6,500,000 (about 2,600,000 males and 3,900,000 females).Each year, about 55,000 more women than men have a stroke. Men’s stroke incidence rates are greater than women’s at younger ages but not at older ages. The male/female incidence ratio is 1.25 at ages 55–64; 1.50 for ages 65–74; 1.07 at 75–84 and 0.76 at 85 and older. Of all strokes, 87 percent are ischemic, 10 percent are intracerebral hemorrhage, and 3 percent are subarachnoid hemorrhage.

The objective of our study is to acquire knowledge on how to deal or manage patient with Cerebrovascular Accident.

This study will aid us, student nurses, in revealing and educating individuals and family members about neurologic disorder, treatment and recovery. This would permit the development of appropriate strategies to target high risk group.

NURSING HEALTH HISTORY

Nursing health history is the first part and one of the most significant aspects aspects in case studies. It is a systematic collection of subjective and objective data, ordering and a step-by-step process inculcating detailed information in determining client's history, health status, functional status and coping pattern. This vital information's provide a conceptual baseline data utilized in developing nursing diagnosis, subsequent plans for individualized care and for nursing process application as a whole.

As I follow the rules and regulation on any hospitals, the ethical guidelines must be realize to withhold for the confidentiality of the patient and privacy. That's why as I go along, you've notice that I hidden the real name of my patient with pseudonym of patient A to protect his right accordingly, and also by its legality.

Patient A is a male, 54 years of age, was born on January 17, 1956, through normal spontaneous vaginal delivery at their home in Buenavista, Agusan Del Norte, a Filipino citizen. He is also Roman Catholic by faith. He finished his elementary education at Alubijid Elementary School and finished his secondary education at Benavista Institute. When he was in collage, he studied at Mindanao State University and transferred at Saint Joseph Institute of Technology but he wasn't able to finish his studies due to financial problem. At the age of 25 he got married to Mrs. B and they have 2 siblings which both are girls. Patient A and his family is currently residing at Purok 2, Alubijid, Buenavista, Agusan Del Norte.

On his early childhood, he had mumps and measles. When he had a fever, his mother wiped his whole body to relieve the heat. He sometimes had diarrhea But he will just take a herbal medicine for it. He also received a complete immunization. He was not able to undergone any operation and doesn't have any allergies to foods.

Patient A owned a farm which also his business. It is the primary source of their income. They have carabao, chickens and pigs. Patient A usually sleep 7-8 hours per day, which helps him to maximize his energy during day time. Everyday he wakes-up at 5 in the morning to feed the chickens and other animals which also one way of his exercise. He usually eat 3 times a day with variety of foods. He likes to eat fatty food such as pork and prefer to eat fried foods rather than soup. Patient A most likely to consume 4-5 glass of water per day. He drink coffee twice a day one in the morning and another one for his snack. He also drink a lot of soft drinks everyday which he can consume about 16 oz and also drink beer occasionally. He started to smoke when he was 18 years old and most likely to consume 8-10 cigarette stick per day. Patient A usually defecates once a day , specifically in the morning.

Patient A, reports that he was already been hospitalized in the year 1993 when he was 33 years old because of mild stroke at Agusan Del Norte Provincial Hospital. It was the first time that hospitalized and according to his doctor ,atherosclerosis the reason of his illness and when his history was taken. Both side of his parents has the history of hypertension, that why he genetically acquired it.

Years passed, Patient A continue his life living with his family, After being hospitalized he doesn't have nay medication maintained for bring hypertensive person. Still, he continue his sedentary life style before. He still drink soft drinks, eat fatty foods and doesn't limit himself to smoke everyday.

Until on November 29 , 2010 at around 6:30 pm in the morning, after taking his breakfast. Patient A felt something wrong on his body. He was weak, dizzy and have tinnitus. He also felt that he can't moved his extremities already. That's why his wife was alarmed and decided to brought him to the hospital.

At 8:20 am , He was admitted in to MJ Santos Hospital with the admitting vital signs of:

T- 37 degree Celsius BP- 180/110 mmhg P- 87 bpm O2 Sat- 99% R- 20 bpm

His under the care of Dr. H with the chief complain of left sided body weakness with elevated blood pressure. His admission orders are:

diet: low salt and low fat dietIVF : PNSS iL 20 gtts/minMonitoring: Vital signs every 2 hours Neuro vital signs every 2 hours

Laboratory test: » CBC» Urinalysis» Stool exam » Electrolyte panel c » Alanine aminotransferase» Lipid profile» Uric acid » Creatinine» FSB» Capillary blood glucose

Diagnostic Procedure:» 12 lead electrocardiogram» CT scan» X-ray, AP

Medication:» Citicholine (citilin) 2 gms IV then 1 gm every 6 hours» Captopril 25 mg 1 tab sl every g hours PRN for BP 160/100» Telmesarten (micardis) 40 mg 1 tab now and OD 7am

Special Measures:» O2 inhilation by nasal cannula 3 L/min» Moderate high back rest» Complete bed rest with toilet privileges

November 29, 2010 at 8:40 am the doctor's order where: - Polynerv 500 mg 1 tab now then OD

– Apirin (bayprin EC) 100mg 1 tab now then 1 tab OD pc lunch– Fondaparinux (Arixtha) 0.5 ml sc now then o.5 ml sc OD– please follow-up CT scan of the brain-plain once financilly

capable– Discontinue citicholine

November 30, 2010 at 7:30 pm the doctor's order where:– Piracetam (Nurocer) 1-2 gms 1 tab QID p.o.

December 1, 2010 at 12:05 noon the doctor's order where:

– IVFTF PNSS at 20 gtts/min

December 2, 2010 at 7:00 pm the doctors order where: - Possible discharge in am

– allow the significant others to photocopy the lab result

When I visited patient A I observed him still weak and need assistance but his BP is already stable 130/90 mmHg. At that time Patient A is for discharge and still waiting for the doctors round.

According to Erick Erickson's psychological developmental of Middle Adulthood from the age of 35-65 years old, patient A belong to Generality vs Stagnation. In this stage,work is the most cucial. Erikson observed that middle-age is when we tend to be occupied with creative and meaningful work and with issues surrounding our family. Also, middle adulthood is when we can expect to "be in charge," the role we've longer envied.

The significant task is to perpetuate culture and transmit values of the culture through the family (taming the kids) and working to establish a stable environment. Strength comes through care of others and production of something that contributes to the betterment of society, which Erikson calls generativity, so when we're in this stage we often fear inactivity and meaninglessness.

As our children leave home, or our relationships or goals change, we may be faced with major life changes—the mid-life crisis—and struggle with finding new meanings and purposes. If we don't get through this stage successfully, we can become self-absorbed and stagnate.

Significant relationships are within the workplace, the community and the family.

PHYSICAL ASSESSMENT

Physical Examination follows a methodical head to toe format in the cephalocaudal assessment. This is done systematically using the techniques of inspection, palpation, percussion and auscultation with the use of materials and investments such as the penlight, thermometer, tape measure, stethoscope and also sense. During the procedure, I made every effort to comfort measures and to follow appropriate safety precautions.

The physical examination Patient A was done last December 2, 2010 at 4:00 pm at MJ Santos Hospital (ANEX Station). The following instrument were used namely BP apparatus, stethoscope, thermometer, wrist watch with second hand, tape measure, penlight notebook and ballpen.

A. General Physical Assessment Received lying on bed, awake, appears weak,coherent upon

interaction, with IVF # 3 PNSS 1L at the level of 500 cc regulated at 20 gtts/min infusing well hooked at right cephalic vein, site is clean and intact

Patient's vital signs were as follows: T-36.8 degree Celsius P-71 bpm R-18 bpm BP-130/90 mmHg

C. Assessment of the skin The patient's skin is brown in color and is generally uniform except in the

areas exposed to the sun. Is is warm and dry to touch upon palpation of the forearm. Skin fold retuens to place within 2 seconds when pinched. There is no edema and abrations or other lesions

D. Assessment of the eyes Eyebrows are symmetrically aligned but dont have equal movement. The

eyelids blinks response is not equal, bulbar conjunctiva is clear, the palpebral conjunctiva is pink and the sclera is white. The palpebral slant is aligning with the tip of the pinna. The corneal sensitivity reflex is present cornea is transparent, the color of his eyes are brown, the shape are equal, it is uniform in color. Pupils are equal in size. Pupils are equally round and reactive to light and accommodation. He can execute the occular movements. He can recognize objects within 12-14 inches away. The lacrimal apparatus are moist

E. Assessment of the ears The ears are of the same color as facial skin. There are symmetrical and

are alined with the outer canthus of the eye. As the pinna is folded forward, it recoils after afterwards. Normal voices tones are audible as he can hear clearly the questions without leaning forward.

G. Assessment of the mouth and oropharynx The lips is symmetrical and pink, the consistency is smooth, buccal

mucosa is pink, the gum is pink, the tongue is in the midline, the color is pink and it is smooth. The tongue movements are not that smooth. Its texture is rough. The color of the hard and soft palate is pink and it is intact. The tonsils are not inflamed. Uvula is inthe midline. The teeth are incomplete.

H. Assessment of the neck neck is symmetrical without masses, scars and carotid pulse is palpated.

The trachea is in the midline of the neck. As the patient was instructed to move the head he can moved it slowly

I. Assessment of the breast The breasts are symmetrical with flat contour. Shape is flat, the skin

surface is smooth. Lympnodes are not palpable. The areola is color brown, shape is round and the nipple is everted, there are no discharges and there are no Lympnodes and no tenderness.

J. Assessment of the lungs and thorax Chest is symmetric and the spinal column is in the normal state.

Chest wall is intact without any tenderness and masses upon palpation. No hair was noted. Thorax expands evenly bilaterally. There are quiet, rhythmic respirations at 18 breaths/min. No abnormal breathing sound were auscultated.

K. Assessment of the Heart Patient has an audible heart sound. PMI is heard between 4th - 5th

intercostals space. Heart is pumping well with a pulse rate of 82 bpm from the normal rate of 60-100 beats per minute.

L. Assessment of the Abdomen Abdominal movement as with respiration, presence of peristalsis

during auscultation. There are no presence of rashes and lesions

N. Assessment of the Upper Extremities Hands: Medium in size with 5 fingernails in each side. Nails are short, small dusty particles are present. Arms: the left arm is weak at cannot able to do passive range of motion

M. Assement of the lower extremities The left leg is weak and cannot be control.

O. Assessment of the Genitourinary not assesed

P. Assessment of the neurologic system Patient A is weak and cannot control his left side of his body,

responsive upon interviewed . He speaks in a soft but not that clear voice. Patient oriented to the parson, place and time.

ANATOMY AND PHYSIOLOGY

Parts of Brain

PATHOPHYSIOLOGY

DIAGNOSTIC TEST AND LABORATORY EXAM

TEST DEFINITION RESULT REFERENCE RANGE

INTERPRETATION CLINICAL SIGNIFICANCE

White Blood Cell

Leukocytes or white blood cells

are responsible for the defense of the

microorganism

9.44 5.0-10.0 x 10 g/dL Normal

- A high count may indicate leukocytosis which is an increase in the number of the WBC due to invading microbes and stress- A low count may due to drug toxicity or bone marrow failure

Hemoglobin

A substance contained within the RBC and responsible for their color, it has a unique property of combining reversibly with oxygen and is the medium by the oxygen is transported within the body.

118 137-167 g/L Decreased

- A high count may indicate hemoconcentration, polycythemia vera and heart failure

- A low count is caused by anemia

Hematocrit

This is the volume of the cell in blood, expressed as fraction of the total volume of the blood

0.37 0.40-0.50 Decreased

-A high value may be due to dehydration, burns, congenital heart disease and polycythemia vera.

-- A low count is caused by imbalance in fluid and electrolytes

Neutrophils

This granulocyte has very tiny light straining granules. The nucleus is frequently multi-lobed with connected by strands of nuclear material. These cells are capable of phagocytizing foreign cell, toxin and viruses

0.73 0.55-0.75 Normal

- If the count exceeds this amount the cause is usually due to an acute infection

- If the count is low, it may be due to addison's disease or aplastic anemia

Fasting Blood Sugar

The level of glucose present in a blood sample drawn a minimum of eight hours after the last meal. Helps to diagnose diabetes and to monitor glucose levels in persons with diabetes.

112.1 74-100 mg/dL Increased

-A persistently high level is referred to as hyperglycemia

- A low levels are referred to as hypoglycemia

Cholesterol

Is different from most tests in that it is not used to diagnose or monitor a disease but is used to estimate risk of developing a disease specifically heart disease

168.5 < 200 mg/dL Normal

- A high blood cholesterol has been associated with hardening of the arteries , heart disease, and a raised risk of death from heart attact, cholesterol testing is considered a routine part of preventive health care.

HDL

Is a lipoprotein which helps to flush bad cholesterol (also known as LDL) out of the body by absorbing cholesterol and carrying it through the blood to the liver, where it is eventually expelled.

38.1 < 40 mg/dL- low

> 60 mg/dL-high

Decreased

- A low levels of HDL may place you at risk of getting coronary heart disease

LDL

It's also sometimes called "bad" cholesterol. Lipoproteins are made of fat and protein. They carry cholesterol, triglycerides, and other fats, called lipids, in the blood to various parts of the body.

115.36 < 130 mg/dL Normal

- A high levels of LDL may place at risk of getting coronary heart disease

CRANIAL CT SCAN (PLAIN STUDY)

Impression:

• Focal subacute infarct in the right fronto-parietal paraventicu;ar with matter region

• Multifocal lacunar infarcts and old capsulo-ganglionic and left fontal periventicular white matter regions right lentiform nucleus an in both centrum semi-ovale

• Small old infarct in the left side of the pons• Minimal inflammatory disease in both sides of ethmoid air cells

ELECTROGRAPHIC REPORT

Interpretation:

• Sinus rhythym/non-specific ST-T wave changes in leads III and AVF, otherwise, WNL's

DRUG STUDY

• Drug No. 1

Generic name: PolynervBrand name: Vitamins B complexClassification: Vitamins and minerals

Action: Vitamins B1, B6 and B12 (Polynerv) oral drops is valuable in conditions where the requirements for B vitamins are increased as in growth, physiologic stress, decreased resistance to infection and chronic illnesses, metabolic disorders and in certain diseases of the digestive tract and nervous system. It can also be given before and after surgical procedures. Vitamins B1, B6 and B12 (Polynerv) oral drops is indicated for the prevention and treatment of deficiency disorders arising from poor dietary intake, impaired B vitamin absorption as in prolonged diarrhea, excessive vomiting and antibiotic therapy, intake of drugs which interfere with theutilization of the B vitamins (i.e. isoniazid). As a nutritional supplement to promote appetite, weight gain and height increase

Dose: 500 mg 1 tabRoute: oralFrequency: OD

Indication:Treatment of vit B deficiencies. Nutritional support in painful neurological manifestations of neuritis & neuropathy eg cervical & shoulder-arm syndrome, lumbago, ischialgia & sciatica. Neuropathies caused by disease states eg diabetes, RA, TB, leprosy & cardiac disorders. Alcoholic neuropathy due to INH or phenothiazine intoxication. Pregnancy, hyperemesis gravidarium

Contraindicated: Vitamin B complex should not be used in hypersensitivity to any of the vitamins, containing in the preparation, as well as in patients with 2-nd or 3-rd degree arterial hypertension

Adverse effect: Anaphylaxis,Pain,GI discomfort

Nursing consideration:• Determine reticulocyte count, hct, Vit. B12, iron, folate levels before

beginning therapy.• Obtain a sensitivity test history before administration• Avoid I.V. Administration bec. faster systemic elimination will reduce

effectiveness of vitamin.• May be taken with or without food (May be taken w/ meals to reduce GI

discomfort.).

Drug No. 2

Generic name: AspirinBrand name: BayprinClassification: Anticoagulants,antiplatelets,fibrinolytics (throbolytics)

Action: inhibits platelet aggregation by blocking thromboxane A2 synthesis in platelets

Dose: 100 mg 1 tabRoute: oralFrequency: OD

Indication: For prophylaxis of thromboembolic disorders, MI, transient ischemic attacks & stroke. For patients w/ stable & unstable angina pectoris.

Contraindication:Active peptic ulcer, hemorrhagic diathesis, history of asthma & last trimester of

pregnancy. Lactation.

Adverse effect:GI: dyspepsia, heartburn,anorexia, nausea, epigastric discomfort, potentiation

of peptic ulcerAllergic:Broncho spasm, asthma-like symptoms, anaphylaxis, skin rashes

urticariaHematologic: prolongation of bleeding time, thrombocytopenia, leucopenia, Other: Thirst, fever, dimness of vision

Nursing Consideration:• Should be taken with food • Assess for pain:type, location and pattern• Determine history of peptic ulcers or bleeding tendencies• Note for asthma • Monitor renal,LFTs and CBC • Do not use in children with chicken pox or flu symptoms•

• Drug No.3

Generic name: TelmisartanBrand name: MicardisClassification: Antihypertensive drug

Action: Blocks vasoconstriction and aldosterone secreting effects of angiotensin II by selectively blocking the binding of angiotensin II to angiotensin I receptor to many tissue

Dose: 40mg 1 tabRoute: oralFrequency: OD

Indication: hypertension and cardiovascular risk reduction

Contraindication: pregnancy and lactation, billary obstructive disorders, severe hepatic impairment

Adverse Effect: headache, upper respiratory tract infection, dizziness and fatigue, diarrhea, sinusitis, back pain

Nursing Consideration:• Instruct the patient that drug may be taken with or without food• Monitor patient for hypotention after starting drug• Tell the patient if he feel dizzy or has low blood pressure on standing he

should lie down and rise slowly from a lying to standing position

Drug No. 4

Generic name: CaptoprilBrand name: CapotenClassification: Antihypertensive and ACE inhibitor

Action: Block ACE fron converting angiotensin I to angiotansin II a powerful vasoconstrictor leading to decreased blood pressure, decrease

secretion of aldosterone , a small increase in serum potassium level and sodium and fluid loss, increase prostaglandin synthesis also may be involved in the antihypertensive action.

Dose: 25 mg 1 tabRoute : oral SLFrequency: every 6 hours PRN for BP 160/100 mmHg

Contraindication: with allergy to captopril, history of angioedema,pregnancy ang lactation,renal impairment

Adverse effect: Tachycardia, rash, pruritus, astric irritation, pepetic ulcers, dysuria,protenuria and cough

Nursing consideration:• Monitor the patients blood pressure and pulse rate frequently• Instruct to take this medication 1 hour before meals food in the GI tract may

reduce absorption• Be aware that elderly patients may be more sensitive to the drugs

hypotensive effects• Tell the patient to use caution in hot weather during exercise• Advice to report any sign of infection such as fever and sore throat

• Drug No.5

Generic name: CiticholineBrand name: citilinClassification: Nootropics and neurotonics

Action: Citicoline is a complex organic molecule that functions as anintermediate in the biosynthesis of cell membrane phospholipids. It is also known as CDP-choline or cytidine diphosphate choline (cytidine 5'- diphosphocholine). CDP-choline belongs to the group of biomolecules in living systems known as nucleotides that play important roles in cellular metabolism.

Dose: 2 gms IV then 1 gmRoute:Frequency: every 6 hoursIndication:Cerebrovascular disorders including ischemic stroke, parkinsonism

& head injury Contraindication: Parasympathetic hypertonia. Adverse effect:Stomach pain,diarrhea; hypotension,tachycardia,

bradycardia. Nursing consideration: • Somazine must not be administered along with medicaments containing

meclophenoxate

PROBLEM LIST

The problem list serve as valuable tool in patient care management. The problem list complies the all past and current patient problem including social, psychological and medical problems onto the document. At a glance, providers can determine which problems are active or resolved, and formulate treatment plans accordingly. Additionally, the problem list serves as communication tool and aids in the evaluation and treatment decision.

NCP NO.

NURSING DIAGNOSIS

DATE IDENTIFIED

DATE EVALUATED

1 Ineffective tissue perfusion related to interruption of blood flow

November 30,2010

November 30,2010

2 Impaired physical mobility related to left sided body weakness

November 30,2010

November 30,2010

3 Self care deficit:bathing, dressing,feeding related to loss of muscle control

November 30,2010

November 30,2010

NURSING CARE PLAN # 1Name: Patient A Date identified: 11/30/10Chief complain: Left sided weakness with Date evaluated: 11/30/10Elevated blood pressure

Assessment:Subjective cues: “binhod ug dili nako malihuk akong wala nga lawas”

Objective Cues:

• restlessness• weak extremities• dizziness• need assistance • low pitch voice • altered level of consciousness• Blood pressure of 160/110 mmHg

Diagnosis: Ineffective tissue perfusion related to interruption of blood flow

Planning: Within 4 hours of nursing intervention the patient will be able to verbalize understanding of condition, therapy regimen,and side effect of medications

Intervention:

Independent:• Determine factors related to individual situation/ cause for decrease cerebral

perfusion Rationale: for appropriate nursing intervention that are applicable to the

patients condition

• Monitor vital signs every 2 hours Rationale: variations may occur because of cerebral pressure/injury in

vasomotor area of the brain. Hypertension may have been a precipitating factors.

• Evaluate pupils,noting size, shape and equity Rationale:To gather baseline data and monitor any further complications/

deviations from normal

• Document changes in vision (eg. Reports of blurred vision) Rationale: Specific visual alterations reflect area of brain involved, indicate

safety concerns and influence choice of intervention

• Elevation head of bed (15 degrees) and maintain head or neck inmidline

Rationale:to promote circulation and venous drainage and to maintain a patent airway.

• Provide quite and restful atmosphere Rationale: for conservation of energy and lowers oxygen demand

• Reposition patient every 2 hours Rationale: to promote circulation and oxygen distribution

• Provide support on affected body part such as pillow and assistance to do activity of daily living's as needed

Rationale: to maintain position of function and reduce discomfort

• Encourage the patient and significant others to avoid sedentary lifestyle such as smoking,drinking liquor,improper exercise and to much fatty foods

Rationale: these factors may affect them in developing various diseases as what like the patient is suffering

Dependent:

• Administer oxygen inhalation by nasal cannula 3L/min Rationale: reduce hypoxemia, which can cause cerebral vasodilation and

increase pressure/edema formation

• Administer medication: citicholine (citilin) 2 gms Iv theb 1 gm every 6 hours

Rationale:It restores the activity and functions of the brain. It improves neuromuscular function.

• Administer antihypertensive medication: captopril 25 mg 1 tab sl every 6 hours PRN for BP 160/100 mmHg

Rationale:Blocks ACE from converting angiotensin I to angiotensin II, a powerful vasoconstrictor, leading to decreased blood pressure, decreased aldosterone secretion, a small increase in serum potassium levels, and sodium and fluid loss; increased prostaglandin synthesis also may be involved in the antihypertensive action.

• Evaluation:

After 4 hours of nursing intervention the patient was able to verbalized understanding of condition, therapy regimen,and side effect of medications

• NURSING CARE PLAN # 2

Name: Patient A Date identified: 11/30/10Chief complain: Left sided weakness with Date evaluated: 11/30/10 Elevated blood pressure

Assessment:Subjective cues: “walay kusog akong wala nga lawas”

Objective cues:

• slow movement• need assistance• drowsy eyes • limited range of motion• postural instability • degree of mobility of 2

Diagnosis: Impaired physical mobility related to decrease muscle strength

Planning: Within 4 hours of nursing intervention the patient will be able to verbalize understanding of the situation and individual treatment regimen and safety measures

• Intervention:

• Independent:

• Determine diagnosis that contributes to immobility Rationale:for appropriate nursing intervention that are applicable to the

patients condition

• Assess functional ability/extent of impairment initially and on a basis. Classify according to 0-4 scale.

Rationale: identifies strengths/deficiencies and may provide information regarding recovery.

• Note emotional/behavioral responses to imobility Rationale: feelings of frustration,powerlessness may impade attainment

goal

• Change position at least every 2 hours (supine,sidelying)and possibly more often if placed on affected side.

Rationale: Reduces risk of tissue ischemia/injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown/decubitus.

• Begin active/passive range of motion to all extremities Rationale: Minimizes muscle atrophy, promotes circulation helps to prevent

contructures.

• Provide support on affected body parts such as pillow Rationale: To maintain position of function and reduce risk of pressure ulcer

• Inspect skin, particularly over bony promimemces regularly. Gently massage any reddened areas as necessary

Rationale: pressure points over bony prominences are most ta risk for decreased perfusion/ischemia. Circulation stimulation helps prevent skin breakdown and decubitus development

• Schedule activities with adequate rest periods during the day Rationale: to reduce fatigue

• Encourage participation in self-care activities Rationale: Enhances self-concept and sense of independence

• Identify energy-conserving techniques for ADLs Rationale: limits fatigue, maximizing participation

• Provide safety precautions by raising up the side rails Rationale: to prevent fall and injury

• Encourage client's/SO's involvement in decision making as much as possible Rationale: Enhances committed to plan, optimizing outcomes

Evaluation:

After 4 hours of nursing intervention the patient was able to verbalized understanding of the situation and individual treatment regimen and safety measures

• NURSING CARE PLAN # 3

Name: Patient A Date identified: 11/30/10• Chief complain: Left sided weakness with Date evaluated: 11/30/10Elevated blood pressure

Assessment:

Subjective cues: “dili ko kabuhat sa akong mga bulahaton tungod kay dili nako malihok akong wala nga lawas”

Objective cues:

• inability to wash body parts• inability to bring food from receptacle to mouth• impaired ability to put on/off clothing• need assistance• degree of mobility of 2

Diagnosis: Self care deficit:bathing, dressing,feeding related to loss of muscle control

Planning: After 8 hours of nursing intervention the patient will be able to demonstrate techniques/lifestyle changes to meet self-care needs

Intervention:

Independent:

• Assess abilities and level of deficit (0–4 scale) for performing adls. Rationale: aids in anticipating/planning for meeting individual needs

• Avoid doing things for patient that patient can do for self, but provide assistance as necessary.

Rationale:these patients may become fearful and dependent, and although assistance is helpful in preventing frustration, it is important for patient to do as much as possible for self to maintain self-esteem and promote recovery.

• Be aware of impulsive behavior/actions suggestive of impaired judgment. Rationale: may indicate need for additional interventions and supervision to

promote patient safety.

• Maintain a supportive, firm attitude. allow patient sufficient time to accomplish tasks.

Rationale:patients need empathy and to know caregivers will be consistent in their assistance.

• Provide positive feedback for efforts and accomplishments. Rationale: enhances sense of self-worth, promotes independence, and

encourages patient to continue endeavors.

• Promote client's/SO's participation in problem identification and desired goals and decision making

Rationale: Enhances commitment to plan, optimizing outcomes and supporting recovery and/or health promotion

• Position furniture against wall/out of travel path Rationale:provides for safety when patient is able to move around the room,

reducing risk of tripping/falling over furniture.

• Plan time for listening to the client's/SO's feelings/concers Rationale: to discover barriers to participation in regimen and to work on

problem solution

• Encourage so to allow patient to do as much as possible for self. Rationale: reestablishes sense of independence and fosters self-worth and

enhances rehabilitation process

• Eliminate extraneous noise/stimuli as necessary Rationale: it helps to reduce anxiety

Evaluation: After 8 hours of nursing intervention the patient was able to

demonstrated techniques/lifestyle changes to meet self-care needs

DISCHARGE PLAN

• DISCHARGE PLAN

- Received patient lying in bed,awake responsive and coherent upon interaction With initial vital signs taken and recorded as follows: T- 36.7 degree Celsius BP- 140/90 mmHg P- 81 bpm O2 sat- 98% R- 19 bpm

M- Instructed to continue the medication according to physician's prescription at the right dose, time, frequency and route

- Encouraged to comply with the medications to prevent further complication

E- Instructed to stay in a safe, cool and well ventilated area to promote comfort

T- Instructed to follow up check-up as instructed by the physician

H- Demonstrated how to do passive range of motion - Instructed the significant others to reposition every 2 hours to promote circulation and

to prevent skin irritation - Demonstrated to do deep breathing exercise to promote lung expansion

- Encouraged the patient and significant others to avoid sedentary lifestyle such as smoking,drinking liquor,improper exercise and to much fatty foods because these factors may affect them in developing various diseases as what like the patient is suffering

- Instructed to perform activities of daily living as tolerated

O- Instructed to go to the nearest hospital if any unusuality occur ,increase vital signs or any abnormalities

D- Instructed to eat foods low in fat and salt such as fish - Instructed to increase fluid intake 8-10 glasses/day - Instructed to eat nutritious foods especially those rich in vitamin c to boost

immune system

- Endorsed to staff nurse on duty

LEARNING OUTCOME

We are surrounded by great challenges and obstacles in our lives but all of the hardship will lead to an outcome of success, To be effective and efficient nurse someday, the key to success is to try our best care for our patients.it is indeed a great previlage to handle any cases of a patient withou expecting anything in return but the experiences and the knowledge that will be learned every exposure.

I was expose in the medical ward of MJ Santos Hospital. The exposure was quit good yet challenging for me since you will truly give the best performance you can brought to your assigned patient. Though I can say it was a little bit hard once your going to avaoid any mistakes but at the end of the roitation its the learning that counts a lot.

I found myself taking the path of training in rendering proper care for the patients in terms of physical, emothinal, psychological and spiritual aspects. During the days of rendering services to my patients it ends up as one of my accomplishment as being a student.

I came to realize that you must have the attitude, the presence of mind while working, also by organizing things to be done, by prioritization in every situation ans the flexibilities in every field you are working with. Above all it is important that we should apply all our knowledge and skills we've learned already since there are interventions that are applicable in specific instansis on situation.

Sometimes I can say students cannot avoid mistakes we commit but the important is we learened from commiting mistake, since I have gained lessons from it, simply it helped me to mold to become a better and more effective student nurse in the nest exposure.

All those things happened during my exposure, I would like to say thank you to our clinical instructor for being motherly guiding us during the exposure and for imparting all her knowledge and the supercision she has done to us.

Above all, much more important us the interest passion and motivation in the choosen course because, it will not be difficult to sacrifice if we really love what we are doing.

-END-