Liceo de Cagayan University

R.N Pelaez Blvd. Carmen, Cagayan de Oro City

College of Nursing

Submitted by:

Kenneth Joy S. Egona

NCM501204

Submitted to:

Mr. Leonard U. Solima

Clinical Instructor

August 2009

TABLE OF CONTENTS

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I. Introduction

a. Overview of the case

b. Objective of the study

c. Scope and Limitation of the study

II. Health History

a. Profile of patient

b. Family and Personal Health history

c. Chief Complaint & History of Present Illness

III. Developmental Data

IV. Medical Management

a. Medical Orders and Rationale

b. Laboratory Results

c. Drug Study

V. Pathophysiology with Anatomy and Physiology

VI. Nursing Assessment (System Review & Nursing Assessment II)

VII. Nursing Management

a. Ideal Nursing Management (NCP)

b. Actual Nursing Management (SOAPIE)

VIII. Referrals and Follow-up

IX. Evaluation and Implications

X. Bibliography

I. INTRODUCTION

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In our field of study it is very important for us to be exposed to different kinds of situations and

cases, which can help us gain more knowledge and is essential for us to be more effective in giving care

towards our patients.

A. Overview of the Case

B. Objective of the Study

The main reason and purpose why, I, as future nurse will conduct a study and exposure in the intensive

care unit is for me to be able to identify the problems encountered by my patient. As a health care provider,

it is indeed my vocation to adjoined hands with the health care team for the promotion of wellness of our

clients.

My main goals for this study are the following:

To establish rapport

To identify chief complaints of clients to give its specific interventions

To determine the family and personal history of the client that many affect clients present condition

To identify the cause and effect the main problem through the correct analysis of the

pathophysiology of the case

To determine the medical management given through identifying doctor’s order and its rationale

To make nursing care plans for the different health problems encountered by the client

To evaluate the effectiveness of the actual nursing care plan that was established

To give referrals and follow-up for the health promotion of the client

C. Scope and Limitation of the Study

Specifically this study is more concerned with the care of the patient in Northern Mindanao Medical

Center, Intensive Care Unit. I performed physical assessment to the patient to properly identify the nursing

problems, which requires necessary and direct interventions and medical regimen. I had 2 days duty or 16

hours care for the patient and some limited informants.

The preventive care and the anticipatory guidance are the integral practice to this practice. Thus

this care study focuses on the particular case of the patient. The study of the medications and doctor’s

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order are limited to our chosen patient, a case of Acute Gastroenteritis with severe Dehydration. Any

referrals and follow up, so as with the nursing management were fully granted and analyzed for the said

case.

II. HEALTH HISTORY

A. Profile of the Patient

Name: Mr. Panerio, Alijo Nacilla

Age: 74 years old

Sex: Male

Birth date: July 17, 1935

Religion: Roman Catholic

Civil Status: Married

Nationality: Filipino

Address: Zone-6 Baluarte, Tagoloan, Misamis Oriental

Occupation: Former Farmer

Date of Admission: October 19, 2009

Time of Admission: 10:00 pm

Admitting Diagnosis: AGE, with Severe Dehydration

A P: Dr. Karen G. Gonzales MD

Vital Signs Assessment

Temperature: 36.7c

Heart Rate: 68 bpm

Respiratory Rate: 18 cpm

Blood Pressure: 60/40 mmhg

Height: 5 ft. and 4 inches

Weight: 45 kgs.

Allergy: No known food and drug allergy

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B. Family History and Personal Health History

The Panerio family resides at Zone-6 Baluarte, Tagoloan, Misamis Oriental. Patient was a former

farmer and his spouse is a house wide. Both of their mother and father side had no history of hypotension.

C. History of Present Illness

A case of Panerio a 73 years old, male, married, a former farmer was admitted for the first time at

Northern Mindanao Medical Center. 5 days prior to admission onset of LBM, watery, mucoid, nonblood

stealed, amounting 1cup/episode x 10 episode. Associated with vomiting x 5 episode AUD, abdominal

pain.

3 days onset of dysuria associated with moderate fever due to LBM thus consult, hence admitted.

D. Chief Complaint

Patient was admitted to the said hospital last October 19, 2009 at 10:0 pm, his chief complaint prior

to admission was LBM associated with moderate fever.

III. DEVELOPMENTAL TASK

A. Erik Erikson’s Stages of Psychosocial Development Theory

Erikson describes eight developmental stages through which a healthily developing human should

pass from infancy to late 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. Each of Erikson's stages of

psychosocial development are marked by a conflict, for which successful resolution will result in a favorable

outcome and by an important event that this conflict resolves itself around.

In the Eriksons 8th stage of psychosocial Development theory which is Senior: Integrity vs. Despair

(65 years onwards). Integrity means moral soundness, whole or completeness of a person, Despair means

being hopeless. When it comes to my patient he was loosing hope that his illness will be cure, it is because

he feels that he was really old and he don’t have the capabilities of living the way it should be. But still,

because of the support of the family little by little he was trying to understand his situation tried to think on

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positive side and for himr to live longer for his family that still need him as a father, as a grandfather and as

a husband.

B. Sigmund Freud’s Psychosexual Development Theory

According to Freud, people enter the world as unbridled pleasure seekers. Specifically, people

seek pleasure through from a series of erogenous zones. These erogenous zones are only part of the

story, as the social relations learned when focused on each of the zones are also important. Freud's theory

of development has 2 primary ideas: One, everything you become is determined by your first few years -

indeed, the adult is exclusively determined by the child's experiences, because whatever actions occur in

adulthood are based on a blueprint laid down in the earliest years of life (childhood solutions to problems

are perpetuated) Two, the story of development is the story of how to handle anti-social impulses in socially

acceptable ways.

My patient belongs to the genital stage which begins at puberty involves the development of the

genitals, and libido begins to be used in its sexual role. However, those feelings for the opposite sex are a

source of anxiety, because they are reminders of the feelings for the parents and the trauma that resulted

from all that.

C. Robert J. Havighurst’s Developmental Task Theory

Havighurst categorized the tasks, in first category are the tasks, which has to be completed in

certain period, and the second are the tasks that continue for a long, sometimes for a lifetime.

So what happens if the task is not completed in that stage or completed in a later date? Havighurst

reply to that it is critical that the tasks should be completed during the appropriate stage, otherwise result

will be the failure to achieve success in future tasks.

D. Jean Piaget’s Theory of Development

According to Piaget, development is driven by the process of equilibration. Equilibration

encompasses assimilation (i.e., people transform incoming information so that it fits within their existing

schemes or thought patterns) and accommodation (i.e., people adapt their schemes to include incoming

information).

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My patient belongs to the formal operational stage. In this stage, individuals move beyond concrete

experiences and begin to think abstractly, reason logically and draw conclusions from the information

available, as well as apply all these processes to hypothetical situations. The abstract quality of the

adolescent's thought at the formal operational level is evident in the adolescent's verbal problem solving

ability. The logical quality of the adolescent's thought is when children are more likely to solve problems in a

trial-and-error fashion. Adolescents begin to think more as a scientist thinks, devising plans to solve

problems and systematically testing solutions. They use hypothetical-deductive reasoning, which means

that they develop hypotheses or best guesses, and systematically deduce, or conclude, which is the best

path to follow in solving the problem.

IV. MEDICAL MANAGEMENT

Doctor’s Order

DATE DOCTOR’S ORDER RATIONALEOctober 19, 2009 4:10pm

BP: 80/60HR:86\RR:20T:38C

Please admit to P1F2/A3T2 (ICCU) Please secure conset to care\ DWI-AGE with severe dehydration DAT\ V/S Q4 reffer the FF:

-BP >140/90 or 90/60mmHg-HR >110 OR < 60BPM-RR >30 OR < 12

Intake and output every shift

Labs: CBC with creatinine, K,BUN, U/A, Chest xray, ECG 12 leads + LII

Start colysis PLR 1L Fd now\ IVF to follow PNSS 1L @ 60gtts/min MEDICATIONS:

-Metronidazole, 500mg IVTT q 8hours-Ciprofloxacin 200mg every 12hours\-Paracertamol 500mg 1TAB Q4-Omeprazole 40mg cap OD

Please chart frequency, character, color, volume of stool and please record in separate sheet.

For proper admission and treatment

To closely monitor patients’ vital signs

To know avoid complications and to observe any problems

To hydrate the patient and to replace the fluid and electrolyte imbalances

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4:10pmAwake, coherent, BM X 4BP 70/60

August 20,2009

1:45pm

Refer if with sign of SOB, chest pain, change of and unsualities.

IVF PLR 1L @ 30GTTS/MIN To 80 gtts/min\

Increase IVF

LABS: o CBCo HGT nowo attach CT scan o (brain) result o to charto Na, K, SGPT, o creatinine, BUNo 12L ECG now

Meds:o coversyl 5mg/80 I tab

OD/ngto Dilantin 100g/cap

iii caps q8h x 3doses/NGTo Omeprazole 40mg IVTT

OD

FBC attached to urobag in placed – bloody urine

I&O q shift Maintain head part @30-40 degree Standby intubation set Monitor neurovitalsigns q2h Pls inform AP once admitted Discussed plan w/ pt.

o transport to cebuo cerebral angio- graphyo Possible coiling/o clipping of

To know any complications and for and for examination purposes

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July 10, 2009 8:00am

10:00am

11:32am

2:40pm

July 11, 2009 10:00am

o aneurysm

Pt seen and examined-(+) HPN > 5yrs. w/ good compliance of medication to atenolol- (-DM), (-) BA

Oral care w/ bactidol IVF TF PNSS rate 20gtts/min Turn side to side q2h chest physiotherapy

Nimodipine drip @ 5cc/hr (Nimodipine 4 vials via infusion pump)

For chest x-ray

For UA

Paracetamol I amp IVTT now

Start nicardipine drip 10mg in 100ml D5W solution in solution set start at 20gtts/min

Give captopril 50mg q6h for SBp ≥ 140mmhg

Please do chest tapping q after nebulization

To consume nicardipine drip

Same IVF to follow; PNSS @ 15gtts/min

May resume nicardipine drip @ 10cc/hr, titrate q 15mins to keep SBp @ 130-140mmhg

Hold vasalat

Resume Amlodipine(Vasalat), 10 mg, OD

IVF TF PNSS reg.@15gtts/min

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1:20pm

5:50 pm

9:40pm

July 12, 2009 9:10am

Besacodyl 10mg/supp; 2 rectal suppository now

Laboratory Results

Date Ordered Diagnostic Exam Result Normal Values Interpretation

Complete Blood Count

7/8/09 WBC 8,100 5,000-10,000/mm³ Normal

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RBC 4.80 4.20-5.40mil Normal

Hemoglobin 14.4 12.0-16.0 g/dl Normal

Hematocrit 43.8 37.0-47.0% Normal

Platelet 233,000 174,000 – 340,000 Normal

Differential Blood Count

Neutrophils 44 43.4-76.7% Normal

Lymphocytes 43 17.4-46.2% Normal

Monocytes 08 4.5-10.5% Normal

Eosinophils 05 0-2% %

Urinalysis

7/8/09 Color: Bloody

ph 6.5

Transparency: Hazy

Sugar Negative

Albumin Negative

Pus: +(0-21hpf)

RBC To numerous to count

Epithelial Cells; Rare

Mucous Threads: Rare

Drug study

Generic Name of

ordered drug

Dexamethasone

Brand Name

Date Ordered

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Classification CorticosteroidGlucocorticoidHormone

Dose/Frequency/Route

Mechanism of Action Enters target cells and binds to specific receptors, initiating many complex reactions that are responsible for its anti-inflammatory and immunosuppressive effects.

Specific Indication Trichinosis with neurologic or myocardial involvement

Contraindication Contraindications and cautions Contraindicated with infections, especially tuberculosis, fungal

infections, amebiasis, vaccinia and varicella, and antibiotic-resistant infections, allergy to any component of the preparation used.

Use cautiously with renal or hepatic disease; hypothyroidism, ulcerative colitis with impending perforation; diverticulitis; active or latent peptic ulcer; inflammatory bowel disease; CHF, hypertension, thromboembolic disorders; osteoporosis; seizure disorders; diabetes mellitus; lactation.

Side Effects/Toxic

Effects

CNS: Seizures, vertigo, headaches, pseudotumor cerebri, euphoria, insomnia, mood swings, depression, psychosis, intracerebral hemorrhage, reversible cerebral atrophy in infants, cataracts, increased IOP, glaucoma

CV: Hypertension, CHF, necrotizing angiitis Endocrine: Growth retardation, decreased carbohydrate

tolerance, diabetes mellitus, cushingoid state, secondary adrenocortical and pituitary unresponsiveness

GI: Peptic or esophageal ulcer, pancreatitis, abdominal distention

GU: Amenorrhea, irregular menses Hematologic: Fluid and electrolyte disturbances, negative

nitrogen balance, increased blood sugar, glycosuria, increased serum cholesterol, decreased serum T3 and T4 levels

Hypersensitivity: Anaphylactoid or hypersensitivity reactions Musculoskeletal: Muscle weakness, steroid myopathy, loss of

muscle mass, osteoporosis, spontaneous fractures Other: Impaired wound healing; petechiae; ecchymoses;

increased sweating; thin and fragile skin; acne; immunosuppression and masking of signs of infection; activation of latent infections, including TB, fungal, and viral eye infections; pneumonia; abscess; septic infection; GI and GU infections

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Intra-articular Musculoskeletal: Osteonecrosis, tendon rupture, infection

Intralesional therapy CNS: Blindness (when used on face and head—rare)

Respiratory inhalant Endocrine: Suppression of HPA function due to systemic

absorption Respiratory: Oral, laryngeal, pharyngeal irritation Other: Fungal infections

Nursing Precaution History for systemic administration: Active infections; renal or hepatic disease; hypothyroidism, ulcerative colitis; diverticulitis; active or latent peptic ulcer; inflammatory bowel disease; CHF, hypertension, thromboembolic disorders; osteoporosis; seizure disorders; diabetes mellitus; lactation

History for ophthalmic preparations: Acute superficial herpes simplex keratitis, fungal infections of ocular structures; vaccinia, varicella, and other viral diseases of the cornea and conjunctiva; ocular TB

Physical for systemic administration: Baseline body weight, T; reflexes, and grip strength, affect, and orientation; P, BP, peripheral perfusion, prominence of superficial veins; R and adventitious sounds; serum electrolytes, blood glucose

Physical for topical dermatologic preparations: Affected area for infections, skin injury

Generic Name of ordered

drug

Chlonidine Hydrchloride

Brand Name Catapres

Date Ordered

Classification AntihypertensiveSympatholytic (centrally acting)Central analgesic

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Dose/Frequency/Route

Mechanism of Action Stimulates CNS alpha2-adrenergic receptors, inhibits sympathetic cardioaccelerator and vasoconstrictor centers, and decreases sympathetic outflow from the CNS.

Specific Indication Hypertension, used alone or as part of combination therapy Treatment of severe pain in cancer patients in combination

with opiates; epidural more effective with neuropathic pain (Duraclon)

Contraindication Contraindicated with hypersensitivity to clonidine or any adhesive layer components of the transdermal system.

Use cautiously with severe coronary insufficiency, recent MI, cerebrovascular disease; chronic renal failure; pregnancy, lactation.

Side Effects/Toxic Effects Adverse effectsOral therapy

CNS: Drowsiness, sedation, dizziness, headache, fatigue that tend to diminish within 4–6 wk, dreams, nightmares, insomnia, hallucinations, delirium, nervousness, restlessness, anxiety, depression, retinal degeneration

CV: CHF, orthostatic hypotension, palpitations, tachycardia, bradycardia, Raynaud's phenomenon, ECG abnormalities manifested as Wenckebach period or ventricular trigeminy

Dermatologic: Rash, angioneurotic edema, hives, urticaria, hair thinning and alopecia, pruritus, dryness, itching or burning of the eyes, pallor

GI: Dry mouth, constipation, anorexia, malaise, nausea, vomiting, parotid pain, parotitis, mild transient abnormalities in LFTs

GU: Impotence, decreased sexual activity, diminished libido, nocturia, difficulty in micturition, urinary retention

Other: Weight gain, transient elevation of blood glucose or serum creatine phosphokinase, gynecomastia, weakness, muscle or joint pain, cramps of the lower limbs, dryness of the nasal mucosa, fever

Nursing Precaution Name confusion has been reported between clonidine and Klonopin (clonazepam); use caution.Assessment

History: Hypersensitivity to clonidine or adhesive layer components of the transdermal system; severe coronary insufficiency, recent MI, cerebrovascular disease; chronic

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renal failure; lactation, pregnancy Physical: Body weight; T; skin color, lesions, T; mucous

membranes—color, lesion; breast examination; orientation, affect, reflexes; ophthalmologic examination; P, BP, orthostatic BP, perfusion, edema, auscultation; bowel sounds, normal output, liver evaluation, palpation of salivary glands; normal urinary output, voiding pattern; LFTs, ECG

Generic Name of ordered

drug

amlodipine besylate

Brand Name Norvasc

Date Ordered

Classification Calcium channel-blockerAntianginal drugAntihypertensive

Dose/Frequency/Route

Mechanism of Action Inhibits the movement of calcium ions across the membranes of cardiac and arterial muscle cells; inhibits transmembrane calcium flow, which results in the depression of impulse formation in specialized cardiac pacemaker cells, slowing of the velocity of conduction of the cardiac impulse, depression of myocardial contractility, and dilation of coronary arteries and arterioles and peripheral arterioles; these effects lead to decreased cardiac work, decreased cardiac oxygen consumption, and in patients with vasospastic (Prinzmetal's) angina, increased delivery of oxygen to cardiac cells.

Specific Indication Angina pectoris due to coronary artery spasm (Prinzmetal's variant angina)

Chronic stable angina, alone or in combination with other drugs

Essential hypertension, alone or in combination with other antihypertensives

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Contraindication Contraindicated with allergy to amlodipine, impaired hepatic or renal function, sick sinus syndrome, heart block (second or third degree), lactation.

Use cautiously with CHF, pregnancy.

Side Effects/Toxic Effects

Nursing Precaution

Generic Name of ordered

drug phenytoin (diphenylhydantoin, phenytoin sodium)

Brand Name Dilantin

Date Ordered

Classification AntiepilepticAntiarrhythmic, group 1bHydantoin

Dose/Frequency/Route

Mechanism of Action Has antiepileptic activity without causing general CNS depression; stabilizes neuronal membranes and prevents hyperexcitability caused by excessive stimulation; limits the spread of seizure activity from an active focus; also effective in treating cardiac arrhythmias, especially those induced by digitalis; antiarrhythmic properties are very similar to those of lidocaine; both are class IB antiarrhythmics.

Specific Indication Control of grand mal (tonic-clonic) and psychomotor seizures

Prevention and treatment of seizures occurring during or following neurosurgery

Parenteral administration: Control of status epilepticus of the grand mal type

Unlabeled uses: Antiarrhythmic, particularly in digitalis-induced arrhythmias (IV preparations); treatment of trigeminal neuralgia (tic douloureux)

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Contraindication Contraindicated with hypersensitivity to hydantoins, sinus bradycardia, sinoatrial block, Stokes-Adams syndrome, pregnancy (data suggest an association between antiepileptic use and an elevated incidence of birth defects; however, do not discontinue antiepileptic therapy in pregnant women who are receiving such therapy to prevent major seizures; this is likely to precipitate status epilepticus, with attendant hypoxia and risk to both mother and fetus), lactation.

Use cautiously with acute intermittent porphyria, hypotension, severe myocardial insufficiency, diabetes mellitus, hyperglycemia.

Side Effects/Toxic Effects CNS: Nystagmus, ataxia, dysarthria, slurred speech, mental confusion, dizziness, drowsiness, insomnia, transient nervousness, motor twitchings, fatigue, irritability, depression, numbness, tremor, headache, photophobia, diplopia, conjunctivitis

CV: CV collapse, hypotension (when administered rapidly IV; not to exceed 50 mg/min)

Dermatologic: Dermatologic reactions, scarlatiniform, morbilliform, maculopapular, urticarial and nonspecific rashes; serious and sometimes fatal dermatologic reactions—bullous, exfoliative, or purpuric dermatitis, lupus erythematosus, and Stevens-Johnson syndrome, toxic epidermal necrolysis, hirsutism, alopecia, coarsening of the facial features, enlargement of the lips, Peyronie's disease

GI: Nausea, vomiting, diarrhea, constipation, gingival hyperplasia, toxic hepatitis, liver damage, sometimes fatal; hypersensitivity reactions with hepatic involvement, including hepatocellular degeneration and fatal hepatocellular necrosis

GU: Nephrosis Hematologic: Hematopoietic complications, sometimes

fatal: thrombocytopenia, leukopenia, granulocytopenia, agranulocytosis, pancytopenia; macrocytosis and megaloblastic anemia that usually respond to folic acid therapy; eosinophilia, monocytosis, leukocytosis, simple anemia, hemolytic anemia, aplastic anemia, hyperglycemia

IV use complications: Hypotension, transient hyperkinesia, drowsiness, nystagmus, circumoral tingling, vertigo, nausea, CV collapse, CNS depression

Respiratory: Pulmonary fibrosis, acute pneumonitis Other: Lymph node hyperplasia, sometimes progressing to

frank malignant lymphoma, monoclonal gammopathy and

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multiple myeloma (prolonged therapy), polyarthropathy, osteomalacia, weight gain, chest pain, periarteritis nodosa, hirsutism, alopecia

Nursing Precaution History: Hypersensitivity to hydantoins; sinus bradycardia, AV heart block, Stokes-Adams syndrome, acute intermittent porphyria, hypotension, severe myocardial insufficiency, diabetes mellitus, hyperglycemia, pregnancy, lactation

Physical: T; skin color, lesions; lymph node palpation; orientation, affect, reflexes, vision examination; P, BP; R, adventitious sounds; bowel sounds, normal output, liver evaluation; periodontal examination; LFTs, urinalysis, CBC and differential, blood proteins, blood and urine glucose, EEG and ECG

Generic Name of ordered

drug

Brand Name

Date Ordered

Classification

Dose/Frequency/Route

Mechanism of Action

Specific Indication

Contraindication

Side Effects/Toxic Effects

Nursing Precaution

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V. Anatomy and Physiology

The Brain

Three cavities, called the primary brain vesicles, form during the early embryonic development of the

brain. These are the forebrain (prosencephalon), the midbrain (mesencephalon), and the hindbrain

(rhombencephalon).

During subsequent development, the three primary brain vesicles develop into five secondary brain

vesicles.

The telencephalon generates the cerebrum (which contains the cerebral cortex, white matter,

and basal ganglia).

The diencephalon generates the thalamus, hypothalamus, and pineal gland.

The mesencephalon generates the midbrain portion of the brain stem.

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The metencephalon generates the pons portion of the brain stem and the cerebellum.

The myelencephalon generates the medulla oblongata portion of the brain stem

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The cerebrum consists of two cerebral hemispheres connected by a bundle of nerve fibers,

the corpus callosum. The largest and most visible part of the brain, the cerebrum, appears as

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folded ridges and grooves, called convolutions. The following terms are used to describe the

convolutions:

A gyrus (plural, gyri) is an elevated ridge among the convolutions.

A sulcus (plural, sulci) is a shallow groove among the convolutions.

A fissure is a deep groove among the convolutions.

The deeper fissures divide the cerebrum into five lobes (most named after bordering skull

bones)—the frontal lobe, the parietal love, the temporal lobe, the occipital lobe, and the insula.

All but the insula are visible from the outside surface of the brain.

A cross section of the cerebrum shows three distinct layers of nervous tissue:

The cerebral cortex is a thin outer layer of gray matter. Such activities as speech,

evaluation of stimuli, conscious thinking, and control of skeletal muscles occur here.

These activities are grouped into motor areas, sensory areas, and association areas.

The cerebral white matter underlies the cerebral cortex. It contains mostly myelinated

axons that connect cerebral hemispheres (association fibers), connect gyri within

hemispheres (commissural fibers), or connect the cerebrum to the spinal cord (projection

fibers). The corpus callosum is a major assemblage of association fibers that forms a

nerve tract that connects the two cerebral hemispheres.

Basal ganglia (basal nuclei) are several pockets of gray matter located deep inside the

cerebral white matter. The major regions in the basal ganglia—the caudate nuclei, the

putamen, and the globus pallidus—are involved in relaying and modifying nerve

impulses passing from the cerebral cortex to the spinal cord. Arm swinging while

walking, for example, is controlled here.

The diencephalon connects the cerebrum to the brain stem. It consists of the following major

regions:

The thalamus is a relay station for sensory nerve impulses traveling from the spinal cord

to the cerebrum. Some nerve impulses are sorted and grouped here before being

transmitted to the cerebrum. Certain sensations, such as pain, pressure, and

temperature, are evaluated here also.

The epithalamus contains the pineal gland. The pineal gland secretes melatonin, a

hormone that helps regulate the biological clock (sleep-wake cycles).

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The hypothalamus regulates numerous important body activities. It controls the

autonomic nervous system and regulates emotion, behavior, hunger, thirst, body

temperature, and the biological clock. It also produces two hormones (ADH and

oxytocin) and various releasing hormones that control hormone production in the

anterior pituitary gland.

The following structures are either included or associated with the hypothalamus.

The mammillary bodies relay sensations of smell.

The infundibulum connects the pituitary gland to the hypothalamus.

The optic chiasma passes between the hypothalamus and the pituitary gland. Here,

portions of the optic nerve from each eye cross over to the cerebral hemisphere on the

opposite side of the brain.

The brain stem connects the diencephalon to the spinal cord. The brain stem resembles the

spinal cord in that both consist of white matter fiber tracts surrounding a core of gray matter.

The brain stem consists of the following four regions, all of which provide connections between

various parts of the brain and between the brain and the spinal cord. (Some prominent

structures are illustrated in Figure 2 ).

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Figure 2 Prominent structures of the brain stem.

The midbrain is the uppermost part of the brain stem.

The pons is the bulging region in the middle of the brain stem.

The medulla oblongata (medulla) is the lower portion of the brain stem that merges with

the spinal cord at the foramen magnum.

The reticular formation consists of small clusters of gray matter interspersed within the

white matter of the brain stem and certain regions of the spinal cord, diencephalon, and

cerebellum. The reticular activation system (RAS), one component of the reticular

formation, is responsible for maintaining wakefulness and alertness and for filtering out

unimportant sensory information. Other components of the reticular formation are

responsible for maintaining muscle tone and regulating visceral motor muscles.

The cerebellum consists of a central region, the vermis, and two winglike lobes, the cerebellar

hemispheres. Like that of the cerebrum, the surface of the cerebellum is convoluted, but the

gyri, called folia, are parallel and give a pleated appearance. The cerebellum evaluates and

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coordinates motor movements by comparing actual skeletal movements to the movement that

was intended.

The limbic system is a network of neurons that extends over a wide range of areas of the brain. The

limbic system imposes an emotional aspect to behaviors, experiences, and memories. Emotions such

as pleasure, fear, anger, sorrow, and affection are imparted to events and experiences. The limbic

system accomplishes this by a system of fiber tracts (white matter) and gray matter that pervades the

diencephalon and encircles the inside border of the cerebrum. The following components are

included:

The hippocampus (located in the cerebral hemisphere)

The denate gyrus (located in cerebral hemisphere)

The amygdala (amygdaloid body) (an almond-shaped body associated with the caudate

nucleus of the basal ganglia)

The mammillary bodies (in the hypothalamus)

The anterior thalamic nuclei (in the thalamus)

The fornix (a bundle of fiber tracts that links components of the limbic system)

Pathophysiology

Definition:

Cerebrovascular accident or stroke (also called brain attack) results from sudden interruption of

blood supply to the brain, which precipitates neurological dysfunction lasting longer than 24 hrs.

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Hemorrhagic stroke is the leakage of blood vessel causes compression of brain tissue and spasm of

adjacent vessels.

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Predisposing Factor - Family History

PrecipitatingFactor - High fat diet

Fatty Dispostion in tunica Intimae sp. Low density lipoprotein

Macropages will treat them as foreign bodies

Will engulf fatty deposits in the tunica Intima

Macrophage will become heavier because of fatty deposits

Macrophages will be deposited together with fats (foam cells)

Acumulate, becomes atherosclerotic plaque

Hyperperfusion of vital organs specially kidney

Juxtaglumerular cells of kidney will secrete renin angiotensin 1

Angiotensin 1 converted to angiotensin 2 by ACE

Increase peripheral assistance

VI. NURSING ASSESSMENTNURSING SYSTEM REVIEW CHART

Name:: Mrs. LML Date: July Pulse: 94bpm Temp.: 36.7 c RR: 22 cpm BP: 160/100 mmhg Weight: 55 kgs. Height: 5’4

EENT:× impaired vision □ blind □ Pain □ reddened □ drainage□ gums □ hard of hearing □ deaf□ burning □ edema □ lesion □ teeth __Diplopia ____________ Assess eyes, ears, nose ___Eyepatch __________ Throat for abnormality □ no problem _____________________RESP: _____________________ □ Asymmetric □ tachypnea _____________________□ apnea □ rales □ cough □ barrel chest _BP- 160/100mmhg_____□ bradypnea □ shallow □ brochi _____________________□ sputum □ diminished □ dyspnea _____________________□ orthopnea □ labored □ wheezing _Dry skin_____________

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Increase Blood Pressure

Hypertension

Blood vessels become weak

Outpouching of brain arteries(aneurysm)

Rupture of Blood vessels

CVA, Hemorrhagic

Increase Intracranial Pressure

s/sx:- diplopia - nausea- nape pain- dizziness

Accumulation of blood in the brain

Compression of brain organs De-creased Brain Perfu -sion

□ pain □ cyanotic _____________________Assess resp, rate, rhythm, depth, pattern, _____________________ breath sounds, comfort × no problem __IVF _site____________CARDIO VASCULAR _____________________□ arrhythmia □ tachycardia □ numbness _____________________□ diminished pulses □ edema □ fatigue ___FBC to Urobag ______ □ irregular □ bradycardia □ murmur _____________________□ tingling □ absent pulses □ pain _____________________ Asses heart sounds, rate rhythm, pulse, blood _____________________ pressure, clrc., fluid retention, comfort _____________________ □ no problem _____________________GASTRO INTESTINAL TRACT _____________________□ obese □ distention □ mass _____________________□dysphagia □ rigidly □ pain ____mild headache _____ Asses abdomen, bowel habits, swallowing, _____________________bowel sounds, comfort × no problem _____________________GENITO-URINARY and GYNE _____________________□ pain □ urine color □ vaginal bleeding _____________________□ hermaturia □ discharge □ noctoria _____________________Asses urine freq., color, control, odor, comfort/ nape pain _ _________ Gyn-bleeding, discharge × no problem _____________________NEURO _____________________□ paralysis □ stuporous □ unsteady □ seizures _____________________□ lethartic □ comatose □ vertigo □ tremors□ confused □ vision □ grip _____________________Asses motor function, sensation, LOC, strength, _____________________ Grip, gait, coordination, orientation, speech, Poor Skin turgor ________ × no problem _____________________MUSCULOSKELETAL and SKIN _____________________□ appliance □ stiffness □itching □ petechiae _____________________ hot □ drainage □ prosthesis □ swelling _____________________□ lesion × poor turgor □ cool □ deformity _____________________□ wound □ rash □ skin color □ flushed _____________________□ atrophy □ pain □ ecchymosis _____________________□ diaphoretic □ moist _____________________Asses mobility, motion. Galt, alignment, joint function _____________________ /skin color, texture, turgor, integrity □ no problem _____________________

__________________________________________

NURSING ASSESSMENT II

SUBJECTIVE OBJECTIVE

COMMUNICATION:

Hearing Loss× Visual Changes Denied

comment: “duha man ang ako panan-aw mao gani gi butangan ko ani tanon sa ako mata. ”

Glasses Contact Lens Pupils size: 3 mmReaction: Pupils Equally round and react to light and accommodation

Languages Hearing Loss Speech Difficulties

OXYGENATION: COMMENT: _”maayo raman pud akong pag-ginhawa, wala man pud ko naglisod, usahay lang kay mutukar ako ubo”

Resp. × Regular Irregular Dyspnea Smoking History× Cough Sputum Denied

Describe: Breathing pattern is regular.

R right lung is symmetrical to the left lung. L left lung is symmetrical to the right lung.

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CIRCULATION: Heart Rhythm × Regular Irregular

Chest Pain Leg Pain Numbness of Extremities×Denied

COMMENT: “,wala man nuon sakit sa ako tiil ug dughan, kani raman ako liog”

Ankle edema: Presence of ankle edemaPulse Car. Rad. DP Femoral*R ___+_______+______+______+____L ___+______ +______+____ _+_____COMMENT: all pulses are present and palpable

NUTRITION:* If applicable

Diet: Low salt, low fat Diet × Dentures None

Full Partial W/ patientUpper ×

Lower

N □V Character:

COMMENT: “katong miaging adlaw ga suka ko, pero karon wala naman, pero wala lng ko gana mukaon.”

×Recent change in weight, appetite Swallowing Diff.Denied

ELIMINATION: COMMENT:Patient has a normal bowel movement. Her urine color is yellowish and aromatic in odor.

Bowel sounds:Normo active bowel sounds

Abdominal Distention: Present Yes × NoUrine* Urine is yellowish in color* If Foley is in placePatients FBC to Urobag is in place.

Usual bowel pattern:1-2x daily_________

Urinary Frequency: Dysuria Hematuria Incontinence Polyuria × Foley in place Denied

Constipation remedies: ___Date of last BM: July 6, 2009Diarrhea Character:None_____________

MGT. OF HEALTH AND ILLNESS: Briefly describe patient’s ability to follow treatments for chronic health problems (if present):

Patient follows treatment regimen properly.

Alcohol × Denied (Amount, Frequency): SBE: Last Pap Smear:__N/A____LMP: ____N/A ________

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SUBJECTIVE OBJECTIVE

SKIN INTEGRITY: ×DryItching OtherDenied

COMMENT: “gamala akong panit karon kay dili man gud ko galigo, tigulang napud gud”

×Dry Cold Pale Flushed Warm Moist Cyanoticrashes, ulcers, decubitus ulcers (describe size, location, drainage): none

ACTIVITY / SAFETY: LOC and Orientation: Patient is oriented to time and space. Gait: Walker Cane Others × Steady Unsteady

Sensory and motor losses in face or extremities: There is having diplopia.

ROM Limitations: The patient cannot bath by itself appropriately and needs guidance when doing it.

Convulsion×Dizziness Limited motion of joints

Limitations in ability to: Ambulate× Bathe self Others Denied

COMMENT: “dili man nako pa kaya magkatindog kay gakalipong ko”

COMFORT / SLEEP / AWAKE: Pain (Location, Freq., Remedies) Nocturia Sleep DifficultiesDenied

COMMENT: “Maaayo man hinuon ang ako pagkatulog”

Facial Grimaces Guarding Other signs of pain: none_ side rail release from signed(60+years) None

COPING: Observed nonverbal behavior:

Patient follows instructions, cooperative, but sometimes she easily get depressedof her situation and she likes to talk things about her life and family.

Occupation: Retired TeacherMumbers of household: _3__Most supportive person:_husband __ ____

VII. NURSING MANAGEMENT A.IDEAL NURSING INTERVENTIONS

30

Nursing Diagnosis: Ineffective cerebral tissue perfusion related to hemorrhage

Interventions Rationale

Independent:

1. Determine factors related to individual

situation/ cause for coma/ cerebral

tissue perfusion and potential

increased in ICP.

2. Monitor or document neurolohgical

status frequently and compare with

baseline.

3. Monitor vital signs

4. Position with head slightly elevated

and in neutral position and maintain

bedrest.

Influences choice of interventions.

Assesses trends in level of consciousness

and potential increase in ICP and is useful

in determining location, extent and

progression of the CNS damage.

Fluctuations in pressure may occur

because of cerebral pressure/ injury in

vasomotor area of the brain. Change in rate

of heart rhythm can occur because of the

brain damage.

Reduces arterial pressure by promoting

venous drainage and may improve cerebral

circulation or perfusion.

Dependent:

5. Administer prescribed medications,

supplemental oxygen,anticoagulants,

antihypertensive drugs as ordered.

Reduces hypoxemia, increase of

ICP and may use to improve

cerebral blood flow.

Nursing Diagnosis: Impaired physical mobility related to neuromuscular involvement

Interventions Rationale

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Independent:

1. Assess functional ability/ extent of

impairment initially and on a regular

basis.

2. Change position at least every 2hrs.

and possibly more often on the

affected side.

3. Inspect skin regularly, particularly over

bony prominences. Gently massage

any reddened areas and provide aids

such as sheepskin pads as necessary.

4. Encourage patient to assist with the

movement and exercisse using the

unaffected extremity to support or

move weaker side.

Identifies strengths/ deficiencies and may

provide information regarding recovery.

Reduces risk of tissue ischemia/injury.

Affected side has poorer circulation and

reduced sensation and is more predisposed

to skin breakdown/ decubitus.

Pressure points over bony priminences are

most at risk for decreased perfusion/

ischemia. Circulatory stimulstion

and ,padding help prevent ski breakdown

and decubitus development.

May respond as if the affected side is no

linger part of the body a nd needs

encouragement and active training to

reincorporate it as a part of its own body.

Dependent:

5. Consult with the physical therapist

regarding active resistive exercises

and patient ambulation.

Individualized program can develop to meet

particular needs/ deal with deficits in

balance, coordination and strength.

Nursing Diagnosis: Disturbed Sensory perception related to altered sensory receptor

Interventions Rationale

32

Independent:

1. Observe behavioral responses

2. Eliminate extrenous noise/ stimuli as

necessary.

3. Speak in calm, quiet voice, using short

sentences. Maintain eye contact.

4. Ascertain/ validate patient’

perceptions. Reorient patient

frequently to environment , staff,

procedures.

5. Evaluate visual deficits. Note loss of

visual field, changes in depth

perception , presence of

diplopia(double vision)

Individual responses are variable, but

commonalities such as emotional ability,

lowered frustration threshold, apathy, and

impulsiveness may complicate care.

Reduces anxiety and exaggerated

emotional responses/ confusion associated

with sensory overload.

Patient may have limited attention span or

problems with comprehension. These

measures can help the patient to attend to

communication.

Assists patient to identify inconsistencies in

reception and integration of stimuli and may

reduce perceptual distortion of reality.

Presence of visual disorders can negatively

affect patient’s ability to perceive

environment and relearn motor skills and

increases risk of accident/ injury.

B. ACTUAL NURSING INTERVENTION

S

o

A

33

P

I

E

B.

S

“ Kani man ang ako liog ang nag sakit ug pag – ayo, unya ga doble na ang ako panan-

aw”

o BP – 160/100 mmhg

34

Appeared weak

Diplopia

Presence of eyepatch

A

Ineffective cerebral tissue perfusion related to hemorrhage.

P Long term: At the end of 2 days duty I will be able to

I

Independent

1. Positioned with head slightly elevated.

Reduces arterial pressure by promoting venous drainage and may improve

cerebral circulation or perfusion.

2. Maintained bed rest.

Continual stimulation or activity ma increase intracranial pressure.

3. Provided quiet environment.

Absolute rest and quiet environment may be needed to prevent rebleeding.

4. Prevented straining at stool, holding breath.

Valsava manuever increase ICP and potential risk of rebleeding.

Dependent

5. Administer and stool softeners per doctor’s order.

Prevent straining during bowel movement and corresponds to increase ICP.

35

E

S

“ Gakalipong paman ko, mao pud gain ga hungitan pako sa ako anak or asawa, ka

para dili ko maglisod. Unya duha pa gyod ako panan-aw.”

o

Eye patch placed alternately q2h

A

Risk for injury related to visual disturbance.

P Long term:

At the end of 8 hours the patient with the help of relatives and health care

provider will be able to modify environment as indicated to enhance safety and use

resources appropriately.

Short term:

At the end of 1 hour the patient will be able to identify individual risk factors.

I Independent

1. Assessed patient for dizziness or diplopia.

To know the extent of disturbance and further interventions to be done.

2. Oriented patient on possible risk factors and on the environment.

To familiarize patient on her environment and identify and avoid where danger

is at its peak.

3. Adjust bed and keep side rails raised up, especially if patient is at

36

rest.

To prevent further injury from falls.

4. Placed unnecessary objects away from clients’ sight.

To enhance safety appropriate use of necessary resources.

5. Administer medication as prescribe by the physician.

E

At the end of 8 hours shift the patiently with the help of relatives and health care

provider was able to modify environment a indicated to enhance safety and use of

resources appropriately.

VIII. Referrals and Follow-up

Patient was transferred to Cebu as what was planned by the family and together

with Dr. Surdilla for proper treatment of the patients condition. Patient, together with the family was

advised to follow medications and treatment regimen. Emotional and spiritual support towards the

patient should be given attention, because the patient easily gets depressed and is sometimes

loose hope on her situation.

Follow – up check ups should also be follow according to the schedule. This is very important so

that the patient and the family may be aware if there are any problems found from the patients of

how the patients responds on the treatment process.

37

IX. Evaluation and Implication

After conducting this care study, I was able to appreciate more the essence of utilizing the

nursing process in the care and management of my patient. It was indeed a tough job on

conducting this study yet, it gave me a big impact regarding how useful it is in my chosen

profession. Nursing really demands a tender loving care attitude. It demands patience and it is

calling that cannot be merely taken for granted.

This study will serve as a reference material in rendering competent care to my client

especially those with similar situation. Through this, I will be able to develop my knowledge as well

as my skills and attitudes in applying the prescribed procedure to improve the health status of the

patient.

Moreover, this care study taught us to stand on our own by not depending on others just to

make this. This provides us, the students, a big learning regarding on how well we take care of or

38

patients in the real clinical setting. Most of all, this study teaches the students to provide clients

care more efficiently and competently to achieve an effective and quality nursing care.

X. BIBLIOGRAPHY

BOOKS

Suzzanne C. Smeltzer, EdD, RN,FAAN,et.al

Medical Surgical Nursing

11th Edition, page 1118

Lippincott Williams and Wilkins

Manual of Nursing Practice

7th Edition page 570-571

© 2001 by Lippincott Williams and Wilkins

Robert Berhow M.D, et al

39

Home Edition, page 562

©1997 by Merck Co. Inc

Microsoft ® Encarta ® Reference Library 2004

©1993-2003 Microsoft Corporation

WEB

www.nursingcrib.com

http://www.wisegeek.com/what-is-cva.htm

http://en.wikipedia.org/wiki/cerebrovascularacciddent

http://www.Emedicinehealth.com/cerebrovascularaccident/pages.em.htm

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