Cerebrovascular accident

Angeles University FoundationAngeles City

College of Nursing

“Cerebrovascular Accident Infarct Right hemisphere”

In Partial Fulfillment of the Requirements in NCM RLE 102

OB- Pedia Ward, Balitucan District Hospital

Submitted by:

Ano Carl Elexer C.

Balilo, Noel Leonicio

Dizon, Requelito

Estrada, Florence Ancel

BSN III-1 Group 1

Submitted To:

Fe Pagado R.N., M.N.

February 21, 2009

I. Introduction

Many studies were conducted regarding cerebrovascular accidents tackling

different aspects of cerebrovascular accident such as; the cause, precipitating factors,

predisposing factor, and its prevalence throughout the world as one of the top ten

leading causes of morbidity.

Cerebrovascular accident (CVA) is the medical term for what is commonly

termed a stroke. It refers to the injury to the brain that occurs when flow of blood to

brain tissue is interrupted by a clogged or ruptured artery, causing brain tissue to die

because of lack of nutrients and oxygen.

The severity associated with cerebrovascular accident can best be demonstrated

by the following facts: CVA is the leading cause of adult disability in the world. Two –

thirds of strokes appear among 65 year old and above. Stroke affects more men than

women and most of the cases are among African American. (Accessed on:

http://www.wikidoc.org/index.php/Cerebrovascular_accident)

A. Current Trends about the Disease Condition

Blunt cerebrovascular injuries can be diagnosed using whole body 16 multi-

detector CT (MDCT); there's no need for an additional neck MDCT angiography

examination according to a recent study conducted by researchers at the University of

Maryland Medical Center and R. Adams Cowley Shock Trauma Center, both in

Baltimore, MD. The study showed that whole body MDCT is just as accurate as neck

MDCTA. Blunt cerebrovascular injuries are uncommon but potentially devastating

injuries that can lead to stroke and death. These include dissections,

pseudoaneurysms, and arteriovenous fistulae.

For the study, the researchers identified 108 blunt trauma patients that were

examined with either whole-body MDCT or neck MDCTA followed by angiography over

a 23-month period. From this group, 77 whole body MDCT and 48 neck MDCTA

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examinations were compared with the results that were pulled from the reports of

correlative angiography.

According to the study, angiography confirmed blunt cerebrovascular injuries in

83 patients with 25 of those showing injury to more than one of the four major arteries

(carotid or vertebral). In the neck, where injuries were most common, each technique

showed low sensitivity for blunt carotid (69% for whole-body MDCT and 64% for

MDCTA) and blunt vertebral artery injuries (74% for whole-body MDCT and 68% for

MDCTA), but specificities were high for both carotid (82% for whole-body MDCT and

94% for MDCTA) and vertebral artery injuries (91% for whole-body MDCT and 100% for

MDCTA). The two techniques diagnosed blunt cerebrovascular injuries with statistically

comparable accuracy. Routine use of whole-body MDCT would facilitate diagnosis and

treatment of asymptomatic blunt cerebrovascular injuries in patients without typical risk

factors for injuries. (Accessed on: http://www.eurekalert.org/pub_releases/2008-03/arrs-

wbm032808.php)

B. Reasons for choosing such case for presentation

Initially the researchers have difficulty of an appropriate case for presentation

since most of the cases present on the institution are common illness such as Acute

Gastroenteritis and Bronchopneumonia where in there is a lot of information available

regarding these diseases.

With that problem in hand, the group decided to ask permission to their clinical

instructor to utilize a medical case, and with the approval of their clinical instructor, the

group came up into a medical case of a 58 years old widowed female with a diagnosis

of Cerebrovascular infarct right hemisphere with accompanying past illnesses of active

renal disease, hypertension and Diabetes mellitus.

Objectives

After the completion of the study, the researchers shall be able to:

Identify and differentiate risks for cerebrovascular accident

Be updated with the latest trends in the treatment of cerebrovascular accident

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Perform a comprehensive assessment of Cerebrovascular accident

Enumerate the different signs and symptoms of Cerebrovascular accident

List down the different diagnostic procedures that would help in the diagnosis of

Cerebrovascular accident.

Identify and understand different types of medical treatment necessary for the

treatment of Cerebrovascular accident.

Formulate nursing care plans utilizing the nursing process

Formulate conclusions based on the findings and enumerated a

recommendations concerning Cerebrovascular accident.

Nurse Centered Objectives:

At the end of the study, the researchers:

Shall have critical thinking skills necessary for providing safe and effective

nursing care.

Shall have a comprehensive assessment and implement care base on our

knowledge and skills of the condition

Shall have familiarized us with effective inter-personal skills to emphasized

health promotion and illness prevention.

Shall have imparted the learning experience from direct patient care.

Patient/Family Centered Objectives:

At the end of this study, the patient/family will be able to:

1. Identify measures that could minimize the risk of occurrence of the disease.

2. Identify possible risk factors that may have contributed to the development of

Cerebrovascular accident.

3. Increase awareness on the risk factors of Cerebrovascular accident.

4. Develop the family’s support system and distinguish their respective roles in

improving patient’s health status.

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5. Involve them in promoting the health care of the patient.

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II. Nursing Assessment

A. Personal Data

1. Demographic data

Mrs. Kitty Sanrio is a 58 year old widow, Filipino who was born on

September 18, 1951 in Magalang, Pampanga.

She is the second child among the 3 siblings of Disney family and all

of them are married. She, together with her youngest daughter Po, currently

resides at San Francisco, Magalang, Pampanga. She is religiously affiliated

as a Roman Catholic. She is presently unemployed but used to be an eatery

vendor. When she was 35 years old she smokes 1 pack of cigarette per day,

yielding a pack year history of 23, she was forced to quit smoking due to her

present illness. She was admitted at Balitucan District Hospital in Magalang

with an admitting diagnosis of cerebrovascular infarct right hemisphere with

chief complaints of left sided weakness.

2. Socio-economic and Cultural Factors

Mrs. Kitty Sanrio was able to finish her high school education but she

was able to pursue a vocational course on dressmaking. She is religiously

affiliated to Roman Catholic. As mentioned the family believed on the

common practices of the Catholics which her daughter termed as “apis –apis”

they also believe in manghihilot. With regards to their sanitary condition of

their home it was reported that Mrs. Sanrio always does the housekeeping.

In the year 2007, Mrs. Sanrio used to work as an eatery vendor that

was specifically year ago before she was been diagnosed of renal disease

last 2008, at present her daughters support her daily expenses including

household bills.

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B. Pertinent Family Health History

Disney Family

7

Father † Mother†

Daughter 1

Mr. Sanrio †Mrs. Sanrio

Sister 2Sister 1

Daughter 4Daughter 3Daughter 2

Renal Failure

Legend:

Heart Attack

HPN

CVA, HPN, DM, Renal

Disease

Normal

Epilepsy

Liver Cancer

Upon interview it was reported that Mrs. Sanrio’s father died of renal failure at the

age of 82, her mother died of heart attack at the age of 89. Mrs. Sanrio has two sisters,

both of them also has hypertension. Mrs. Sanrio’s husband died 8 years ago at the age

of 52 due to liver cancer. 3 years after, specifically 2005, Mrs. Sanrio was diagnosed

Diabetes Mellitus type 2. At the year 2008, she was diagnosed of renal disease and

hypertension by accident. Her four daughters do not have any major illness except for

her youngest daughter which has epilepsy which was diagnosed at the age of 15.

C. History of Past Illness

Upon interview, her daughter told the student nurses that Mrs. Sanrio was

diagnosed of Diabetes Mellitus Type II in the year 2004, and she is taking Diamicron as

her medication, according to her mother is also fond of eating foods which are rich in fat

and cholesterol. She has also mentioned that Kitty cannot eat without putting extra salt

on her food. Information relayed by Tinky Winky states that Kitty undergone an incision

and drainage surgery due to thumbtacks pricks which became infected and developed a

large pus filled lesion in the year 2008. Together with that during her stay on the

hospital, it was found out that Kitty has a renal disease; Tinky Winky was not able to

specify the exact diagnosis given by the physician, it has also found out that she has a

hypertension. In line with this, Kitty managed her renal disease with Bactrim and Eprex.

She is also taking Capoten and Neobloc for her Hypertension. Mrs. Sanrio wears a

prescribed eyeglass for 3 years now with a grade of 200 as mentioned by Tinky winky.

D. History of Present Ilness

As narrated by Tinky winky at the district hospital 2-3 days prior to Kitty’s

admission she is already complaining of headache, and they regarded it as the usual

headache associated with high blood pressure. They have just managed it with her

medicines for hypertension. The symptoms persisted for another day and managed it

the same way.

January 27, 2009 1:30 am, Kitty woke them up with complains of numbness on

her body and blurry vision “dudurut ya kanu lawe”, she doesn’t want anybody to touch

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her as she can feel that her conditions aggravates every time someone will touch her.

According also to Tinky winky upon seeing her mother, she have noticed that there is an

obvious asymmetry on her mother’s face “balamu mekubit ya lupa, balamu babalag ya

lupa” and slurring of speech, she then had an idea that it may be a stroke.

They planned to bring Kitty to a private hospital, but Mrs. Sanrio disagreed

insisting that she wants to be admitted at the district hospital. So after a few hours of

debate, they have decided to bring her to the District Hospital. Upon consult, she was

advised to stay at the hospital on January 27, 2009 with admitting diagnosis of CVA

infarct right Hemisphere, with accompanying illnesses of renal disease, hypertension

and diabetes mellitus.

A. Physical Examination

January 27, 2009 (lifted from chart)

Patient has chief complaints of left sided body weakness, conscious, alert, (+)

facial asymmetry, normal rate and regular rhythm, clear breath sounds,

normoactive bowel sounds, GCS= 15, BP= 200/100 mmHg, PR= 85, RR= 16

General Appearance - Initial [(January 29, 2009)]

Patient is wearing a black with floral design clothing, with unkempt hair,

appears weak; patient has halitosis, conscious and coherent. She is lying on bed

with an ongoing IVF of #2 D5 0.3 NaCl 500 cc x 20 - 21 µgtts/ min infusing well

on the right metacarpal vein currently at 50 cc level, patient has an indwelling

Foley catheter attached to urine bag with current urine out put of 2000 ml.

9

5/5

5/5

1/5

1/5

R L

Patient has the following vital signs:

T= 35.8 ° C

P= 79 bpm

R= 20 cpm

BP= 190/90 mmHg

Upon the assessment of her head, the researchers noted a normal finding,

characterized by symmetrical skull, no presence of nodules and lesions, and with

hair properly distributed.

Upon the assessment of the client’s face, most of the findings are of

normal findings characterized by pupils which are equally round in shape,

reactive to light and accommodation, with her right eyebrows evenly distributed

and symmetrically aligned. With eyelashes of normal growth, there are no

purulent or any discharges seen on the client’s eyes. No periorbital edema noted,

cornea is transparent and shiny. Ears are of normal findings. Nose is also of

normal findings.

Further more upon the assessment of the throat and the mouth, the

researchers have noted the following manifestations: lips that are dark and dry,

difficulty of swallowing, tongue which deviates towards the right side. Gums are

pale. There are no abnormal findings found upon the assessment of the neck.

The patient does not have any reports of chest pain upon assessment;

there were no presence of murmurs heard upon auscultation of the heart rate.

With the gastrointestinal assessment, abdomen is soft and not tender, there were

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5/5

5/5

0/5

4/5

R L

5 bowel sounds/ min/ quadrant upon auscultation, there were no presence of

organomegaly upon palpation.

The client was observed with no ROM and sensation on the upper left

extremity, there were no presence of edema and with a capillary refill of less than

3 sec, it was also noted that her both lower extremities has scars specifically on

the dorsal right lower extremity. It was also noted that the client has weakness on

the left lower extremity.

January 31, 2009

General Appearance

Patient is wearing a dark blue with floral design clothing, with unkempt hair,

appears weak, conscious, lethargic. She is lying on bed with an ongoing IVF of

#5 D5 0.3 NaCl 500 cc x 20 - 21 µgtts/ min infusing well on the right metacarpal

vein currently at 150 cc level, patient has an indwelling Foley catheter attached to

urine bag with current urine out put of 100 ml and currently undergoing bladder

training.

Patient has the following vital signs:

T= 36° C

P= 63 bpm

R= 18 cpm

BP= 170/60 mmHg

Upon the assessment of her head, the researchers noted a normal finding,

characterized by symmetrical skull, no presence of nodules and lesions, and with

hair properly distributed.

Upon the assessment of the client’s face, most of the findings are of

normal findings characterized by pupils which are equally round in shape,

11

R L

1/55/5

5/5 4/5

reactive to light and accommodation, with her right eyebrows evenly distributed

and symmetrically aligned. Patient has eyelashes of normal growth, with dried

exudates, with a prescribed eyeglasses “200 ya gradu ing salamin na”. No

periorbital edema noted, cornea is transparent and shiny. Ears are of normal

findings. Nose is also of normal findings.

Further more upon the assessment of the throat and the mouth, the

researchers have noted the following manifestations: lips that are dark and dry,

with visible cracking of the lips, difficulty of swallowing, tongue which deviates

towards the right side. Gums are pale. There are no abnormal findings found

upon the assessment of the neck.

The patient does not have any reports of chest pain upon assessment;

there were no presence of murmurs heard upon auscultation of the heart rate.

With the gastrointestinal assessment, abdomen is soft and not tender, there were

5 bowel sounds/ min/ quadrant upon auscultation, there were no presence of

organomegaly upon palpation.

The client was observed with no ROM and sensation on the upper left

extremity, there were no presence of edema and with a capillary refill of less than

3 sec, it was also noted that her both lower extremities has scars specifically on

the dorsal right lower extremity. It was also noted that the client has weakness on

the left lower extremity.

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F. Diagnostic and Laboratory Procedures

DIAGNOSTIC OR LABORATORY PROCEDURES

DATE ORDERED AND DATE

RESULTS IN

INDICATIONS OR PURPOSES

RESULTSNORMAL VALUES

ANALYSIS AND INTERPRETATIO

N

CLINICAL CHEMISTRY

FBS

Date Ordered:1/27/09

Date Results

In:1/28/09

A fasting blood sugar

test measures the amount of sugar in your blood after

you fast for at least eight hours or

overnight. It is a test that is

routinely done in all clients

with possible cardiovascular disorders to

determine blood glucose

levels.

117mg/dL

70- 105 mg/dL

A fasting blood sugar level 117mg/ dL

which is obviously above the

normal limits.This justifies the patients

current health condition of

Type II Diabetes

Mellitus as reflected on

the pathophysiolo

gy.

FBS, Blood: Pre-test:1. Inform the patient that the test is used to assist in the evaluation of fasting

hypoglycemia2. Obtain a history of the patient’s complaints, including a list of known allergens such

as allergy to latex.3. Obtain a history of the patient’s endocrine system and results of previously

performed laboratory tests, surgical procedures, and other diagnostic procedures.4. Note any procedures that can interfere with the test results.5. Obtain a list of medications patient is taking, including herbs, and nutritional

supplements.

Intra-test;1. Ensure that the patient has complied with dietary or medication restrictions and other

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pretesting preparations.2. Instruct the patient to cooperate fully and to follow directions. Direct patient to

breathe normally and to avoid unnecessary movement.3. If the patient has a history of severe allergic reaction to latex, care should be taken

and to avoid the use of equipment containing latex.4. Observe Standard precautions.5. After obtaining the specimen, promptly transport to the laboratory for processing and

analysis.

Post-test:1. Observe venipuncture site for bleeding or hematoma formation. 2. Instruct the patient to report signs and symptoms of hypoglycemia or hyperglycemia.3. Emphasize that good glycemic control delays the onset of and slows the progression

of diabetic retinopathy, nephropathy, and neuropathy.4. Reinforce information regarding the test results and address concerns voiced by the

family or the patient.

Potassium

Date requested

:1/27/09

Date results in:1/28/09

It is checked in order to assess

a known and suspected disorder

associated with renal disease,

glucose metabolism,

trauma or burns.

3.6 mmoL/L

3.5 – 5.3 mmoL/L

The potassium electrolyte level is within normal

range.

Potassium, blood, Before

1. Check the doctor’s order2. Explain the procedure3. Explain the purpose and what to expect4. No food or fluid restrictions

During

1. Do not take the blood sample from hand or arm with receiving IVF2. The tourniquet should be less on a minute3. Do not squeeze the punctured site rightly4. Wipe away the first drop of blood5. Collect 2ml venous blood in a lavender top tube

After

1. Observed and record vital signs.2. Check injection sites for bleeding, infection, tenderness or thrombosis.3. Report untoward reaction to the physician.4. Apply warm compress to ease discomfort, as ordered.5. Encourage relaxation by allowing client to discuss experiences and verbalize

14

feelings.6. Interpret results and provide counsel appropriately. Provide health teachings

regarding proper lifestyle changes and symptoms that may warrant immediate medical attention.

Creatinine

Date requested

:1/27/09

Date results in:1/28/09

The creatinine test is used to

diagnose impaired kidney function and to determine renal

(kidney) damage.

41mg/dL 0.6 – 1.2 mg/dL

The creatinine level is

significantly above the

normal limits which is a

result of renal impairment

related to the client’s active renal disease.

BUA

Date requested

:1/27/09

Date results in:1/28/09

The blood uric acid test

measures the amount of uric acid in a blood

sample. Increased level of uric acid in the blood is

brought by too much uric acid

is being produced or if

the kidneys are not able to

remove it from the blood normally.

8.5 mg/ dL

2.0 – 6.0 mg/dL

The uric acid level is

significantly above the

normal limits this also gives justification to

the deteriorating

function of the renal system.

BUN Date requested

:1/27/09

Date results in:1/28/09

Blood urea nitrogen (BUN) measures the

amount of urea nitrogen, a

waste product of protein

metabolism, in the blood. Urea

is formed by the liver and

64 mg/dL 7-18 mg/ dL

The BUN level is significantly

above the normal limits

which denotes an impairment

in renal function

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carried by the blood to the kidneys for excretion.

Because urea is cleared from

the bloodstream by the kidneys, a test measuring how much urea

nitrogen remains in the blood can be used as a test

of renal function.

However, there are many

factors besides renal disease

that can cause BUN

alterations, including protein

breakdown, hydration

status, and liver failure.

Creatinine, BUN, BUA, Blood,

Prior:

1. Select vein for venipuncture (usually antecubital space).2. Apply tourniquet several inches above intended venipuncture site3. Clean venipuncture site (with povidone iodine or alcohol, allow area to dry).

During:

1. Perform venipuncture by entering the skin with needle at approximately a 15-degree angle to the skin, needle bevel up.

2. If using a Vacutainer, ease tube forward in holder once in the vein. If using a syringe, pull back on the barrel with slow, even tension as blood fills the syringe.

3. Release tourniquet when the blood begins to flow.

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After:

1. After the blood is drawn, place cotton ball over site; withdraw the needle and exert pressure. Apply bandage if needed.

2. Properly dispose contaminated materials.3. Record the date and time of blood collection. Attach a label to each blood tube.4. Relay results to the doctor.

LIPID PROFILE

HDL

Date requested

:1/27/09

Date results in:1/28/09

This is a blood test that

measures a kind of fat

(lipid) in the blood. The HDL

test helps check your risk

for heart disease or

atherosclerosis, which is a hardening,

narrowing, or blockage of the

arteries.

87mg/dL30mg/dL >

The LDL level is within the

normal range

CHOLESTEROL

Date requested

:1/27/09

Date results in:1/28/09

Used to estimate risk of developing a

disease specifically

heart disease. Because high

blood cholesterol has

been associated with

hardening of the arteries,

heart disease and a raised risk of death from heart

attacks.

351 mg/dL

140-250mg/dL

The client has an increased cholesterol

level which is one of the

precipitating factor of the

client’s Hypertension.

LDL Date requested

:1/27/09

Date

The LDL test measures how

much low-density

lipoprotein (LDL) you have in your blood.

219 mg/dL

<178 mg/dL

This is also one of the

factors that aggravates or triggers the

client’s hypertensive

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results in:1/28/09

Too much LDL in the blood

can clog arteries.

episodes.

Triglycerides

A test to determine the

cholesterol level circulating

in the bloodstream

209 mg/dL

10-190mg/dL

This is also one of the

factors that aggravates or triggers the

client’s hypertensive

episodes.

Total Cholesterol Test: (NSG. Implications) Pretest:1. Inform the patient that the test is used to assess and monitor risk for coronary artery

disease.2. Obtain history of the patient’s past health history and previously performed laboratory

tests, surgical procedures, and other diagnostic procedures.3. Instruct the patient to withhold drugs and alcohol known to alter cholesterol levels for

12 to 24 hours before specimen collection.4. Fasting 6 to 12 hours before specimen collection is required if triglyceride

measurements are included; it is recommended if cholesterol levels alone are measured for screening.

Intratest:1. Ensure that the patient has complied with the dietary restrictions and pre testing

precautions.2. If the patient has a history of severe allergic reaction to latex, care should be taken to

avoid the use of equipment containing latex.3. Instruct the client to cooperate fully and to follow directions.4. Observe Standard Precautions.5. Remove the needle and apply pressure dressing over the puncture site.6. Immediately transport the specimen to the laboratory for processing and analysis. Post-test:1. Observe venipuncture site for bleeding or hematoma formation.2. Instruct the patient to reduce intake of foods high in saturated fats and cholesterol

and triglyceride levels. (E.g. red meats, eggs, and dairy products are major sources of saturated fats and cholesterol.

3. Consider social and cultural beliefs and practices of the client.4. Recognize anxiety related to test results. Discuss the implications of abnormal test

results on the patient’s lifestyle. 5. Provide teaching and information regarding the clinical indications of the test results.

BLOOD HEMATOLOGY

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Hemoglobin (Hgb)

Date requested

:1/27/09

Date results in:1/28/09

- to monitor Hgb value in

the RBC- to suggest the

presence of body fluid

deficit due to elevated Hgb

level

8.0mg%12-16 mg

%

The patient having a

decreased hemoglobin

level with accompanying signs of pallor indicates that the client has

anemia.

Hematocrit (Hct)

Date requested

:1/27/09

Date results in:1/28/09

To aid diagnosis of

abnormal states of

hydration, polycythemia and anemia.

- It measures the

concentration of RBC within

the blood volume and is

expressed as a percentage.

27.0 vol%37-47 vol

%

The hematocrit

level is below the normal

range, which denotes a decreased

concentration of RBC in the

blood or hemodilution.

WBC

Date requested

:1/27/09

Date results in:1/28/09

The test is performed to find out how many white

blood cells you have. Your

body produces more white blood cells

when you have an infection or

allergic reaction, even when you are under general

stress

4900/ cu. mm

5-10 x 103mm

The WBC count is below

the normal limits a

decrease or increase in the

WBC count denotes

infection or inflammation.

Neutrophils/ Segmenters

Date requested

:1/27/09

To detect presence of

infection in the body

76% 50-70% The Neutrophils is

above the normal limits

indicating infection.

19

Date results in:1/28/09

Lymphocytes

Date requested

:1/27/09

Date results in:1/28/09

To detect presence of

infection within the body.

24% 25-40%

The number of lymphocytes is

slightly decreased

which indicates infection

Eosinophils

Date requested

:1/27/09

Date results in:1/28/09

To detect presence of

infection within the body.

1% 1-4%

The eosinophils count is within

the normal range

Nursing Implications for Blood Hematology Test: Pretest:1. Inform the patient that the test is used to evaluate numerous conditions inflammation,

infection, and response to chemotherapy.2. Obtain a history of the patient’s complaints (such as allergies and sensitivity to latex.3. Obtain a history of the patient’s gastrointestinal, hematopoietic, immune, and

respiratory systems, as well as results of previously performed laboratory tests, surgical procedures, and other diagnostic procedures.

4. Obtain a list of medications the patient is taking, including herbs, nutritional supplements, and nutraceuticals.

5. Review the procedure with the patient. Explain the duration of the procedure and inform the client that there may be some discomforts during the procedure.

6. Consider the patient’s cultural beliefs and practices and it is important to provide psychological support before, during, and after the procedure.

Intratest:1. Avoid using equipment containing latex if the patient has allergy to it.2. Instruct the patient to cooperate fully and to follow directions. Direct the patient to

breathe normally and to avoid unnecessary movement.3. Observe Standard precautions.4. Remove the needle, and apply a pressure dressing over the puncture site.5. Promptly transport the specimen to the laboratory for processing and analysis.

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Post-test:1. Observe venipuncture site for bleeding or hematoma formation. Apply paper tape or

other adhesive to hold pressure bandage in place.2. Instruct the patient to limit salt intake, alcohol intake and cut down smoking.

3. Reinforce information regarding the test results and address any concerns voiced by the patient or family.

IMAGING

CXR APL

Date requested

:1/27/09

Date results in:1/30/09

X-rays - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. Chest radiographs may depict segmental or lobar infiltrate but they more commonly reveal a diffuse, fine, reticulogranular pattern, much like what is observed in RDS. Pleural effusions may also be observed.

Chest Roentgen

ogram reveals minimal

hazy infiltrates on both lower lung

fields. Heat and

great vessels are of normal

size and configurat

ion.

Hemidiagphragms, sulci, and

other visualized including

chest structures

are unremark

able.

Remarks:Pneumon

itis , bilateral

Normal anatomical feature of the lungs. Without signs of effusion, and other abnormal findings.

The chest x- ray denotes abnormal

features of the patient lungs, it shows that her

both lung parenchyma are inflamed.

Nursing Implication

BEFORE:

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1. Explain the purpose of the CXR to the mother.2. Inform the mother whether they will be transported to the radiology department or

have the x-ray done at bedside (portable CXR).3. Tell the mother that the test will take only a few minutes and is painless

DURING:1. Provide a lead apron for any person who must hold the patient during the procedure.2. Provide extra blankets for patient chilled from exposure during CXR.

AFTER:No aftercare is generally required following a chest x - ray. Immediately following the exam,

the technologist will continue to watch the patient for patient’s respiratory pattern.FECALYSIS

FECALYIS

Date requested

:1/27/09

Date results in:1/30/09

This was done to the patient

as a screening for

abnormalities within the

gastrointestinal tract including bleeding and

parasitic infection.

Color:Brown

Consistency:Soft

Trichiuris:0-1/hpf

Color:Brown

Consistency:Soft

Trichiuris:none

Amoeba:None

Hookworm:None

Pus Cells:None

RBC:None

Bacteria:None

Fecalysis shows that the patient

has a positive parasitic

infestation specifically

trichiuris

Nursing Implication

Prior:1. Explain the procedure to the client in order to gain her 2. Inform the client that there is no need for NPO.3. Educate the patient on the proper way of collecting fecal matter4. Prepare the container for the stool.

During:1. Provide privacy.2. Assist the patient if unable to get her stool sample on her own.3. Instruct the patient to prevent contamination of the stool and not to add water to the

stool specimen, to prevent alteration of results.22

After:1. Continue taking the medications that were stopped prior to the procedure.

URINALYSIS

URINALYSIS

Date requested

:1/27/09

Date results in:1/29/09

This was done to the patient

as a screening for

abnormalities within the

urinary system as well as for

system problems that may manifest through the urinary tract.

Color:Yellow

Appearance:

Clear

Ph: Acidic

Pus Cells:

4-6/HPF

Red Cells:

6-8/HPF

Albumin: 4

Glucose: rare

Color:Yellow

Appearance:

Clear

Ph: Acidic

Pus Cells:none

Red Cells:none

Albumin: negative

Glucose: negative

Urinalysis shows that patient is

manifesting pyuria

indicating infection within the

urinary tract. She also

manifests red blood cells on

her urine indicating a problem on the kidney

filtration; this is supported

by albuminuria

and glucosuria.

Nursing Implication

Prior:5. Explain the procedure to the client in order to gain her 6. Inform the client that there is no need for NPO.7. Educate the patient on the proper way of collecting urine (clean catch midstream

specimen).8. Prepare the container for the urine.

During:4. Provide privacy.5. Assist the patient if unable to get her urine sample on her own.6. Instruct the patient to prevent contamination of the urine and not to add water to the

urine specimen, to prevent alteration of results.

After:1. Refrigerate the specimen.2. Continue taking the medications that were stopped prior to the procedure.

23

III. ANATOMY AND PHYSIOLOGY

The Cardiovascular System

The heart and circulatory system make up

the cardiovascular system. The heart works as a

pump that pushes blood to the organs, tissues,

and cells of the body. Blood delivers oxygen and

nutrients to every cell and removes the carbon

dioxide and waste products made by those cells.

Blood is carried from the heart to the rest of the

body through a complex network of arteries,

arterioles, and capillaries. Blood is returned to the

heart through venules and veins.

The one-way circulatory system carries

blood to all parts of the body. This process of

blood flow within the body is called circulation.

Arteries carry oxygen-rich blood away from the heart, and veins carry oxygen-poor

blood back to the heart. In pulmonary circulation, though, the roles are switched. It is the

24

pulmonary artery that brings oxygen-poor blood into the lungs and the pulmonary vein

that brings oxygen-rich blood back to the heart. (Rod R. Seeley et. al, Essentials of

Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

Twenty major arteries make a path through the tissues, where they branch into

smaller vessels called arterioles. Arterioles further branch into capillaries, the true

deliverers of oxygen and nutrients to the cells. Most capillaries are thinner than a hair. In

fact, many are so tiny, only one blood cell can move through them at a time. Once the

capillaries deliver oxygen and nutrients and pick up carbon dioxide and other waste,

they move the blood back through wider vessels called venules. Venules eventually join

to form veins, which deliver the blood back to the heart to pick up oxygen.

Vasoconstriction or the spasm of smooth muscles around the blood vessels causes and

decrease in blood flow but an increase in pressure. In vasodilation, the lumen of the

blood vessel increase in diameter thereby allowing increase in blood flow. There is no

tension on the walls of the vessels therefore, there is lower pressure. (Rod R. Seeley et.

al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

Various external factors also cause changes in blood pressure and pulse rate. An

elevation or decline may be detrimental to health. Changes may also be caused or

aggravated by other disease conditions existing in other parts of the body.

The blood is part of the circulatory system. Whole blood contains three types of

blood cells, including: red blood cells, white blood cells and platelets.

These three types of blood cells are mostly manufactured in the bone marrow of

the vertebrae, ribs, pelvis, skull, and sternum. These cells travel through the circulatory

system suspended in a yellowish fluid called plasma. Plasma is 90% water and contains

nutrients, proteins, hormones, and waste products. Whole blood is a mixture of blood

cells and plasma.

Red blood cells (also called erythrocytes) are shaped like slightly indented,

flattened disks. Red blood cells contain an iron-rich protein called hemoglobin. Blood

gets its bright red color when hemoglobin in red blood cells picks up oxygen in the

25

lungs. As the blood travels through the body, the hemoglobin releases oxygen to the

tissues. The body contains more red blood cells than any other type of cell, and each

red blood cell has a life span of about 4 months. Each day, the body produces new red

blood cells to replace those that die or are lost from the body.

White blood cells (also called leukocytes) are a key part of the body's system for

defending itself against infection. They can move in and out of the bloodstream to reach

affected tissues. The blood contains far fewer white blood cells than red cells, although

the body can increase production of white blood cells to fight infection. There are

several types of white blood cells, and their life spans vary from a few days to months.

New cells are constantly being formed in the bone marrow.

Several different parts of blood are involved in fighting infection. White blood cells

called granulocytes and lymphocytes travel along the walls of blood vessels. They fight

bacteria and viruses and may also attempt to destroy cells that have become infected or

have changed into cancer cells. (Rod R. Seeley et. al, Essentials of Anatomy and

Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

Certain types of white blood cells produce antibodies, special proteins that

recognize foreign materials and help the body destroy or neutralize them. When a

person has an infection, his or her white cell count often is higher than when he or she

is well because more white blood cells are being produced or are entering the

bloodstream to battle the infection. After the body has been challenged by some

infections, lymphocytes remember how to make the specific antibodies that will quickly

attack the same germ if it enters the body again.

Platelets (also called thrombocytes) are tiny oval-shaped cells made in the bone

marrow. They help in the clotting process. When a blood vessel breaks, platelets gather

in the area and help seal off the leak. Platelets survive only about 9 days in the

bloodstream and are constantly being replaced by new cells.

Blood also contains important proteins called clotting factors, which are critical to

the clotting process. Although platelets alone can plug small blood vessel leaks and

26

temporarily stop or slow bleeding, the action of clotting factors is needed to produce a

strong, stable clot.

Platelets and clotting factors work together to form solid lumps to seal leaks,

wounds, cuts, and scratches and to prevent bleeding inside and on the surfaces of our

bodies. The process of clotting is like a puzzle with interlocking parts. When the last part

is in place, the clot is formed.

When large blood vessels are cut the body may not be able to repair itself

through clotting alone. In these cases, dressings or stitches are used to help control

bleeding.

In addition to the cells and clotting factors, blood contains other important

substances, such as nutrients from the food that has been processed by the digestive

system. Blood also carries hormones released by the endocrine glands and carries

them to the body parts that need them. (Rod R. Seeley et. al, Essentials of Anatomy

and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

Blood is essential for good health because the body depends on a steady supply

of fuel and oxygen to reach its billions of cells. Even the heart couldn't survive without

blood flowing through the vessels that bring

nourishment to its muscular walls. Blood also

carries carbon dioxide and other waste

materials to the lungs, kidneys, and digestive

system, from where they are removed from

the body. (Rod R. Seeley et. al, Essentials of

Anatomy and Physiology 5th edition,

McGraw-Hill Int. NY 10020 2005)

The Endocrine System

The endocrine system is made up of

glands that produce and secrete hormones.

These hormones regulate the body’s growth, 27

metabolism (the physical and chemical processes of the body), and sexual development

and function. The hormones are released into the bloodstream and may affect one or

several organs throughout the body. (Rod R. Seeley et. al, Essentials of Anatomy and

Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

  The role of the endocrine system is to maintain the body in balance through the

release of hormones which transfer information and instructions from one set of cells to

another. Many different hormones move through the bloodstream, but each type of

hormone is designed to affect only certain cells.

Hormones are chemical messengers created by the body. They transfer

information from one set of cells to another to coordinate the functions of different parts

of the body. Hormones can act on some specific cells because they themselves do not

actually cause an effect. It is only through binding with a receptor (part of the cell

specifically designed to recognize the hormone) like a key into a lock - that causes a

chain reaction to occur, changing the activity of the cells. If a cell does not have a

receptor for a hormone then there will be no effect. Also, there can be different

receptors for the same hormone, and so the same hormone can have different effects

on different cells. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5 th

edition, McGraw-Hill Int. NY 10020 2005)

  The major glands of the endocrine system are the pituitary, thyroid, parathyroids,

adrenals, pineal body, thymus, and the reproductive organs (ovaries and testes). The

pancreas is also a part of this system; it has a role in hormone production as well as in

digestion. A gland is a group of cells that produces and secretes chemicals. A gland

selects and removes materials from the blood, processes them, and secretes the

finished chemical product for use somewhere in the body. The endocrine gland cells

release a hormone into the blood stream for distribution throughout the entire body.

These hormones act as chemical messengers and can alter the activity of many organs

at once. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5 th edition,

McGraw-Hill Int. NY 10020 2005)

28

  The hypothalamus controls all the processes undergone by the anterior and

posterior pituitary glands. It initiates the production of hormones by the APG. The APG

is controlled by releasing hormones which are chemical signals produced by the nerve

cells of the hypothalamus, causing either stimulation or inhibition of hormone

production.  Secretion of hormones by the PPG is controlled by nervous system

stimulation of nerve cells in the hypothalamus. Parathyroid glands secrete parathyroid

hormone which is essential for the regulation of blood calcium levels. Adrenal glands

produce epinephrine and norepinephrine which are fight-or-flight hormones that prepare

the body for vigorous physical activity. Testes and ovaries produce hormones that are

responsible for secondary sex characteristics, spermatogenesis, and oogenesis. The

thymus gland secretes thymosin which aids in the synthesis of WBC for fighting

infection. This gland decreases in size in some older adults. The pineal body releases

melatonin that is thought to decrease the secretion of LSH & FSH by decreasing the

release of hypothalamic-releasing hormones. The thyroid gland, located on either side

of the trachea, is controlled by the thyroid stimulating hormone releases by the anterior

pituitary gland, which was initially stimulated by the TSH releasing hormone from the

hypothalamus. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition,

McGraw-Hill Int. NY 10020 2005)

 The pancreas is also part of the body's hormone-secreting system, even though

it is also associated with the digestive system because it produces and secretes

digestive enzymes. The pancreas produces two important hormones, insulin and

glucagon. They work together to maintain a steady level of glucose, or sugar, in the

blood and to keep the body supplied with fuel to produce and maintain stores of energy.

The pancreas completes the job of breaking down protein, carbohydrates, and fats

using digestive juices of pancreas combined with juices from the intestines, secretes

hormones that affect the level of sugar in the blood, and produces chemicals that

neutralize stomach acids that pass from the stomach into the small intestine by using

substances in pancreatic juice. It contains Islets of Langerhans, which are tiny groups of

specialized cells that are scattered throughout the organ. 

29

 In humans, the pancreas is a 15-25 cm (6-10 inch) elongated organ in the

abdomen adjacent to the small intestine and lies toward the back. It has three regions: a

head (abuts a part of the duodenum), body (at the level of L2 of the spine) and tail

(extends toward the spleen). (Rod R. Seeley et. al, Essentials of Anatomy and

Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

 The pancreatic duct (also called the duct of Wirsung) runs the length of the

pancreas and empties into the second part of the duodenum at the ampulla of Vater.

The common bile duct usually joins the pancreatic duct at or near this point. Many

people also have a small accessory duct, the duct of Santorini, which extends from the

main duct more upstream (towards the tail) to the duodenum, joining it more proximal

than the ampulla of Vater.

 The pancreas is supplied arterially by the Pancreaticoduodenal arteries and the

splenic artery: the splenic artery supplies the neck, body, and tail of the pancreas; the

superior mesenteric artery provides the inferior pancreaticoduodenal artery; and the

gastroduodenal artery provides the superior pancreaticoduodenal artery.

 Venous drainage is via the pancreaticoduodenal veins which end up in the portal

vein. The splenic vein passes posterior to the pancreas but is said to not drain the

pancreas itself. The portal vein is formed by the union of the superior mesenteric vein

and splenic vein posterior to the neck of the pancreas. In some people (some books say

40% of people); the inferior mesenteric vein also joins with the splenic vein behind the

pancreas (in others it simply joins with the superior mesenteric vein instead). (Rod R.

Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY

10020 2005)

 The pancreas is a compound gland in the sense that it is composed of both

exocrine and endocrine tissues. The exocrine function of the pancreas involves the

synthesis and secretion of pancreatic juices. The endocrine function resides in the

million or so cellular islands (the islets of Langerhans) embedded between the exocrine

units of the pancreas. Beta cells of the islands secrete insulin, which helps control

30

carbohydrate metabolism. Alpha cells of the islets secrete glucagon that counters the

action of insulin.

There are four main types of cells in the islets of Langerhans. They are relatively

difficult to distinguish using standard staining techniques, but they can be classified by

their secretion: Beta cells secretes Insulin and Amylin lower blood sugar, Alpha Cells

secretes Glucagon raise blood sugar, Delta Cells secretes Somastotatin inhibit

endocrine pancreas, PP Cells secretes pancreatic polypeptide which inhibits exocrine

pancreas

The islets are a compact collection of endocrine cells arranged in clusters and

cords and are crisscrossed by a dense network of capillaries. The capillaries of the

islets are lined by layers of endocrine cells in direct contact with vessels, and most

endocrine cells are in direct contact with blood vessels, by either cytoplasmic processes

or by direct apposition. There are two main types of exocrine pancreatic cells,

responsible for two main classes of secretions: Centroacinar cells secretes bicarbonate

ions, Basophilic cells secretes digestive enzymes such as pancreatic amylase,

pancreatic lipase. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5 th

edition, McGraw-Hill Int. NY 10020 2005)

The Nervous System

The nervous system is a network of

specialized cells that communicate information

about an animals surroundings and its self, it

processes this information and causes reactions

in other parts of the body. It is composed of

neurons and other specialized cells called glia,

that aid in the function of the neurons.

The nervous system is divided broadly

into two categories; the peripheral nervous

system and the central nervous system. Neurons

31

generate and conduct impulses between and within the two systems. The peripheral

nervous system is composed of sensory neurons and the neurons that connect them to

the nerve cord, spinal cord and brain, which make up the central nervous system. In

response to stimuli, sensory neurons generate and propagate signals to the central

nervous system which then process and conduct back signals to the muscles and

glands. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5 th edition,

McGraw-Hill Int. NY 10020 2005)

The neurons of the nervous systems of animals are interconnected in complex

arrangements and use electrochemical signals and neurotransmitters to transmit

impulses from one neuron to the next. The interaction of the different neurons form

neural circuits that regulate an organism’s perception of the world and what is going on

with its body, thus regulating its behavior. Nervous systems are found in many

multicellular animals but differ greatly in complexity between species

The central nervous system (CNS) is the largest part of the nervous system, and

includes the brain and spinal cord. The spinal cavity holds and protects the spinal cord,

while the head contains and protects the brain. The CNS is covered by the meninges, a

three layered protective coat. The brain is also protected by the skull, and the spinal

cord is also protected by the vertebrae. (Rod R. Seeley et. al, Essentials of Anatomy

and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

Brain is a part of the Central Nervous System, it plays a central role in the

control of most bodily functions, including awareness, movements, sensations,

thoughts, speech, and memory. Some reflex movements can occur via spinal cord

pathways without the participation of brain structures. (Rod R. Seeley et. al, Essentials

of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

The cerebrum is the largest part of the brain and controls voluntary actions,

speech, senses, thought, and memory. 

The surface of the cerebral cortex has grooves or infoldings (called sulci), the largest of

which are termed fissures. Some fissures separate lobes.

32

The convolutions of the cortex give it a wormy appearance. Each convolution is

delimited by two sulci and is also called a gyrus (gyri in plural). The cerebrum is divided

into two halves, known as the right and left hemispheres. A mass of fibers called the

corpus callosum links the hemispheres. The right hemisphere controls voluntary limb

movements on the left side of the body, and the left hemisphere controls voluntary limb

movements on the right side of the body. Almost every person has one dominant

hemisphere. Each hemisphere is divided into four lobes, or areas, which are

interconnected.

The frontal lobes are located in the front of the brain and are responsible for

voluntary movement and, via their connections with other lobes, participate in the

execution of sequential tasks; speech output; organizational skills; and certain

aspects of behavior, mood, and memory.

The parietal lobes are located behind the frontal lobes and in front of the occipital

lobes. They process sensory information such as temperature, pain, taste, and

touch. In addition, the processing includes information about numbers,

attentiveness to the position of one’s body parts, the space around one’s body,

and one's relationship to this space.

The temporal lobes are located on each side of the brain. They process memory

and auditory (hearing) information and speech and language functions.

The occipital lobes are located at the back of the brain. They receive and process

visual information (Rod R. Seeley et. al, Essentials of Anatomy and Physiology

5th edition, McGraw-Hill Int. NY 10020 2005)

33

The urinary system is system of organs that

produces and excretes urine from the body. Urine is a

transparent yellow fluid containing unwanted wastes, mostly

excess water, salts, and nitrogen compounds. The major

organs of the urinary system are the kidneys, a pair of

bean-shaped organs that continuously filter substances

from the blood and produce urine. Urine flows from the

kidneys through two long, thin tubes called ureters. With the

aid of gravity and wavelike contractions, the ureters

transport the urine to the bladder, a muscular vessel. The

normal adult bladder can store up to about 0.5 liter (1 pt) of

urine, which it excretes through the tubelike urethra.

An average adult produces about 1.5 liters of urine

each day, and the body needs, at a minimum, to excrete

about 0.5 liter of urine daily to get rid of its waste products.

Excessive or inadequate production of urine may indicate illness and doctors often use

urinalysis (examination of a patient’s urine) as part of diagnosing disease. For instance,

the presence of glucose, or blood sugar, in the urine is a sign of diabetes mellitus;

bacteria in the urine signal an infection of the urinary system; and red blood cells in the

urine may indicate cancer of the urinary tract. (Rod R. Seeley et. al, Essentials of

Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

Kidney

s are

paired or gans w

hose fun ctions

include

34

removing waste products from the blood and regulating the amount of fluid in the body.

The basic units of the kidneys are microscopically thin structures called nephrons, which

filter the blood and cause wastes to be removed in the form of urine. Together with the

bladder, two ureters, and the single urethra, the kidneys make up the body’s urinary

system. Human beings, as well as members of all other vertebrate species, typically

have two kidneys. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th

edition, McGraw-Hill Int. NY 10020 2005)

Like kidney beans, the body’s kidneys are dark red in color and have a shape in

which one side is convex, or rounded, and the other is concave, or indented. The

kidneys of adult humans are about 10 to 13 cm (4 to 5 in) long and about 5 to 7.5 cm (2

to 3 in) wide—about the size of a computer mouse.

The kidneys lie against the rear wall of the abdomen, on either side of the spine.

They are situated below the middle of the back, beneath the liver on the right and the

spleen on the left. Each kidney is encased in a transparent, fibrous membrane called a

renal capsule, which helps protect it against trauma and infection. The concave part of

the kidney attaches to two of the body’s crucial blood vessels—the renal artery and the

renal vein—and the ureter, a tubelike structure that carries urine to the bladder. (Rod R.

Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY

10020 2005)

A primary function of kidneys is the removal of poisonous wastes from the blood.

Chief among these wastes are the nitrogen-containing compounds urea and uric acid,

which result from the breakdown of proteins and nucleic acids. Life-threatening illnesses

occur when too many of these waste products accumulate in the bloodstream.

Fortunately, a healthy kidney can easily rid the body of these substances.

In addition to cleaning the blood, the kidneys perform several other essential

functions. One such activity is regulation of the amount of water contained in the blood.

35

This process is influenced by antidiuretic hormone (ADH), also called vasopressin,

which is produced in the hypothalamus (a part of the brain that regulates many internal

functions) and stored in the nearby pituitary gland. Receptors in the brain monitor the

blood’s water concentration. When the amount of salt and other substances in the blood

becomes too high, the pituitary gland releases ADH into the bloodstream. When it

enters the kidney, ADH makes the walls of the renal tubules and collecting ducts more

permeable to water, so that more water is reabsorbed into the bloodstream. (Rod R.

Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY

10020 2005)

The hormone aldosterone, produced by the adrenal glands, interacts with the

kidneys to regulate the blood’s sodium and potassium content. High amounts of

aldosterone cause the nephrons to reabsorb more sodium ions, more water, and fewer

potassium ions; low levels of aldosterone have the reverse effect. The kidney’s

responses to aldosterone help keep the blood’s salt levels within the narrow range that

is best for crucial physiological activities. (Rod R. Seeley et. al, Essentials of Anatomy

and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

Aldosterone also helps regulate blood pressure. When blood pressure starts to

fall, the kidney releases an enzyme (a specialized protein) called renin, which converts

a blood protein into the hormone angiotensin. This hormone causes blood vessels to

constrict, resulting in a rise in blood pressure. Angiotensin then induces the adrenal

glands to release aldosterone, which promotes sodium and water to be reabsorbed,

further increasing blood volume and blood pressure.

The kidney also adjusts the body's acid-base balance to prevent such blood

disorders as acidosis and alkalosis, both of which impair the functioning of the central

nervous system. If the blood is too acidic, meaning that there is an excess of hydrogen

ions, the kidney moves these ions to the urine through the process of tubular secretion.

An additional function of the kidney is the processing of vitamin D; the kidney converts

this vitamin to an active form that stimulates bone development. (Rod R. Seeley et. al,

Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

36

Several hormones are produced in the kidney. One of these, erythropoietin,

influences the production of red blood cells in the bone marrow. When the kidney

detects that the number of red blood cells in the body is declining, it secretes

erythropoietin. This hormone travels in the bloodstream to the bone marrow, stimulating

the production and release of more red cells. (Rod R. Seeley et. al, Essentials of

Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

The respiratory system generally includes tubes, such as the bronchi, used to carry air

to the lungs, where gas exchange takes place. A diaphragm pulls air in and pushes it

out. Respiratory systems of various types are found in a wide variety of organisms.

Even trees have respiratory systems.

In humans, the respiratory system

consists of the airways, the lungs, and the

respiratory muscles that mediate the

movement of air into and out of the body.

Within the alveolar system of the lungs,

molecules of oxygen and carbon dioxide

are passively exchanged, by diffusion,

between the gaseous environment and

the blood. Thus, the respiratory system

facilitates oxygenation of the blood with a

concomitant removal of carbon dioxide

and other gaseous metabolic wastes from

the circulation. The system also helps to maintain the acid-base balance of the body 37

through the efficient removal of carbon dioxide from the blood. (Rod R. Seeley et. al,

Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

1. The SINUSES (frontal, maxillary, and sphenoidal) are hollow spaces in the bones

of the head. Small openings connect them to the nose. The functions they serve include

helping to regulate the temperature and humidity of air breathed in, as well as to lighten

the bone structure of the head and to give resonance to the voice.

2. The NOSE (nasal cavity) is the preferred entrance for outside air into the respiratory

system. The hairs that line the wall are part of the air-cleaning system.

3. Air also enter through the MOUTH (oral cavity), especially in people who have a

mouth-breathing habit or whose nasal passages may be temporarily obstructed, as by a

cold or during heavy exercise.

4. The ADENOIDS are lymph tissue at the top of the throat. When they enlarge and

interfere with breathing, they may be removed. The lymph system, consisting of nodes

(knots of cells) and connecting vessels, carries fluid throughout the body. This system

helps to resist body infection by filtering out foreign matter, including germs, and

producing cells (lymphocytes) to fight them.

5. The TONSILS are lymph nodes in the wall of the throat (pharynx) that often become

infected. They are part of the germ-fighting system of the body.

6. The THROAT (pharynx) collects incoming air from the nose and mouth and passes it

downward to the windpipe (trachea).

7. The EPIGLOTTIS is a flap of tissue that guards the entrance to the windpipe

(trachea), closing when anything is swallowed that should go into the esophagus and

stomach.

8. The VOICE BOX (larynx) contains the vocal chords. It is the place where moving air

being breathed in and out creates voice sounds.

9. The ESOPHAGUS is the passage leading from the mouth and throat to the stomach.

38

10. The WINDPIPE (trachea) is the passage leading from the throat (pharynx) to the

lungs.

11. The LYMPH NODES of the lungs are found against the walls of the bronchial tubes

and windpipe.

12. The RIBS are bones supporting and protecting the chest cavity. They move to a

limited degree, helping the lungs to expand and contract.

13. The windpipe divides into the two main BRONCHIAL TUBES, one for each lung,

which subdivide into each lobe of the lungs. These, in turn, subdivide further.

14. The right lung is divided into three LOBES, or sections. Each lobe is like a balloon

filled with sponge-like tissue. Air moves in and out through one opening -- a branch of

the bronchial tube.

15. The left lung is divided into two LOBES.

16. The PLEURA are the two membranes, actually one continuous one folded on itself,

that surround each lobe of the lungs and separate the lungs from the chest wall.

17. The bronchial tubes are lines with CILIA (like very small hairs) that have a wave-like

motion. This motion carried MUCUS (sticky phlegm or liquid) upward and out into the

throat, where it is either coughed up or swallowed. The mucus catches and holds much

of the dust, germs, and other unwanted matte that has invaded the lungs. You get rid of

this matter when you cough, sneeze, clear your throat or swallow.

18. The DIAPHRAGM is the strong wall of muscle that separates the chest cavity from

the abdominal cavity. By moving downward, it creates suction in the chest to draw in air

and expand the lungs.

19. The smallest subdivisions of the bronchial tubes are called BRONCHIOLES, at the

end of which are the air sacs or alveoli (plural of alveolus).

20. The ALVEOLI are the very small air sacs that are the destination of air breathed in.

The CAPILLARIES are blood vessels that are imbedded in the walls of the alveoli. 39

Blood passes through the capillaries, brought to them by the PULMONARY ARTERY

and taken away by the PULMONARY VEIN. While in the capillaries the blood gives off

carbon dioxide through the capillary wall into the alveoli and takes up oxygen from the

air in the alveoli. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th

edition, McGraw-Hill Int. NY 10020 2005)

Mechanics of Breathing

To take a breath in, the external intercostal muscles contract, moving the ribcage up

and out. The diaphragm moves down at the same time, creating negative pressure

within the thorax. The lungs are held to the thoracic wall by the pleural membranes, and

so expand outwards as well. This creates negative pressure within the lungs, and so air

rushes in through the upper and lower airways.

Expiration is mainly due to the natural elasticity of the lungs, which tend to collapse if

they are not held against the thoracic wall. This is the mechanism behind lung collapse

if there is air in the pleural space (pneumothorax). (Rod R. Seeley et. al, Essentials of

Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

Physiology of Gas Exchange

Each branch of the bronchial tree eventually sub-divides to form

very narrow terminal bronchioles, which terminate in the alveoli.

There are many millions of alveloi in each lung, and these are

the areas responsible for gaseous exchange, presenting a

massive surface area for exchange to occur over.

Each alveolus is very closely associated with a network of

capillaries containing deoxygenated blood from the pulmonary

artery. The capillary and alveolar walls are very thin, allowing

rapid exchange of gases by passive diffusion along concentration gradients.

CO2 moves into the alveolus as the concentration is much lower in the alveolus than in

the blood, and O2 moves out of the alveolus as the continuous flow of blood through the 40

capillaries prevents saturation of the blood with O2 and allows maximal transfer across

the membrane. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition,

McGraw-Hill Int. NY 10020 2005)

IV. THE PATIENT AND HIS ILLNESS

A. PATHOPHYSIOLOGY (BOOK BASED)

41

Production of glucose from protein

and fat stores

Production of glucose from protein

and fat stores

Wasting of lean body mass

Wasting of lean body mass

Weight lossWeight loss

FatigueFatigue

AcidosisAcidosis

Acetone breathAcetone breath

Inc. KetonesInc. Ketones

Impaired immune function

(decrease level of morphonuclear

leukocytes)

Inc. serum glucose level

Glycoprotein cell wall deposits

Inc. osmolarity due to glucose

Destruction of alpha and beta cells of the pancreas

Failure to produce insulin Production of excess glucagon

Polydipsia Polyphagia Polyuria

Weight Loss

Modifiable Factors Non Modifiable Factors

Age, Family History of CVA, Family History of DM, Sex

(Men), Race

Smoking, Obesity, Hypertension, High Cholesterol Level, Excessive Alcohol Consumption, Drug

Addiction, High Dose of estrogen OC, Diabetes Mellitus, Atrial Fibrillation, Type A personality,

Sedentary Life Style

42

Diabetic Nephropathy

Accelerated atherosclerosis

Hypertension

Increase LDL levels

Renal Disease

Small vessel disease

Neuropathy

Infection Delayed wound healing

Symmetrical loss of protective sensation

Numbness and tingling

in the extremities

Wasting of intrinsic muscle

Charcot changes in

joints

Autonomic neuropathy

Dry cracked skin

Gastro paresis

Impotence

Neurogenic bladder

Diabetic Retinopathy

Loss of vision Blindness

Cerebral ischemiaCerebral ischemia

Long term Eschemia

(>10-15mins)

Long term Eschemia

(>10-15mins)

Short term Eschemia

(<10-15mins)

Short term Eschemia

(<10-15mins)

Temporary Deficit

Temporary Deficit

Permanent Deficit

Permanent Deficit

Decreased Tissue perfusion (brain)

Decreased Tissue perfusion (brain)

HemiparesisHemiparesis

Loss of speechLoss of speech

Hemisensory lossHemisensory loss

Cerebral HypoxiaCerebral Hypoxia

Syncope/ VertigoSyncope/ Vertigo

CEREBROVASCULAR ACCIDENT

CEREBROVASCULAR ACCIDENT

ThrombusThrombus

EmboliEmboli

No permanent

damage

No permanent

damage

Irreversible damage

Irreversible damage

MID CEREBRAL ARTERY

MID CEREBRAL ARTERY

ANTERIOR CEREBRAL A.

ANTERIOR CEREBRAL A.

POSTERIOR CEREBRAL A.

POSTERIOR CEREBRAL A.

VERTEBROBASILAR ARTERY

VERTEBROBASILAR ARTERY

Source: Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005

B. PATHOPHYSIOLOGY (CLIENT BASED)

43Impaired immune

function (decrease level of

morphonuclear leukocytes)

Inc. serum glucose level

Glycoprotein cell wall deposits

Inc. osmolarity due to glucose

Destruction of alpha and beta cells of the pancreas

Failure to produce insulin Production of excess glucagon

Polyuria

Modifiable Factors Non Modifiable Factors

Production of glucose from protein

and fat stores

Wasting of lean body mass Fatigue

Hemiparesis/ Hemiplegia

Aphasia

DysarthiaDysphagia

Apraxia

Visual Changes

Ataxia

Agnosia Hemisensory loss

Horner’s Syndrome

Unilarteral Neglect

Incontinence

Hypertension (BP-200/100 -01/27/09), High Cholesterol Level (Total Chol: 351), Diabetes

Mellitus (Diagnosed with since 2004)

Age (58 yrs. Old), Family History of Cardiovascular diseases

(Mother of the patient died from heart attack), Family History of

DM,

Pneumonitis- radiology report (01-30-09)

FBS: 117 mg/dl (01/28/09)

01/29/09 -01/31/09

01/29/09 -01/31/09

Smoking (23 pack years)

Source: Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005

44

Accelerated atherosclerosis

Hypertension

Increase LDL levelsRenal

Affectation

Small vessel disease

Infection Delayed wound healing

Diabetic Retinopathy

Blurred Vision

Diabetic Nephropathy

Proteinuria

Pus Cell

Glucosuria

Cerebral ischemia

Short term Eschemia

(<10-15mins)

Temporary Deficit

No permanent

damage

Decreased Tissue perfusion (brain)

Hemiparesis

Slurred speech

Hemisensory loss

Cerebral HypoxiaVertigo

CEREBROVASCULAR ACCIDENT

ThrombusThrombus

EmboliEmboli

UrinalysisAlbumin: highSugar: rare

Pus cells: 46 /hpfRBC: 68 /hpf

(01/29/09)

BP- 200/100 (01/27/09)

Lab results:Total Chol: 351

HDL: 87LDL: 219

Triglycerides: 209(1/28/09)

01/27/09

01/27/09

01/27/09

01/27/09

01/27/09 -01/31/09

Decreased Production of Erythropoeitin

Decreased RBC production in the

bone marrowLab results:

Hemoglobin: 8 (F: 12-16)Hematocrit: 27 (F: 37-

47)(01/28/09)

Lab results:WBC: 4,900 Normal:

(5-10x103)(01/28/09)

Anemia

B. SYNTHESIS OF THE DISEASE

B.1. DEFINITION OF DISEASE

Stroke is a term used to describe neurologic changes caused by an interruption

in the blood supply to part of the brain. Two major types of stroke are ischemic and

hemorrhagic. Ischemic stroke is caused by thrombotic or embolic blockage of blood flow

to the brain. Bleeding into the brain tissue or the subarachnoid space causes a

hemorrhagic stroke. Ischemic strokes account for about 83% of all strokes. The

remaining 17% of strokes are hemorrhagic.

Cerebrovascular disorders are the third leading cause of death in United States

and account for about 164, 000 mortalities

annually. An estimated 550,000 strokes people 45

Hemiparesis (left upper extremities) Hemiplegia (left

lower extremities)

DysarthiaDysphagia

Apraxia

Ataxia Hemisensory loss Left upper extremities

MID CEREBRAL ARTERY

ANTERIOR CEREBRAL A.

POSTERIOR CEREBRAL A.

VERTEBROBASILAR ARTERY

01/29/09 -01/31/09

01/29/09 -01/31/09

01/29/09 -01/31/0901/29/09 -01/31/09

01/29/09 -01/31/09

01/29/09 -01/31/09

experience a stroke each year. When second strokes are considered in the estimates,

the incidence increases to 700, 000 per year in the united States alone. Stroke is a

leading cause of adult disability and leading primary diagnosis for long term care. More

than four million stroke survivors are living with varying degrees of disability in the

United States. Along with a high mortality rate, strokes produce significant morbidity in

people who survive them. (Joyce M. Black et al Medical Surgical Nursing 7th edition

Elsevier Suanders 2005)

Vascular Disease which includes C.V.A. is the second leading cause of death in

the Philippines with a total of 51,680 according to DOH 2004. Along with this are 37,092

who survived with it. (http://www.doh.gov.ph/kp/statistics/morbidity)

New therapies can now prevent or limit the extent can now prevent or limit the

extent of damage to brain tissue caused by acute ischemic stroke. Thrombolytic therapy

must be administered as soon as possible after onset of the stroke; a treatment window

3 hours from the onset of manifestations has been established. To convey this sense of

urgency regarding the evaluation and treatment of stroke, health care professionals now

refer to stroke as brain attack. Public education is focused on prevention, recognition of

manifestation, and early treatment of brain attack. (Joyce M. Black et al Medical

Surgical Nursing 7th edition Elsevier Suanders 2005)

Diabetes Mellitus is a chronic systemic disease characterized by either a

deficiency of insulin or a decreased ability of the body to use insulin Diabetes mellitus is

sometimes referred to as “high sugars” by both clients and health care providers. The

notion of associating sugar with diabetes is appropriate because the passage of large

amounts of sugar-laden urine is characteristic of poorly controlled diabetes. However

high levels of blood glucose are only one component of the pathologic process and

clinical manifestation associated with DM. DM can be associated serious complications,

but people with diabetes can take preventive measures to reduce the likelihood of such

occurrences. (Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier

Suanders 2005)

46

B.2. Modifiable and Non Modifiable Factors (Book Based)

1. Modifiable

a. Smoking –nicotine content of cigarettes causes vasoconstriction there by resulting

hypertension which may lead to CVA.

b. Hypertension –this is due to plaque deposits on the wall of the arteries which causes

narrowing of the blood vessel thereby causing hypertension which may lead to

hemorrhagic stroke.

c. Obesity –This is due to increase cholesterol in the body which may contribute plaque

formation that will narrow the blood vessel or may cause thrombus formation.

d. Hyperlipidemia –too much lipid in the blood may cause increase plaque formation

which may cause thrombus formation.

e. Drug addiction –This may cause vasopasm, hypertension, hypercoagulability and

cerebral eschemia which may cause CVA.

f. Excessive alcohol consumption –heavy alcohol consumption increases one’s risk of a

stroke, light or moderate alcohol may protect against ischemic stroke.

(Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005)

47

g. High dose Estrogen Oral Contraceptives –increases the risk of stroke in women.

h. Diabetes Mellitus –The mechanism is related to macrovascular changes in people

with diabetes mellitus. There is an increase viscousity of blood which may cause

formation of thrombus formation.

i. Atrial fibrillation –pulling of blood from poorly emptying atrial which leads to formation

of tiny clots in Left atrium which can move on the cerebral circulation.

j. Type A personality –stress causes hypertension thereby increasing chance of having

hemorrhagic stroke.

k. Sedentary lifestyle –increase of having DM and Obesity which one of the factors of

having CVA

(Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005)

2. Non-Modifiable

a. Age –Intracranial hemorrhage is most often secondary to hypertension and is most

common after age 50 years.

b. Family history of CVA – Family history of stroke increase one’s risk

48

c. Family history of DM –Family which has history of DM especially type 2 is high risk of

having stroke due to accelerated atherosclerosis.

d. Sex (Male) –Incidence of stroke in men is slightly higher than that of women.

e. Race – (more prevalent among African Americans than whites or Hispanics)

(Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005)

SIGNS AND SYMPTOMS (Book Based)

DIABETES MELLITUS

HYPERGLYCEMIA (INCREASED BLOOD SUGAR LEVEL)

Diabetes Mellitus type II may be due to lack of physiologically active insulin that

stimulates glucose uptake in the muscles and tissues. Therefore, it leads to an

accumulation of glucose in the intravascular space. The glucose is not utilized by the

body and it remains in the blood stream.

POLYURIA

49

Polyuria is an increased frequency of urination. This may be due to the osmotic diuretic

effect of the glucose, wherein it attracts water during urination.

When you have diabetes, excess sugar (glucose) builds up in your blood. Your kidneys

are forced to work overtime to filter and absorb the excess sugar. If your kidneys can't

keep up, the excess sugar is excreted into your urine along with fluids drawn from your

tissues. This triggers more frequent urination, which may leave you dehydrated.

POLYDIPSIA

Polydipsia is an increased thirst and fluid intake. This may be due to the activation of

the thirst center in the hypothalamus resulting from the intracellular dehydration or

volume depletion caused by excessive urine production.

POLYPHAGIA

Increased hunger and food intake. Because glucose cannot enter cells of the satiety

center of the brain without insulin, the satiety center in the hypothalamus is stimulated

resulting in a “hunger sensation” as if there were very little blood glucose, resulting in an

exaggerated appetite.

BODY MALAISE

This is due to the decreased glucose uptake by the tissues leading to decreased energy

production.

(Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005)

GLYCOSURIA

50

The kidney filters the blood, making it to its normal state. Glucose was filtered out and

excreted in the urine. Due to the excess glucose ad compared to the kidney threshold,

which results to the excretion of glucose in the urine.

BLURRED VISION

Diabetes can affect the lens, vitreous, and retina, causing visual symptoms. Visual

blurring may develop acutely as the lens changes shape with marked changes in blood

glucose concentrations. This effect, which is caused by osmotic fluxes of water into and

out of the lens, usually occurs as hyperglycemia increases.

WEIGHT LOSS

Despite eating more than usual to relieve constant hunger by the stimulation of satiety

center, weight loss may still exist. Without the glucose supplies, muscle tissues and fat

stores may deplete.

SLOW-HEALING SORE AND FREQUENT INFECTION

High levels of blood sugar impair your body's natural healing process and your ability to

fight infections. For women, bladder and vaginal infections are especially common.

TINGLING SENSATION/ NUMBNESS IN THE HAND AND FEET

Excess sugar in your blood can lead to nerve damage. You may notice tingling and loss

of sensation in your hands and feet, as well as burning pain in your arms, hands, legs

and feet.

51

PROTEINURIA

Testing the urine for microalbuminuria shows early nephropathy, long before it would be

on routine urinalysis,

ANEMIA

If there are renal affectations, this might bring to decrease production of erythropoietin

which brings to decrease production of RBC from the bone marrow that may result to

anemia.

CEREBROVASCULAR ACCIDENT

Clinical Manifestations

1. headache and vomiting – due to an increase ICP which causes cerebral

edema, and compressing the medulla oblongata

2. seizures – due to hyper-excitability of neurons because of irritation.

3. changes in mental status – affectation in the RAS

4. fever – affectation in the hypothalamus

5. ECG changes – problem with the medulla oblongata

Warning Signs

1. transient hemiparesis

2. loss of speech

52

3. hemisensory loss

4. vertigo/syncope

Specific Deficits

1. Hemiparesis/Hemiplegia – the former means weakness of one side of the body while

the latter means paralysis of one side of the body.

2. Aphasia – defects on using and interpreting symbols of language

3. Apraxia - a condition in which a client can move the affected part but cannot use it for

purposeful actions.

4. Homonymous Hemianopsia – a defective vision or vision loss in the same half of the

visual field.

5. Agnosia – a problem in interpreting visual, tactile or other sensory information.

6. Dysarthia – imperfect articulation condition.

7. Kinesthesia – alteration in sensation.

8. Incontinence – due to inattention, memory lapses, emotional factors, and inability to

communicate.

9. Shoulder pain – severe pain in the affected shoulder after CVA

10. Horner’s syndrome – paralysis of sympathetic nerves to the eye causing sinking of

the eyeball, ptosis of the upper eyelid, constriction of pupil, and lack of tearing in the

eye.

11. Unilateral neglect – inability to respond to stimulus on the contralateral side.

12. Dysphagia (01/29/09 -01/31/09) – difficulty of swallowing

53

13. Ataxia (01/29/09 -01/31/09) –Problem with motor coordination

B.2. Modifiable and Non Modifiable Factors (Client Based)

1. Modifiable

a. Smoking – (23 pack years) nicotine content of cigarettes causes vasoconstriction

there by resulting hypertension which may lead to CVA.

b. Hypertension – (BP-200/100 -01/27/09) this is due to plaque deposits on the wall of

the arteries which causes narrowing of the blood vessel thereby causing hypertension

which may lead to hemorrhagic stroke.

d. Hyperlipidemia – Total Cholesterol: 351 (01/28/09) too much lipid in the blood may

cause increase plaque formation which may cause thrombus formation.

e. Diabetes Mellitus – (She was diagnosed with DM since 2004) The mechanism is

related to macrovascular changes in people with diabetes mellitus. There is an increase

viscousity of blood which may cause formation of thrombus formation.

2. Non-Modifiable

54

a. Age –Intracranial hemorrhage is most often secondary to hypertension and is most

common after age 50 years. (Kitty Sanrio is 58 yrs. Old)

b. Family history of Cardiovascular Diseases – Family history of stroke increases one’s

risk. Kitty Sanrio’s mother died from cardiovascular disease specifically heart attack.

c. Family history of DM –Family which has history of DM especially type 2 is high risk of

having stroke due to accelerated atherosclerosis.

SIGNS AND SYMPTOMS (Client Based)

DIABETES MELLITUS

HYPERGLYCEMIA (INCREASED BLOOD SUGAR LEVEL) (01/28/09)

Diabetes Mellitus type II may be due to lack of physiologically active insulin that

stimulates glucose uptake in the muscles and tissues. Therefore, it leads to an

accumulation of glucose in the intravascular space. The glucose is not utilized by the

body and it remains in the blood stream.

POLYURIA (01/29/09 -01/31/09)

Polyuria is an increased frequency of urination. This may be due to the osmotic diuretic

effect of the glucose, wherein it attracts water during urination.

When you have diabetes, excess sugar (glucose) builds up in your blood. Your kidneys

are forced to work overtime to filter and absorb the excess sugar. If your kidneys can't

55

keep up, the excess sugar is excreted into your urine along with fluids drawn from your

tissues. This triggers more frequent urination, which may leave you dehydrated.

BODY MALAISE (01/29/09 -01/31/09)

This is due to the decreased glucose uptake by the tissues leading to decreased energy

production.

GLYCOSURIA (01/29/09)

The kidney filters the blood, making it to its normal state. Glucose was filtered out and

excreted in the urine. Due to the excess glucose ad compared to the kidney threshold,

which results to the excretion of glucose in the urine.

BLURRED VISION (01/29/09 -01/31/09)

Diabetes can affect the lens, vitreous, and retina, causing visual symptoms. Visual

blurring may develop acutely as the lens changes shape with marked changes in blood

glucose concentrations. This effect, which is caused by osmotic fluxes of water into and

out of the lens, usually occurs as hyperglycemia increases.

ANEMIA [Hemoglobin: 8 (F: 12-16) (01/28/09)]

If there are renal affectations, this might bring to decrease production of erythropoietin

which brings to decrease production of RBC from the bone marrow that may result to

anemia.

56

FREQUENT INFECTION (01/29/09 -01/30/09)

High levels of blood sugar impair your body's natural healing process and your ability to

fight infections. This is due to low morphonuclear leukocytes which decreases her

resistance from infection. For women, bladder and vaginal infections are especially

common.

PROTEINURIA (01/29/09)

Testing the urine for microalbuminuria shows early nephropathy, long before it would be

on routine urinalysis,

PNEUMONITIS – Radiology report (01-30-09). Many factors can cause pneumonitis,

including breathing in animal dander, inhaling small food particles "down the wrong

pipe" and receiving radiation therapy to your chest and smoking.

CEREBROVASCULAR ACCIDENT

Clinical Manifestations

1. headache and vomiting – due to an increase ICP which causes cerebral

edema, and compressing the medulla oblongata

2. seizures – due to hyper-excitability of neurons because of irritation.

3. changes in mental status – affectation in the RAS

4. fever – affectation in the hypothalamus

5. ECG changes – problem with the medulla oblongata

57

Warning Signs

1. transient hemiparesis (01/27/09)

2. slurred speech (01/27/09)

3. hemisensory loss(01/27/09)

4. vertigo/syncope (01/27/09)

Specific Deficits

1. Hemiparesis/Hemiplegia (01/29/09 -01/31/09) – the former means weakness of one

side of the body whiles the latter means paralysis of one side of the body.

2. Apraxia (01/29/09 -01/31/09) –a condition in which a client can move the affected

part but cannot use it for purposeful actions.

3. Dysarthia (01/29/09 -01/31/09) – imperfect articulation condition.

4. Dysphagia (01/29/09 -01/31/09) – difficulty of swallowing

5. Ataxia (01/29/09 -01/31/09) –Problem with motor coordination

58

V. The Patient and His Care

A. Medical Management

a. IVF’s, BT, NGT Feedings, Nebulization, TPN, Oxygen Therapy.etc.

Medical Management/

Treatment

Date ordered/ Date

Performed

General Description

Indication or purpose

Client’s Response

D5 LRS (5% Dextrose Lactated Ringer’s Solution) 1L

D5 0.3 NaCl

(5% Dextrose 0.3

Sodium Chloride)

500cc

01-27-09

Jan. 27-31, ‘09

Hypertonic solution that has higher osmolarity than the serum. It pulls fluid and electrolytes from the intracellular and interstitial compartments into the intravascular compartment. It is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment and caloric supply administered intravenously.

Hypotonic

solution that has

greater

concentration of

free water

molecules that

are found inside

Since the patient was on NPO upon admission, she was given D5 LRS as her IVF administered intravenously to serve as a source of water, electrolytes, and calories. It also serves as a route for medication administration.

To maintain

rehydration and to

replace fluid loss,

patient was given

this IVF. Also, for

medication

administration.

The patient was

able to maintain

normal hydration

status and

electrolyte

balance AEB

patient had

moist skin and

good skin turgor.

Patient

responded well

as she did not

manifest any

signs and

symptoms of

dehydration

59

the cell. such as dry skin

and mucous

membranes.

Nursing Implication:

Before:1. Check the physician’s order for IV solution and explain to the client the procedure. 2. Check the potency of IV line and needle 3. Check the type of infusion, condition of the vein and medical condition of the patient

During:1. Maintenance of Aseptic Technique 2. Proper procedure and steps in infusing IV solution3. Count drops per minute in drip chamber.

After:1. Monitor IV infusion at least every 2 hour 2. Adjust IV clamp as needed and recount drop per minute.3. Monitor client for fluid overflow 4. More frequent check maybe prn if a medication(s) are being infused.5. Inspect site for pain, swelling, coolness or pallor at the site of insertion, which may

indicate infiltration of IV 6. Inspect site for redness, swelling, heat and pain which may indicate phlebitis

60

b. Drugs

Name of Drugs

Date Ordered/

Date Performed/ Date

Given

Dosage, Route,

Frequency of

Administration

General Action

Indication or Purpose

Client’s Response

Nursing Responsibilities

Piracetam 01-27-09 800mg 1 tab PO q6 hrs then BID on

01-28-09

Piracetam improves the

function of the neurotransmit

ter acetylcholine via muscarinic

cholinergic (ACh)

receptors which are

implicated in memory

processes. It improves

brain function and

stimulates the central

nervous

Since the patient is diagnosed of

CVA, she is given this drug to

improve her brain function

The client improved her

mentation as she is able to feel deep

touch and could raise his right arm and leg as well as comprehend with

what the SO is saying. There are no side/adverse

effects noted

Prior to:

Wash hands

thoroughly.

Ask the patients

name

Always observe

aseptic technique

During:

Explain the

procedure to the

patient/SO.

Explain what is the

general action of the

61

system without any toxicity or addictive properties

drug to the body.

After:

Record the drug after

its administration

(charting).

Observe the patients

for possible untoward

reaction.

Instruct to take the

medication exactly as

directed.

Captopril Jan. 27-31, ‘09

25mg SL TID

Captopril lower blood pressure by inhibiting the formation of

angiotensin II, thus relaxing the arteries. Relaxing the arteries not only lowers

blood

Indicated for the patient since the drug is said to

treat hypertension.

Patient did not improve condition since she still had

elevated blood pressure of

180/100

Prior to:

Wash hands

thoroughly.

Ask the patients

name

Always observe

aseptic technique

During:

62

pressure, but also improves the pumping

efficiency of a failing heart

and improves cardiac output

in patients with heart

failure.

Explain the

procedure to the

patient/SO.

Instruct the patient to

put the medicine

under her tongue or

sublingually.

After:

Record the drug after

its administration

(charting).

Observe the patients

for possible untoward

reaction.

Instruct to take the

medication exactly as

directed.

Monitor blood pressure

Ranitidine 01-27-09 50mg IV It is a This is indicated The patient Prior to:

63

q8 then d/c on Jan.

30,’09

competitive, reversible

inhibitor of the action of

histamine at the histamine H2 receptors,

including receptors on the gastric

cells

for the patient as she manifested abdominal pain

improved condition as she did not

manifest abdominal pain.

Wash hands

thoroughly.

Ask the patients

name.

Recheck the order of

the doctor

Always observe

aseptic technique

Check the patency of

the IV site

During:

Explain the

procedure to the

patient/SO.

Observe patient

closely for at least 30

minutes following

administration.

After:

Record the drug after

64

its administration

(charting).

Observe the patients

for possible untoward

reaction.

Simvastatin 01-28-09 40mg 1tab OD

Simvastatin is a

hypolipidemic drug

belonging to the class of

pharmaceuticals called

"statins". It is used to control

hypercholesterolemia

(elevated cholesterol

levels) and to prevent

cardiovascular disease.

Since the patient had high levels of cholesterol with 351 mg/dl, she was given this

drug.

Patient did not improve condition since she still has

elevated cholesterol..

Prior to:

Wash hands

thoroughly.

Ask the patients

name

Always observe

aseptic technique

During:

Explain the

procedure to the

patient/SO.

After:

Record the drug after

its administration

(charting).

65

Observe the patients

for possible untoward

reaction.

Instruct to take the

medication exactly as

directed.

Metoprolol 01-28-09 50mg 1tab BID then increased frequency of 100mg on Jan. 30,’09

Metoprolol reduces heart

rate and cardiac output

at rest and upon

exercise, reduces

systolic blood pressure

upon exercise, inhibits

isoproterenol-induced

tachycardia, and reduces

reflex orthostatic

It is also indicated for the patient because the patient has

elevated blood pressure.

The client did not improve condition since she still had

elevated blood pressure

Prior to:

Wash hands

thoroughly.

Ask the patients

name

Always observe

aseptic technique

During:

Explain the

procedure to the

patient/SO.

After:

Record the drug after

66

tachycardia. its administration

(charting).

Observe the patients

for possible untoward

reaction.

Instruct to take the medication exactly as

directed.

Monitor BP

Ketosteril 01-30-09 2 tabs TID Ketosteril normalizes metabolic

processes, Improves nitrogen

exchange, reduce ion

concentrations of

potassium, magnesium

and phosphate.

Protein-energy malnutrition,

prevention and treatment of

conditions caused by modified or

insufficient protein metabolism.

Patient improved condition as she did not manifest body weakness because of the

energy supplemented.

Prior to:

Wash hands

thoroughly.

Ask the patients

name

Always observe

aseptic technique

During:

Explain the

procedure to the

patient/SO.

67

After:

Record the drug after

its administration

(charting).

Observe the patients

for possible untoward

reaction.

Instruct to take the

medication exactly as

directed.

Ferrous Sulfate

01-30-09 1 cap OD Ferrous Sulfate is an

essential body mineral.

Ferrous sulfate is

used to treat iron

deficiency anemia

Indicated for the patient as a

supplement for iron

Patient did not improve condition as she still has low hemoglobin count.

Prior to:

Wash hands

thoroughly.

Ask the patients

name

Always observe

aseptic technique

During:

Explain the

procedure to the

68

patient/SO.

After:

Record the drug after

its administration

(charting).

Observe the patients

for possible untoward

reaction.

Instruct to take the

medication exactly as

directed.

Hydralazine 01-29-09 5mg IV q6hrs

PRN for BP 130/90

Hydralazine is a direct-acting

smooth muscle

relaxant used to treat

hypertension by acting as a

vasodilator primarily in arteries and

arterioles. By relaxing vascular

Indicated for the patient as she has

elevated blood pressure

The patient did not improve her

condition as she still had elevated blood pressure of

180/100

Prior to:

Wash hands

thoroughly.

Ask the patients

name.

Recheck the order of

the doctor

Always observe

aseptic technique

69

smooth muscle,

vasodilators act to

decrease peripheral resistance,

thereby lowering

blood pressure.

Check the patency of

the IV site

During:

Explain the

procedure to the

patient/SO.

Observe patient

closely for at least 30

minutes following

administration.

After:

Record the drug after

its administration

(charting).

Observe the patients

for possible untoward

reaction.

Monitor BP

70

c. Diet

TypeOf

diet

Date ordered

Date givenDate

changed

General description

IndicationSpecificFoodsTaken

Client’s response

Nothing per Orem (NPO)

01-27-09 A type of Diet where the patient cannot eat or drink anything

It is for the purpose of observation precaution

None The patient participated with the Doctor’s order

Soft Diet 01-28-09 Very similar to regular diet except that the textures of foods have been modified.

This was ordered to provide a transitional diet between liquids and regular food for patients who have difficult in swallowing or who undergone surgery.

Boiled Eggs, Sopas, Lugaw

The client enjoyed eating her food and manifested feeling of fullness after the meal. She did not manifest dysphagia.

Nursing Responsibilities for NPO

● Check the doctor’s order.● Educate the patient and significant others why NPO is indicated.● Discuss to the patient the importance of the diet.● Assess patient’s level of hydration.

Nursing Responsibilities for soft diet

● Check the doctor’s order.● Educate the patient and significant others on the right foods to be taken.● Discuss to the patient the importance of nutrition.● Provide a variety of choices of foods.● Assess patient’s appetite.

71

d. Activity/ Exercise

TypeOf

exercise

Date orderedDate given

Date changed

General description

IndicationClient’s

response

High Back Rest

01-27-09 A type of activity or exercise wherein the patient is kept on bed with the head of bed held at at least 45° with limitations to other activities.

To reduce oxygen demand and prevent fatigue. Rest decreases body metabolic rate. Since the patient is old, she is prone to have pressure ulcers and she is more likely to manifest fatigue.

Patient shows gradual increase in strength.

Nursing Responsibilities● Assist patient if with such privilege in going to the bathroom.● Change client’s position from time to time, to promote circulation and prevent bed sores.

72

B. Nursing Management

NURSING CARE PLAN

Problem No:1 Acute Pain

ASSESSMENTNURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATIONPLANNING INTERVENTIONS RATIONALE

EXPECTED

OUTCOME

S=” Masakit ku

atsan”

The patient

manifested the

following:

O= with facial

grimace, with

guarding

behaviors, pain

scale of 8/10, at

abdominal area,

with quality of dull

Acute Pain

Lots of medicine has the

side effect of gastric

upset causing

abdominal pain to

patient after intake of

medication specially PO

drugs. It has a side

effect of causing

abdominal cramps, and

pain.

Short Term

Objective:

After 2 hr of

nursing

intervention the pt

will verbalized

rlieve of pain from

8/10 to 4/10

Long Term

Objective:

After 3 days of NI,

pt will

Establish rapport

Monitor v/s

Assess pt’s

general condition

Encourage rest

opportunities

Ecourage

To gain pt’s

therapeutic

relationship

To obtain

baseline data

To note for the

etiology or

precipitating

factors that can

lead to fever.

To overcome pain

at rest

to divert the pt’s

Short Term

Objective:

After the nsg int the

pt shall verbalized a

relief of pain.

Long Term

Objective:

After the nsg int the

pt shall

demonstratetechniq

ue to alleviate pain

73

pain, after intake

of meds, left side

paralysis

The patient may

also manifest he

following:

>discomfort

>anxiety

>irritable

>Fatigue

>headache

demonstrate

technique to

alleviate pain

diversional

activities such as

talking to S.O.

Encourage deep

breathing

exercises

Provide comfort

measures and

safety

Provide Health

information

regarding the

occurring problem

Provide

conducive

environment for

resting

attention

Helps to lessen

the feeling of

pain.

To let pt feel safe

and comfortable

To lessen the pt’s

feeling of anxiety

To promote rest

and pt’s wellness

74

Problem No: 2 impaired cerebral tissue perfusion r/t vascular occlusion secondary to disease condition

ASSESSMENTNURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATIONPLANNING INTERVENTIONS RATIONALE

EXPECTED

OUTCOME

S= 0

The patient

manifested the

ff:

O= without signs

of IV infiltration, w/

contralateral

hemiparesis,

sensory loss,

muscle weakness,

slurred speech,

with GCS=15

The patient may

also manifest the

ff:

Impaired cerebral

tissue perfusion

r/t vascular

occlusion

secondary to

disease condition

In cerebral tissue

perfusion, there is a

decrease in oxygen

supply which results in

the failure to nourish the

tissues at the capillary

level. Blood vessels

which function is to

supply blood to the

different parts of the

brain are impaired.

Thus, the O2 supply

going to the brain is also

impaired. Proper

perfusion is needed in

order to give adequate

nourishment to he

different parts of the

brain in order for it to

Short term

objective:

After 5hrs. of

Nursing

intervention, the

pt. will

demonstrate

increased

perfusion as

individually

appropriate

Long Term

Objective:

After 2-3 days of

Nursing

Intervention, the

pt. will be able o

demonstrate

Establish Rapport

Monitor Vital

signs

Assist pt. in

assuming

semifowler’s

position w/ head

midline.

Administer

medications as

ordered such as

antihypertensive

> To gain pt’s

therapeutic

relationship

> To identify any

other deviations

from normal.

>To aid with

proper perfusion

or flow of blood

(circulation or

venous drainage).

>To probably

decrease cardiac

workload and in

maximizing tissue

Short term

objective:

After 5hrs. of

Nursing

intervention, the pt.

shall be able to

demonstrate

increased perfusion

as individually

appropriate

Long Term

Objective:

After 2-3 days of

Nursing

Intervention, the pt.

shall be able to

demonstrate

behaviors which 75

>Change in

pupillary reactions

>Change in

Mental Status

>Behavioral

Changes

>Capillary refill

longer than 3

secs.

function well. behaviors which

may improve

proper circulation

such as

compliance to

health

management &

therapies

provided.

or diuretics.

>Encourage quiet

and restful

atmosphere.

>Exercise caution

in using hot or

cold pads.

>Encourage use

of relaxation

techniques or

exercises.

>Discuss the

importance of

preventing

exposure to cold

or extreme cold

temp

perfusion

>To conserve

energy which

could aid in

lowering the O2

tissue demand.

>The t issues

may have

decreased

sensitivity due to

ischemia.

>To decrease the

tension level

>To retain heat or

warmth efficiently

may improve proper

circulation such as

compliance to

health management

& therapies

provided.

76

>Discuss to the

patient’s SO the

importance of

care of dependent

limbs, body

hygiene, and foot

care when

circulation is

impaired.

>To promote

wellness

Problem No: 3 Impaired Physical Mobility Neuromuscular and Musculoskeletal Impairment

ASSESSMENTNURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATIONPLANNING INTERVENTIONS RATIONALE

EXPECTED

OUTCOME

S= 0

The patient

manifested the

following:

O= w/ pale

palpebral

conjunctiva, w/

Impaired physical

mobility

neuromuscular

and

musculoskeletal

impairment as

evidence by

limited motor

The nervous system is

made up of nerve cells

called neurons that

serve as the

communication system

of the body. They carry

messages in the form of

electrical impulses. The

messages move from

Short Term

Objective:

After 4 hrs. Of

Nursing

Intervention, the

pt. will be able to

maintain

increased

strength and

>Establish

Rapport

>Monitor Vital

signs

>Assess patient

condition

> To gain pt’s

therapeutic

relationship

> To identify any

other deviations

from normal.

>To determine

any other

Short Term

Objective:

After 4 hrs. Of

Nursing

Intervention, the pt.

shall be able to

maintain increased

strength and

function of affected 77

pale nail beds, w/

capillary refill

time, <3sec. pt. is

able to feel deep

touch, raise his

right arm and leg,

w/ slurred speech,

w/ left sided

weakness, with

limited ROM on

upper and lower

extremities,

afebrile, (-) DOB,

(-) chest pain.

The patient may

also manifest he

following:

>Slowed

movement,

>Postural

instability during

skills. one neuron to another

to keep the body

functioning. Because

neurons have, limited

ability to repair

themselves unlike other

body tissues that is why

nerve cells cannot be

repaired if damaged

due to injury or disease.

function of

affected or

compensatory

part.

Long Term

Objective:

After 2-3 days of

nursing

intervention, the

pt. will be able to

demonstrate

behaviors that

enable

resumption of

activities.

>Provide

adequate rest

periods as well as

comfort & safety

measures

>Turn pt. slowly

from side to side

>Determine pt.

level of mobility

>Assist pt. in his

activities

>Encourage

adequate intake

of fluids &

underlying cause

of manifestations

> To prevent

further stress &

fatigue

> To provide

proper circulation

of blood flow on

both sides

>To assess

functional ability

>To promote

optimal level of

function

>Promotes well-

being and

maximizes

energy

or compensatory

part.

Long Term

Objective:

After 2-3 days of

nursing

intervention, the pt.

shall be able to

demonstrate

behaviors that

enable resumption

of activities.

78

performance of

ADLs

>Movement

induced shortness

of breath.

Nutritious foods

>Involve client’s

SO in care

production.

>To assist in

learning ways of

managing

problems of

immobility.

Problem: 4 Activity Intolerance r/t immobility

AssessmentNursing

Diagnosis

Scientific

ExplanationObjective

Nursing

InterventionRationale

Expected

Outcome

S>O

O>The Patient

Manifests:

>with Paralysis

of the Left Body

Side

>with Left side

Activity

Intolerance r/t

immobility

Infarction on the

right hemisphere

has a contra

lateral

manifestation of

either left side

paralysis and/or

weakness due to

left hemisphere

affectation

causing the

immobility

Short Term:

After 3 hrs of

nursing

intervention the

patient will use

identified

techniques to

enhance activity

tolerance.

>Establish Rapport

>Assess V.S.

>Assess General

Condition

>Adjust Activity

>To gain

patient’s Trust

>To gain

baseline data

>To note for

signs and

symptoms

>To prevent

overexertion

Short Term:

After the

nursing

intervention the

patient shall use

identified

techniques to

enhance activity

tolerance.

79

weakness

>with Blurred

Vision

>with infraction

on right

hemisphere

>requires

assistance and

guidance from

S.O.

The Patient may

Manifest:

>headache

>pain

>irritable

>discomfort

>cold clammy

skin

>dehydration

because of

stiffness of

muscle and

unability to

mobilize due to

the

manifestation of

the disease

condition.

Long Term:

After 3 days

of nursing

intervention the

patient will

demonstrate

increase in

activity

tolerance.

>Provide positive

atmosphere

>Promote comfort

measure and

provide for relief of

pain

>Provide ROM

>Give client

information that

provides

evidence/difference

>Assist client in

learning and

demonstrating

appropriate safety

measures

>to minimize

frustration

>to enhance

ability to

participate in

activities

>to promote

circulation

>to sustain

motivation

>to prevent

injuries

Long term:

After the

nursing

intervention the

patient shall

demonstrate

increase in

activity

tolerance.

80

Problem No: 5 impaired verbal and/or written communication r/t impaired cerebral circulation

ASSESSMENTNURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATIONPLANNING INTERVENTIONS RATIONALE

EXPECTED

OUTCOME

S= 0

The patient

manifested the

following:

O= w/ pale

palpebral

conjunctiva, w/

pale nail beds, w/

capillary refill

time, <3sec., pt.

is able to feel

deep touch, raise

impaired verbal

and/or written

communication

r/t impaired

cerebral

circulation

There is an affectation

of the certain brain

lobes that caused by

impaired cerebral

circulation that affects

its proper functions that

leads to decreased,

delayed or absent

ability to receive,

process, transmit and

use a system o

symbols in

communicating

resulting in impaired

verbal communication.

Short Term

Objective:

After 3 hrs of nsg

int. the pt will be

able to verbalize

or indicate

understanding of

the

communication

difficulty and

plans for ways of

handling.

Long Term

Establish rapport

Monitor v/s

Assess pt’s

general condition

Note results of

neurological

To gain pt’s

therapeutic

relationship

To obtain

baseline data

To note for the

etiology or

precipitating

factors that can

lead to fever.

To assess

causative/contrib

Short Term

Objective:

After the nrsing

intervention the pt

shall verbalize ir

indicate

understanding of

communication

difficulty and plans

for ways of

handling

Long Term

81

his right arm and

leg, w/ slurred

speech, w/ left

sided weakness,

with limited ROM

on upper and

lower extremities,

The patient may

also manifest he

following:

>weakness

>headache

>dyspnea

>unable to speak

>discomfort

>irritability

>low self esteem

>Difficulty in

expressing needs

Objective:

After 3 days of

nursing

intervention the

pt will establish

method of

communication in

which needs can

be expressed.

testing such as

EEG/CTscan and

the likes

Assess

environment

factors that may

affect ability to

communicate

Establish

relationship with

the client ,

listening carefully

and attending to

clients

verbal/nonverbal

expressions

Maintain a calm,

unhurried

manner, provide

sufficient time for

the client to

uting factors

To assess

causative/contrib

uting factors

To assist client to

establish a

means of

communication to

express needs,

wants, ideas and

questions

Individuals may

talk more easily

when they are

rested and

Objective:

After the nursing

intervention the pt

shall be albe to

establish methods

of communication

in which can be

expressed.

82

responds

Anticipate needs

until effective

communication is

reestablished

Administer due

meds

relaxed

To attend pt’s

needs

immediately

For pt’s recovery

and to treat

underlying

conditions

Problem No: 6 Risk for Aspiration

ASSESSMENT NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME

S= 0

The patient manifested the ff:

O= Dysphagia, impaired swallowing

The patient may

Risk for Aspiration When there is a blockage of vertebrobasilar artery there will be Cranial nerves affectations. CN V, VII, IX, XII blockage may result to dysphagia or difficulty of swallowing which thereby having high risk for aspiration.

Short term objective:After 5hrs. of Nursing intervention, the pt. demonstrate techniques to prevent aspiration.

Long Term

>Established Rapport

>Monitored Vital signs

>Note level of consciousness of surroundings, and

>To gain the trust & compliance of the patient & SO

> To identify any other deviations from normal.

>To assess if there is gag reflex or difficulty of

Short term objective:The patient shall have demonstrated techniques to prevent aspiration.

Long Term Objective:The patient shall have experienced

83

also manifest the ff:

>Depressed gag reflex.>Reduced level of consciousness

Objective:After 1-2 days of Nursing Intervention, the pt. will experience no aspiration aeb noiseless respirations, and clear breath sounds.

cognitive impairment.

>Suction as needed

>Auscultate lung sounds

>Give semisolid foods; avoid pureed that may increase risk of aspiration.

>Provide very warm or cold liquids

>Refer to speech therapist

swallowing.

>To clear secretions

>to determine presence of secretions

>To prevent aspiration and to aide swallowing effort.

>This activates temperature receptors in the mouth that help to stimulate swallowing.

>To strengthen muscles and techniques to enhance swallowing.

no aspiration aeb noiseless respirations, and clear breath sounds.

84

Problem no: 7 Risk for impaired skin integrity

ASSESSMENTNURSING

DIAGNOSISSCIENTIFIC EXPLANATION PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME

S= 0

The patient manifested the following:

O= with dysphagia, with reports of body malaise, increased urine output indwelling Foley catheter,

Risk for Impaired skin integrity

The skin is the baseline defense of the body against infection. Any break in the skin may harbor microorganisms that may invade the normal processing of the body, which may inflict or aggravate the pt’s disease condition.

Short Term Objective:

After 4 hr of nursing intervention the pt will take actions regarding minimizing the risk

Long Term Objective:

Establish therapeutic relationship

Monitor v/s

Assess pt’s general condition

Monitor I&O

To gain pt’ and SO’s trust and cooperation

To obtain baseline data

To note for the etiology or precipitating factors that can aggravate the risk.To have a baseline data regarding input

The pt shall have

took actions

regarding

minimizing the risk

The pt shall have

been free from risk.

85

pallor, cold skin, physical immobility.

After 3 days of NI, pt will be free of the risk. Encourage

increase OFI to al least 2-3 liters per day

Arrange bed linens

Encourage and assist client to active and passive ROM exercises

Encourage rest opportunities

Provided comfort measures and safety

Carefully wash and pat dry skin, including skinfold area. Use hydration and moisturization on

and output

To maintain hydration status.

To prevent increase pressure

To maintain blood flow

To promote optimum level of functioning

To let pt feel safe and comfortable

To maintain skin moisture

86

all at-risk surfaces.

Assist client in changing positions every two hours

Provided Health information regarding the occurring problem

Provided conducive environment for resting

Encourage client to have balanced diet especially with increased intake of vitamin C and Protein.

Monitor and Regulate IVF as per doctor’s order

To prevent pressure ulcer

To lessen the pt’s feeling of anxiety

To promote rest and pt’s wellness

To promote adequate nourishment.

For proper replacement of fluid losses.

87

Problem: 8 Risk for deficient fluid volume

AssessmentNursing

DiagnosisScientific Explanation Objectives Interventions Rationale

Expected Outcome

S>

O>the patient manifested: Fatigue Weakness Polyuria Pale to pink

palpebral conjunctiva

Change in mental status

Risk for Deficient Fluid Volume AEB polyuria

Since the patient had polyuria, she experienced frequent urination and with that, she might have lost fluids that could lead to deficient fluid volume. She, then is at risk of fluid volume deficit.

Short TermAfter 4 hours of nursing interventions, patient/SO demonstrate behaviors and techniques to correct deficit

Long Term:After 2-3 days of nursing

>Evaluate nutritional status, noting current intake, weight changes, and problems with oral intake. Measure subcutaneous fat and muscle mass

>Assess vital signs; note strength of

> Assess causative factors leading to deficit

>Evaluate degree of deficit

Short Term:

Patient shall have demonstrated behaviors and techniques to correct deficit

Long Term:

Patient shall have

88

The patient may manifests:

Hemoconcentration

Pale skin Poor skin turgor Capillary refill

time of less than 3 secs.

interventions, patient will demonstrate management to prevent fluid volume deficit

peripheral pulses. Measure blood pressure. Note presence of physical signs. Monitor I/O, color measure amount and specific gravity of the urine.

>Establish 24-hour replacement needs and routes to be used.>Note client preference concerning fluids and foods with high fluid content

>Provide nutritious diet via appropriate route

>Weigh daily

>Bathe less

> Prevent peaks and valleys in fluid level

>Encourage the client to increase intake of foods high in fluid content

>Correct/Replace fluid losses to reverse pathophysiologic mechanism

>Assess progress or status of efforts

>Maintain skin

demonstrated management to prevent fluid volume deficit.

89

frequently using mild cleanser/soap and provide optimal skin care

>Provide frequent oral and eye care

>Change position frequently

>Discuss factors related to occurrence of the deficit as individually appropriate. Instruct client how to measure and record I/O

integrity and prevent excessive dryness

>Prevent injury from dryness

>Promote comfort and safety

>Promote wellness

Problem: 9 Risk for imbalanced nutrition: less than body requirements

AssessmentNursing

DiagnosisScientific

ExplanationObjectives

Nursing Interventions

Rationale Expected Outcome

S>

O> The patient manifested:-muscle weakness- with contralateral

Risk for imbalanced nutrition: less than body requirementsAEB inability to

A paralysis and muscle weakness could lead to impaired mobility, lack of adequate strength to do activities of daily living such as

SHORT TERM:After 4 hours of NI, the patient will verbalize understanding of causative factors

>Establish therapeutic relationship

>Assess and monitor vital signs

>To obtain trust and cooperation of the pt.

>To obtain baseline date

SHORT TERM:The patient shall have verbalized understanding of causative factors when known and

90

hemiparesis- pale to pink palpebral conjunctiva- sensory loss

> The patient may manifest:- loss of weight- capillary fragility- decreased in subcutaneous fats and muscle mass

ingest adequate nutrition

eating. As the patient does not ingest adequate food first because she was ordered to be on NPO, second because she could not ingest the food adequately as she has paralysis, she could be at risk of imbalanced nutrition: less than body requirements.

when known and necessary interventions.

LONG TERM:After 4 days of NI, the patient will demonstrate behaviors to regain or maintain appropriate weight.

>Identify clients at risk for malnutrition

>Determine ability to chew, swallow and taste

>Discuss eating habits, including food preferences, intolerances, aversions

>Assess weight, age, body build, strength, activity/rest level

>Note total daily intake

>Provide diet modifications indicated for the client’s condition or health status

>Increase oral fluid

>To assess causative factors

>Factors that can affect ingestion or digestion of nutrients

>To appeal to clients likes/desires

>Provides comparative baseline

>To reveal changes that should be made in client’s dietary intake

>To establish a nutritional plan that meets individual needs

>To prevent

necessary interventions.

LONG TERM:The patient shall have demonstrated behaviors to regain or maintain appropriate weight.

91

intake

>Encourage client to choose foods that are appealing

>Limit fiber/bulk if indicated

>Promote pleasant, relaxing environment

>Provide oral care before/after meals

>Emphasize importance of well-balanced, nutritious intake

>Give supplemental humidification as needed (oxygen supply)

dehydration and liquefy respiratory secretions

>To stimulate appetite

>May result to early satiety

>To enhance intake

>To keep mouth clean

>To promote wellness

>To humidify airways and supplement need for oxygen

Problem no: 10 Risk for Infection

ASSESSMENTNURSING

DIAGNOSISSCIENTIFIC EXPLANATION PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME

Risk for Infection An infection is the Short Term Establish To gain pt’ and The patient shall

92

S= 0

The patient manifested the following:

O= with dysphagia, with reports of body malaise, increased urine output indwelling Foley catheter, pallor, cold skin, cracked and cry lips.

detrimental colonization of a host organism by a foreign species. In an infection, the infecting organism seeks to utilize the host's resources to multiply. The infecting organism, or pathogen, interferes with the normal functioning of the host and can lead to chronic wounds, gangrene, loss of an infected limb, and even death.

Objective:

After 4 hr of nursing intervention the pt will demonstrate appropriate hygienic measures such as hand washing, oral care, and perineal care

Long Term Objective:

After 3 days of NI, pt will maintain white blood cell (WBC) count and differential within normal limits.

therapeutic relationship

Monitor VS

Assess pt. general condition

Observe and report signs of infection such as redness, warmth, discharge, and increased body temperature.

Assess skin for color, moisture, texture, and turgor (elasticity). Keep accurate, ongoing documentation of changes.

Preventive skin

SO’s trust and cooperation

To obtain baseline data

To note for the etiology or precipitating factors that can aggravate the risk.

To have a baseline data regarding client’s risk

To note for degree of deficiency

To promote

have demonstrated

appropriate hygienic

measures such as

hand washing, oral

care, and perineal

care

The pt shall have

maintained white

blood cell (WBC)

count and

differential within

normal limits.

93

assessment protocol, including documentation, assists in the prevention of skin breakdown.

Carefully wash and pat dry skin, including skinfold areas. Use hydration and moisturization on all at-risk surfaces.

Encourage a balanced diet, emphasizing proteins, fatty acids, and vitamins listed below.

Encourage fluid intake.

Use appropriate "hand hygiene" (i.e., hand washing or use of

optimum level of functioning

To prevent skin impariment

To promote pt’s wellness

To maintain hydration status

To prevent nosocomial infection

94

alcohol-based hand rubs).

Use careful technique when changing and emptying urinary catheter bags.

Ensure the client's appropriate hygienic care with hand washing; bathing; and hair, nail, and perineal care performed by either the nurse or the client.

Administer antibiotics; use antibiotics sparingly as per doctor’s order

To avoid cross contamination

To prevent good source of bacterial multiplication

To pharmacologically manage the problem.

Problem No: 11 Risk for Injury

ASSESSMENT NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME

95

S= 0

The patient manifested the following:

O= with limited range of motion. contralateral hemiparesis, sensory loss, muscle weakness, Blurred vision

The patient may also manifest he following:

>Fatigue>headache>Dizziness

Risk for Injury Because of limited range of motion and slightly paralyze body the patient is unable to mobilize properly which maybe a risk for injury.

Short Term Objective: After 2 hr of nursing intervention the pt will demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury

Long Term Objective:After 2 days of NI, pt will be free of injury

>Establish rapport

>Monitor v/s

>Assess pt’s general condition

>Assess mood, coping abilities, personality styles

>Identify interventions and safety devices

>Encourage participation in self-help programs, such as assertiveness training, positive

>To gain pt’ and SO’s trust and cooperation

>To obtain baseline data

>To note for the etiology or precipitating factors that can lead to fever.

>that may result in carelessness and increased risk taking without considerations of consequences

>To promote safe physical environment and individual safety

>To enhance self esteem. sense of worth

Short Term Objective: The patient shall have demonstrated behaviors, lifestyle changes to reduce risk factors and protect self from injury

Long Term Objective:The patient shall have been free of injury.

96

self image

>raise the side rails of the bed

>Frequent skin inspection

>Use effective lighting

>Remind client to walk slowly

>Keep things into right premises and clear the way going to the restroom

>To promote safe physical environment and individual safety

> To assess if there is presence of pressure ulcers.

>To promote safety and easy scanning of the environment.

>To prevent injury due to slipping, and to promote safety.

>To prevent injury and promote safety.

Problem No: 12 Self Care Deficit: Bathing/Hygiene

97

ASSESSMENTNURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATIONPLANNING

INTERVENTION

SRATIONALE

EXPECTED

OUTCOME

S= 0

The patient

manifested the

following:

O= w/ pale

palpebral

conjunctiva, w/

pale nail beds, w/

capillary refill

time, 1-3sec., pt.

is able to feel

deep touch, raise

his right arm and

leg, w/ slurred

speech, w/ left

sided weakness,

with limited ROM

on upper and

lower extremities,

afebrile, (-) DOB,

Self Care deficit

r/t

neuromuscular,

musculoskeletal

impairment

Body movements are

possible because of the

movement of impulses

elicited by such stimuli

which then passes

through our nerves

going to our neurons

which are then

interpreted by our brain.

Nerves and Neurons

serve as messengers. If

these are impaired, the

affectation to the brain

function would be

decreased function

which may later on

cause impairment also

to other structures of

the body and this could

affect the performance

of ADLs. An example of

that is Impaired ability

Short Term

Objective:

After 4 hrs. Of

Nursing

Intervention, the

pt. will be able to

identify personal

resources which

can help in

providing

assistance.

Long Term

Objective:

After 2-3 days of

nursing

intervention, the

pt. will be able to

demonstrate

techniques or

changes to meet

>Established

Rapport

>Monitored Vital

signs

>Assessed

patient condition

>Provided

adequate rest

periods as well as

comfort & safety

> To gain trust of

the patient and

SO in order to

acquire

compliance with

appropriate

treatments or

teachings

> To identify any

other deviations

from normal.

>To determine

any other

underlying cause

of manifestations

> To prevent

further stress &

fatigue

Short Term

Objective:

After 4 hrs. Of

Nursing

Intervention, the

pt. shall be able to

identify personal

resources which

can help in

providing

assistance.

Long Term

Objective:

After 2-3 days of

nursing

intervention, the

pt. shall be able to

demonstrate

techniques or

changes to meet

98

(-) chest pain.

The patient may

also manifest he

following:

>Inability to get

bath supplies

>Inability to wash

body parts

>Inability to pick

appropriate

clothing

>Inabiliy to

replace articles or

clothing on own

>Inability to

maintain

appearance at a

satisfactory level

to perform

bathing/hygiene,

dressing or grooming.

self care needs. measures

>Turned pt.

slowly from side

to side

>Determined pt.

strengths and

skills

>Assisted pt. in

his activities

>Encouraged

adequate intake

of fluids &

Nutritious foods

>Provided time

for listening to

patient and SO,

> To provide

proper circulation

of blood flow on

both sides of he

body

>To assess

degree of

disability

>To promote

optimal level of

function

>Promotes well-

being and

maximizes

energy

production.

>To assist with

the patient’s

current disability

self care needs.

99

and provided

privacy during

personal care

activities.

>Involved client’s

SO in care

> Provided health

teachings and

support o the SO

for care options

or condition.

>To assist in

learning ways of

managing

problems of

immobility and for

providing

appropriate

nursing care.

>To provide

clarification

Reinforcement

and and periodic

Review by

client/caregivers.

100

B. Actual Soapies

01-30-09

S =”masakit ku atsan”

O =received with patient lying on bed awake and coherent, afebrile with Ivf # 2 of D50.3 NaCl

regulated at 20 gtts/min at level of 400cc infusing well on right hand with indwelling folley

catheter connected to urine bag draining a dark yellow urine at level of 1000cc, with facial

grimace, with guarding behaviors, with dull abdominal pain, with pain scale of 8/10, with pale to

pink palpebral conjunctiva, with capillary refill time of 1-3 seconds, with left side paralysis, with

VS are as follows: Temp: 36.7c, PR: 71 bpm, RR: 21 bpm, BP: 130/70 mmHG

A =Acute Pain

P =After 2 hrs of nursing intervention the pt will verbalize relief of pain from 8/10 to 4/10

I = Established rapport

= Assessed and Recorded VS

= Maintained and Regulated IVF

= Assessed General Condition

= Encouraged diversional activities such as talking to S.O.

= Encouraged rest to overcome pain

= Assisted the pt to turn to side q 2hr

= Encouraged deep breathing and coughing exercises

= Provided comfort and safety measures

= Provided back rubbing to alleviate pain

= Secured and Documented Lab Result

= Seen on round by Dr lumboy with orders made and carried out:

-hold hydralazine IV PRN – meds updated

101

-for fecalysis – requested

-D/C ranitidine – meds updated

-Monitor BD q 4hr

-Bladder training q2

= Due meds Given as ordered and indicated by doctors

E = Goal met as pt verbalized a relief of pain

01-31-09

S=O

O = received with patient on bed conscious and coherent, afebrile with an IVF #2 d5 0.3 NaCl

500cc regulated at 20 gtts/min at level of 50cc infusing well on right hand with indwelling folley

catheter connected to a urine bag draining a dark yellow urine, with weak appearance, with

moist skin, with good skin turgor, (+) pallor, GCS of 15, with dec. Hgb 8mg, with dec. Hct 27 Vol.

right ext. 5/5 and 5/5 and left extremity of 0/5 and 4/5, with left side body paralysis.

A = Ineffective tissue perfusion r/t decreased Hgb concentration in the blood

P = after 4 hrs of nsg. Int. the pt will demonstrate understanding of health teachings

I = Established Rapport

= Assessed and Recorded VS

= Assessed General Condition

= Maintained and Monitored IVF

= Instructed pt to increase OFI

= Instructed pt to Iron rich foods

= Provided assistance in turning pt to side q 2 hr

= Provided ROM exercises to promote blood circulation

102

= Instructed pt on strict compliance to medication

= Changed IVF with D5o.3 NaCl 500cc regulated at 20 gtts/min

= Provided Adequate rest periods

= Assessed range of movement

= Prescribed all unavailable meds

= Provided health teaching regarding problems

E = Goal met As evidenced by pt and S.O. adheres with the health teachings

VI. CLIENT’S DAILY PROGRESS IN THE HOSPITAL

1. Client’s Daily Progress Chart (From admission to discharge)

Days 01-27-09

(Admission)

01-28-09 01-29-09 01-30-09 01-31-09

Nursing Problems:

1.) Acute Pain

2.) Impaired

cerebral tissue

perfusion

3.) Impaired

physical

mobility

4.) Activity

Intolerance

5.) Impaired verbal

and/or written

communication

6.) Risk for

Aspiration

7.) Risk for

impaired skin

integrity

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

103

8.) Risk for

deficient fluid

volume

9.) Risk for

imbalanced

nutrition: less

than body

requirements

10.) Risk for

Infection

11.) Risk for

Injury

12.) Self

care Deficit

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

Vital Signs:

Temperature

Pulse Rate

Respiratory rate

Blood Pressure

36.2c

84 bpm

18 bpm

170/100

mmHg

36.5c

88 bpm

22 mmHg

140/50

mmHg

37c

76 bpm

19 bpm

180/90

mmHg

36c

71 bpm

17 bpm

180/90

mmHg

36c

69 bpm

18 pbm

170/90

mmHG

Diagnostics

Procedures:

1.) CXR APL

2.) Fecalysis

3.) Urinalysis

4.) Potassium K

* *

*

*

104

5.) CBC

*

*

Drugs:

1. Piracetam

2. Captopril

3. Ranitidine

4. Simvastatin

5. Metoprolol

6. Ketosteril

7. FeSo4

8. Hydralazine

*

*

*

*

*

*

*

*

*

*

*

*

D/C

*

*

*

*

Hold

*

*

*

Medical

managements:

1. D5 LRS 1L

2. D5 0.3 NaCl

500cc

*

* * * *

Diet:

1. NPO

2. Soft Diet

*

* * * *

Activity/Exercises:

1. High Back Rest * * * * *

VII. Conclusion

105

Stroke is a term used to describe the neurologic changes caused by an

interruption in the blood supply to a part of the brain. The incidence of stroke and stroke

mortalities has gradually declined in many industrialized countries in recent years as a

result of increased recognition and treatment of risk factors, which may include

modifiable risk factors such as hypertension

Public education is focused on prevention, recognition of manifestations and

early treatment of brain attack. As they say prevention is better than cure. Therefore it is

important for each and every one of us to avoid these modifiable risk factors and

change sedentary lifestyles to healthy lifestyles. Cholesterol levels should be brought to

a normal level, diabetes should be controlled and reducing heavy alcohol consumption.

The best intervention is to stop smoking cigarettes.

As nursing students, this study showed us the importance of early detection of

diseases such as stroke since it may lead to more serious conditions if it is not properly

managed or treated. Knowledge of the risk factors and preventive measures can help in

reducing the incidence of stroke. Prompt recognition, which allows for early treatment of

stroke is recommended to lessen residual deficits and decreased disability. Through this

study, may we be able to help others to understand and know more about stroke and

ways to prevent and treat its signs and symptoms.

The group was able to assess one patient having a case of Cerebral vascular

accident and through the study of case the group was able to identify of the causative

factors that predisposes the patient in acquiring such disease condition. Furthermore

the group was able to identify how was it occurred and how it would be worse if left

untreated, with several condition such as this case a lot of problems has occurred that

would might permanently affect the lifestyle of the patient.

In this study the group was able to be familiarized to medical managements and

its benefits and s side effect to patient during therapy

106

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Smeltzer, S. et. al. (2008). Brunner and Suddarth’s Textbook of Medical-Surgical Nursing 11 th edition . Philadelphia: Lippincott-Williams & Wilkins

Spratto, G. and Woods, A. (2008). 2008 Edition PDR ® Nurse’s Drug Handbook . New York: Thomson Delmar Learning.

Berman, A. et. al. (2008). Kozier & Erb’s Fundamentals of Nursing: Concepts, Process and Practice 8 th edition Jurong, Singapore: Pearson Education South Asia

Seely, R., Stephens, T., Tate, P. (2007). Essentials of Human Anatomy & Physiology 6 th

edition. New York: McGraw-Hill.

Van Leeuwen, A., Kranpitz, T., Smith, L., (2006) Davis’s Comprehensive Handbook of Laboratory and Diagnostic Test with Nursing Implication 2 nd edition , U.S.A, F.A Davis Company

Nurse’s Quick Check - Signs and Symptoms (2006) Philadelphia, Lippincott Williams & Wilkins

Nurse’s 5- minute Clinical Consult – Diseases, (2007) Philadelphia, Lippincott Williams & Wilkins

Hansel, D., Dintzis, R. (2006) Lippincott’s Pocket Pathology, Philadelphia, Lippincott Williams & Wilkins

Stewart, Joseph (1989) Clinical Anatomy and Pathophysiology for the Health Professional, Miami, MedMasters Inc.

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