I. Introduction. Overview of the Study
Cerebrova Cerebrovascul scular ar Accident Accident:: The sudden death of some some brain brain cells cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain. A CVA is also referred to as a stroke. Symptoms of a stroke depend on the area of the brain affected. The most common symptom is weakness or paralysis of one side of the body with partial or complete loss of voluntary movement or sensation in a leg or arm. There can be speech problems and weak face muscles, causing drooling. Numbness or tingling is very common. A stroke involving the base of the brain can affect balance, vision, swallowing, breathing and even unconsciousness. A stroke is a medical emergency. Anyone suspected of having a stroke should be taken immediately to a medical facility for diagnosis and treatment. The causes of stroke: An artery to the brain may be blocked by a clot (thrombosis) which which typica typically lly occur occurs s in a blood blood vessel vessel that that has has previ previous ously ly been been narrow narrowed ed due due to atherosclerosis atherosclerosis ("hardening ("hardening of of the artery"). artery"). When When a blood clot clot or a a piece of atherosclerotic plaque (a cholesterol and calcium deposit on the wall of the artery) breaks loose, it can travel through the circulation and lodge in an artery of the brain, plugging it up and stopping the flow of blood; this is referred to as an embolic stroke. A blood clot can form in a chamber of the heart when the heart beats irregularly, as in atrial fibrillation; such clots usually stay attached to the inner lining of the heart but they may break off, travel through the blood stream, form a plug (embolus) in a brain artery and cause a stroke. A cerebral hemorrhage (bleeding in the brain), as from an aneurysm (a widening and weakening) of a blood vessel in the brain, also causes stroke. The diagnosis of stroke involves a medical history and a physical examination. Tests are done to search for treatable causes of a stroke and help prevent further brain damage. A CAT scan (a special X-ray study) of the brain is often done to show bleeding into the brain; this is treated differently than a stroke caused by lack of blood supply. A CAT scan also can rule out some other conditions that may mimic a stroke. A soundwave of the heart (echocardiogram) may be done to look for a source of blood clots in the heart. Narrowing of the carotid artery (the main artery that supplies blood to each side of the brain) in the neck can be seen with a soundwave test called a carotid ultrasound. Blood tests tests are done to look for sig signs ns of inflamm inflammatio ation n which which can suggest inflamed inflamed arteries arteries.. Certain blood proteins are tested that can increase the chance of stroke by thickening the blood. Stroke look-alikes: Just because a person has slurred speech or weakness on one side of the body does not necessarily mean that person has had a stroke. There are many other other nervou nervous s system system dis disord orders ers that that can can mimi mimic c a strok stroke e includ including ing a brain brain tumor, tumor, a subdural hematoma (a collection of blood between the brain and the skull) or a brain abscess (a pool of pus in the brain caused by bacteria or a fungus). Virus infection of the brain (viral encephalitis) can cause symptoms similar to those of a stroke, as can an overdose overdose of certain certain medicati medications. ons. Dehydration Dehydration or an imbalanc imbalance e of sodium, sodium, calcium, calcium, or glucose can cause neurologic abnormalities similar to a stroke. Treatment of a stroke: Early use of anticoagulants to minimize blood clotting has value in some patients. Treatment of blood pressure that is too high or too low may be nece necess ssar ary. y. (Low (Lower erin ing g elev elevat ated ed bloo blood d pres pressu sure re into into the the norm normal al rang range e is no long longer er recommended during the first few days following a stroke since this may further reduce blood blood flow flow throug through h narro narrowed wed arteri arteries es and make make the stroke stroke worse worse.) .) The blood blood sugar sugar glucose in diabetics is often quite high after a stroke; controlling the glucose level may minimize the size of a stroke. Drugs that can dissolve blood clots may be useful in stroke
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treatment. Oxygen is given as needed. New medications that can help oxygen-starved brain cells survive while circulation is reestablished are being developed. Rehabilitation: When a patient is no longer acutely ill after a stroke, the aim turns to maximizing the patient's functional abilities. This can be done in an inpatient rehabilitation hospital or in a special area of a general hospital and in a nursing facility. The rehabilitation process can involve speech therapy to relearn talking and swallowing, occupational therapy for regaining dexterity of the arms and hands, physical therapy for improving strength and walking, etc. The goal is for the patient to resume as many of their pre-stroke activities as possible.
II. Patient Profile. Client’s Name: Mrs. S Age: 82 years old Address: Kawit, Cavite Sex: Female Religion: Roman Catholic Date of admission: February 07, 2011 Time of admission: 11:35 am Chief complaint: Slurring of Speech Admitting diagnosis: t/c CVA prob. Infarct, (L) MCA Attending physician: Dr. G. Espiritu
II. Patient History. History of Present Illness: 5 days PTA - Px was noted to have slurring of speech, sought consult to AP & admitted at Salamanca Hospital then transferred @ Bautista Hospital; Px’s relatives opted transfer to Cavite Medical Center hence admission.
Family Health History: (-) DM (-) BA (-) Allergies
Past Health History: *No previous surgery or confinement
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III. Physical Assessment. Vital signs The client’s pulse rate is 88 beats per minute, her respiratory rate is 20 breaths per minute, temperature is 37°c, blood pressure is 160/90. General appearance The client is in medium frame with decorticate posture, the client is bedridden since she was admitted to the hospital last February 07, 2011. Well groomed and has no body odor. She doesn’t have any deformity. Mental status The client can’t talk because she was stroke. Skin The client’s skin is of normal racial tone which is brown. It is dry and smooth. The skin turgor is wrinkled and loss of elasticity. The body hair is evenly distributed. She doesn’t have any edema. Nail The client’s nail shape is convex clubbing, the nail is rough and the nail bed is pink. The capillary refill is within 3 seconds and this is an absence of beau’s line. Head and Face The client’s skull is proportionate to the body size, There were no tenderness in the scalp. There were no presence of nodules, and infestation. Her hair is evenly distributed and the strands are thin and brittle. The color of her hair is a mixture of white and black. Her head is round and symmetrical its consistency is hard. She can’t control her head and the shape of her face is round and asymmetrical and its consistency is soft. Eyes Pupils are equal in size. Pupils are equally round and reactive to light and accommodation. The lacrimal apparatus are moist. Ear The color of the ear is of normal racial tone which is brown, it is symmetrical. The alignment of the pinna is symmetrical. The pinnas are elastic and recoil when folded. The mastoid process is tender. The auditory canal contains some cerumen, the color is brown and there is an absent of discharges.
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Nose The color of the client’s nose is of racial tone which is brown. Her septum is in the midline. The mucosa is pink, nostrils are both patent, nasal flaring is absent. Landmarks are visible. Sinuses are non-tender. There is an NGT in her right nostrils.
Mouth and Oropharynx The lips is symmetrical and pink, the consistency is smooth, buccal mucosa is pink, the gum is pink, the tongue is in the midline, the color is pink and it is smooth. The tongue movements are not that smooth. Neck The neck has involuntary movement and with resistance, the muscle strength 3/5. The trachea is in the midline, thyroid is in the midline and it is smooth. Maxillary lymph nodes are palpable. Breast The breasts are symmetrical with flat contour. Shape is flat, the skin surface is smooth. Chest and Lungs The color of the chest is of normal racial tone which is brown, the shape is AP to lateral ratio 1:2. There is absence of intercoastal retraction, costal angle is 45° chest wall are symmetrical, and the chest expansion is symmetrical. No adrentition sound. Respiratory rate is 20 breaths per minute. Heart The rhythm is regular. PMI is located in the apical pulse. Heart rate is 88 beats per minute. Abdomen Skin is of normal racial tone which is brown, the contour is flat. Peristalsis is non-visible. Upper extremities The client cannot resist force when asked to resist. Muscle strength is 3/5. She have a skin lesion in her right elbow, The peripheral pulses are equal. Lympnodes are not palpable. The IV site is in her left arm. Lower extremities The client cannot resist force when asked to resist. Muscle strength is 2/5. she doesn’t have any deformity. The peripheral pulses are equal. Lympnodes are non-palpable.
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VI. Anatomy and Physiology.: BRAIN Cerebrum - The biggest part of the brain is the cerebrum. The cerebrum makes up 85% of the brain's weight, and it's easy to see why. The cerebrum is the thinking part of the brain and it controls your voluntary muscles Cerebellum - The cerebellum is at the back of the brain, below the cerebrum. It's a lot smaller than the cerebrum at only 1/8 of its size. But it's a very important part of the brain. It controls balance, movement, and coordination (how your muscles work together). Brain Stem - The brain stem sits beneath the cerebrum and in front of the cerebellum. It connects the rest of the brain to the spinal cord, which runs down your neck and back. The brain stem is in charge of all the functions your body needs to stay alive, like breathing air, digesting food, and circulating blood. Midbrain/ Mesencephalon - the rostral part of the brain stem, which includes the tectum and tegmentum. It is involved in functions such as vision, hearing, eyemovement, and body movement. The anterior part has the cerebral peduncle, which is a huge bundle of axons traveling from the cerebral cortex through the brain stem and these fibers (along with other structures) are important for voluntary motor function. Pons - part of the metencephalon in the hindbrain. It is involved in motor control and sensory analysis... for example, information from the ear first enters the brain in the pons. It has parts that are important for the level of consciousness and for sleep. Some structures within the pons are linked to the cerebellum, thus are involved in movement and posture. Medulla Oblongata - is the lower portion of the Brainstem. It deals with autonomic functions, such as breathing and blood pressure. The cardiac center is the part of the medulla oblongata responsible for controlling the heart rate. Hypothalamus - The hypothalamus is like your brain's inner thermostat (that little box on the wall that controls the heat in your house). The hypothalamus knows what temperature your body should be (about 98.6° Fahrenheit or 37° Celsius). 5
VII. Pathophysiology. VIII. Nursing Care Plan. Assessment Subjective: “Suka siya ng suka” as verbalized by the patient’s mother. Objective: Cool extremities Sunken eyes Dry skin Watery stool Persistent vomiting
Diagnosis
Planning
Intervention
Evaluatio n At the end of • Encourage to increase At the end Impaired verbal 4 hours fluid intake of 8 hours communication nursing Rationale: To regain fluid nursing related to intervention, loss. interventio neuromuscular the patient n, the impairment as will be able to • Monitor intake and output patient evidence by restore fluid balance. was able to absence of and Rationale: To ensure restore responding electrolyte accurate picture of fluid fluid and imbalances status electrolyte imbalances • Observed for excessively dry skin and mucous Goal Partially membranes, decreased skin Met turgor, slowed capillary refill. Rationale: Indicates excessive fluid loss/resultant dehydration Dependent: Provide supplement fluids as indicated D5LR 1Lx8 o Rationale: Fluids may be given in this manner if patient is unable to take oral fluid
IX. Laboratory Test. CBC: Result
Normal Value
Interpretation 6
Hemoglobin
183 g/L
Hematocrit
0.38 %
White Cell Count
Female: 110 – 170 g/L Female: 0.37% - 0.54%
14,351 g/L
UA: Color – Light Yellow CHON – Negative Epithelial Cells – Few
Dehydrationproduces a falsely high hemoglobin which disappears when proper fluid balance is restored. Normal
4,500 - 10,000 g/L
Transparency - Hazy
Occurs an infection, allergy, systemic illness, inflammation, tissue injury, and leukemia.
Glucose – Negative
Reaction (pH) – 7.5 RBC – 0 – 2/hpf
Mucus Threads – Moderate
Urate/Phospates - Moderate
Specific Gravity – 1.010 PUS Cells – 1 – 2/hpf Bacteria - Moderate
X. Drug Study: Drug Name Cifroflaxa cin Cipro “antibiotic”
Drug Name
Action
Indication
Ciprofloxacin inhibits an enzyme called DNA gyrase that is an essential component of the mechanism that passes genetic information onto daighter cells when a cell divides.
Recommended for use against against a wide variety of infections when susceptibility is demonstrated. Specific dosage regimes are at the discretion of the attending physician acting on information from the manufacturer and the national authority for drug safety and use. Suggested dosages for specific agents may be on the individual agent pages,
Action
Indication
Contraindication Any previous adverse reaction to Ciprofloxaci n. Avoid giving to adolescent s, pregnant or lactating women, those with known neurologica l problems.
Contraindication
Adverse Effects Dizziness to tremors, hallucinations, psychosis and convulsions have been seen in small numbers of patients. As with many other antibiotics it can kill the healthy bacteria of the gut and give rise to a disorder called pseudomembra nous colitis. It can also make users sunburn easily and can cause muscle or tendon inflammation or damage. Adverse Effects
Nsg. Resp This medication may make you more sensitive to the sun. Avoid prolonged sun exposure, tanning booths, and sunlamps. Use a sunscreen and wear protective clothing when outdoors. This medication may be taken with or without food, usually twice a day in the morning and evening or as directed by your doctor. .
Nsg. Resp 7
Omepraz ole Omepron “GI Agent”
Drug Name
Gastric acidpump inhibitor: Suppresses gastric acid secretion by specific inhibition of the hydrogenpotassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the final step of acid production.
Short-term treatment of active duodenal ulcer; First-line therapy in treatment of heartburn or symptoms of gastroesophageal reflux disease (GERD); Short-term treatment of active benign gastric ulcer; GERD, severe erosive esophagitis, poorly responsive symptomatic GERD; Long-term therapy: Treatment of pathologic hypersecretory conditions (Zollinger-Ellison syndrome, multiple adenomas, systemic mastocytosis); Eradication of H. pylori with amoxicillin or metronidazole and clarithromycin; Prilosec
Contraindic ated with hypersensit ivity to omeprazole or its component s; Use cautiously with pregnancy, lactation.
CNS: Headache, dizziness, asthenia, vertigo, insomnia, apathy, anxiety, paresthesias, dream abnormalities Dermatologic: Rash, inflammation, urticaria, pruritus, alopecia, dry skin GI: Diarrhea, abdominal pain, nausea, vomiting, constipation, dry mouth, tongue atrophy Respiratory: URI symptoms, cough, epistaxis Other: Cancer in preclinical studies, back pain, fever
Administer before meals. Caution patient to swallow capsules whole not to open, chew, or crush them. Arrange for further evaluation of patient after 8 wk of therapy for gastroreflux disorders; not intended for maintenance therapy. Symptomatic improvement does not rule out gastric cancer, which did occur in preclinical studies.
Action
Indication
Contraindication
Adverse Effects
Nsg. Resp
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Erceflora “Antidiarrhe als”
Drug Name Buscopan HYOSCINE BUTYLBROMI DE “Antispasmo dic”
Contributes to the recovery of the intestinal microbial flora altered during the course of microbial disorders of diverse origin. It produces various vitamins, particularly group B vitamins thus contributing to correction of vitamin disorders caused by antibiotics & chemotherape utic agents. Promotes normalization of intestinal flora.
Acute diarrhea with duration of ≤14 days due to infection, drugs or poisons. Chronic or persistent diarrhea with duration of >14 days.
Not for use in immunocom promised patients (cancer patients on chemothera py, patients taking immunosupp ressant meds)
CNS: Headache, dizziness, asthenia, vertigo, insomnia, apathy, anxiety, paresthesias, dream abnormalities Dermatologic: Rash, inflammation, urticaria, pruritus, alopecia, dry skin GI: Diarrhea, abdominal pain, nausea, vomiting, constipation, dry mouth, tongue atrophy Respiratory: URI symptoms, cough, epistaxis Other: Cancer in preclinical studies, back pain, fever
Action
Indication
Contraindication
Contributes to the recovery of the intestinal microbial flora altered during the course of microbial disorders of diverse origin. It produces various vitamins, particularly group B vitamins thus contributing to correction of vitamin disorders caused by antibiotics & chemotherape utic agents. Promotes normalization of intestinal flora.
Relief of smooth muscle spasm of the gastrointestinal and genitourinary systems
• contraindicate d in Glaucoma
Adverse Effects • tachycardia
• other adverse effects include: dry mouth, decreased perspiration, mydriasis, increased intraocular pressure • use with caution in prostatic hypertrophy
• Shake drug well before administration. • Monitor patient for any unusual effects from drug. • Administer drug wi thin 30 minutes after opening container. • Dilute drug with sweetened milk, orange juice or tea. • Administer drug orally.
Nsg. Resp Drug compatibility should be monitored closely in patients requiring adjunctive therapy. The safety of Buscopan has not been established for intramuscular (IM) administration. Administration of Buscopan results in heart rate elevation. Heart rate can not be used as a valid indicator of severity of pain for 30 minutes following IV injection.
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X. Discharge Planning. Medication: • Patient has to continue his medication. Amlodipine 5mg/ tab once a day, Zantac 150 mg twice a day, 8am and 6pm. Exercise: • The patient was advised to have complete bed rest until strength is regained. Have turn side to side every 2 hours to prevent bed soars. Have ROM exercise on to enhance client's body function. Treatment: • Should undergo speech therapy to learn talking and swallowing. Oxygen inhalation if necessary and if possible 3-4 liters per minute. Health Teaching: • Teach the client how to have a healthy lifestyle. Teach patient the foods to eat and the foods to avoid. Teach the family members how to prepare low sodium and low fat diet. Encourage environmental modification to enhance safety and prevent injury. Out Patient Follow-Up: • The client was advised to have a follow-up check-up, as indicated by the physician. Diet: • Patient was instructed to maintain the low salt and low fat diet. The low salt diet is designed to induce a loss of sodium and water from the body or avoid sodium retention. A 2000 mg low sodium diet is sufficient to control blood pressure. A low fat diet help lose weight to decrease risk of having CVA again
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Emilio Aguinaldo College College of Nursing Dasmariñas, Cavite
Case Study of
Acute Gastroenteritis In Partial Fulfillment of the Requirement in NCM 104 – RLE
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Submitted To:
Fritz Ian Estrella Floresca, RN Submitted By: Group 3 (2nd Group) Pineda, Paul Stephen E. Regala, Laarni Nasser Robles, Robin Sabilala, Neil Anderson Solis, Michelle Tana, Kim Aron Zamora, Ma. Cristina
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