Cerebrovascular accident

Angeles University Foundation Foundation Angeles 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 Requelito Estrada, Florence Ancel BSN III-1 Group 1

Submitted Submitt ed To: Fe Pagado R.N., M.N.

February 21, 2009

I. Introduction

Many studies studies were were conduct conducted ed regardin regarding g cerebro cerebrovasc vascular ular acciden accidents ts tackling 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.

Cereb Cerebro rovas vascu cular lar accid acciden entt (CV (CVA) is the the medic medical al term term for what what is comm common only ly 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 omen and and most most of the the case cases s are are amon among g Afri Africa can n Ameri merica can. n. (Access (Accessed ed on: http://www.wikidoc.org/index.php/Cerebrovascular_accident) A. Current Trends about the Disease Condition Blunt Blunt cerebrov cerebrovascu ascular lar injuries injuries can be diagnos diagnosed ed using using whole whole body 16 multimultidetec detector tor CT (MDCT (MDCT); ); there' there's s no need need for for an addit addition ional al neck neck MDCT MDCT angio angiogra graphy phy examination according to a recent study conducted by researchers at the University of  Maryl Maryland and Medica Medicall Cente Centerr and and R. Adams Adams Cowle Cowley y Shock Shock Traum rauma a Cente Centerr, both both in Baltimore, MD. The study showed that whole body MDCT is just as accurate as neck MDCT MDCTA. Blunt Blunt cerebrov cerebrovasc ascula ularr injuries injuries are uncomm uncommon on but potenti potentially ally devasta devastating ting 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 examined with either whole-body whole-body MDCT or neck MDCTA MDCTA followed by angiography angiography over  a 23-m 23-mont onth h perio period. d. From From this this grou group, p, 77 whole whole body body MDCT MDCT and 48 neck neck MDCT MDCTA examina examination tions s were compared compared with the results that were were pulled pulled from from the reports of  correlative angiography.

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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 show showed ed low sens sensiti itivit vity y for blunt blunt carot carotid id (69% (69% for whole whole-bo -body dy MDCT MDCT and and 64% 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). MDCTA). The two techniques diagnosed blunt cerebrovascular cerebrovascular injuries with statistically statistically comparable comparable accuracy. accuracy. Routine use of whole-body 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/arrswbm032808.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 instructor to utilize a medical case, and with the approval approval of their clinical instructor instructor,, the group came up into a medical case case of a 58 years old widowed female 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



Perform a comprehensive assessment of Cerebrovascular accident



Enumerate the different signs and symptoms of Cerebrovascular accident

3



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 Shall have have criti critica call thinki thinking ng skill skills s nece necessa ssary ry for provi providi ding ng safe safe and and effe effecti ctive ve nursing care.

•

Shall Shall have have a comp compreh rehens ensive ive asses assessm sment ent and and imple impleme ment nt care care base base on our  knowledge and skills of the condition

•

Shall Shall have have familia familiarize rized d us with effect effective ive inter-pe inter-person rsonal al skills skills to emphas emphasized ized 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 measures that could could minimize minimize the risk of occurrence occurrence of the the disease. 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 family’s support support system system and distinguish distinguish their their respective respective roles roles in improving patient’s health status. 5. Involve them in promoting the health care of the patient.

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II. Nursing Assessment

A. Pers Person onal al Dat Data a

1. Demo Demogr grap aphi hic c dat data a

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-e Socio-econ conomic omic and Cultu Cultural ral Facto Factors rs 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 affil affilia iated ted to Roma Roman n Catho Catholic lic.. As ment mention ioned ed the famil family y belie believe ved d 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 present her daughte daughters rs support support her daily expenses expenses including including household bills.

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B. Pertinent Family Health History Disney Family

Father

Mother

Legend: Renal Heart

Sister

Sister

HPN CVA, HPN, DM, Renal Disease

Mrs.

Mr. Sanrio

E ile s Liver Normal

Dau hte

Dau hte

Dau hte

Dau hte 6

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 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 Upon inter intervi view ew,, her her daug daughte hterr told told the stude student nt nurse nurses s that that Mrs. Mrs. Sanri Sanrio o was was diagnosed diagnosed of Diabetes Diabetes Mellitus Type II in the year 2004, and she is taking Diamicron Diamicron as her medication, according to her mother is also fond of eating foods which are rich in fat

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 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 Upon inter intervi view ew,, her her daug daughte hterr told told the stude student nt nurse nurses s that that Mrs. Mrs. Sanri Sanrio o was was diagnosed diagnosed of Diabetes Diabetes Mellitus Type II in the year 2004, and she is taking Diamicron 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 large pus pus filled filled lesion lesion in the the year year 2008. 2008. Tog Togeth ether er with with that that durin during g her her stay 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. 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 narra narrated ted by Tinky inky winky winky at the distri district ct hosp hospita itall 2-3 2-3 days days prior prior to Kitty Kitty’s ’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. 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 her as she can feel that her conditions aggravates every time someone will touch her. 7

According also to Tinky winky upon seeing her mother, she have noticed that there is an obvious asymmetry asymmetry on her mother’s face “balamu mekubit ya lupa, balamu babalag ya lupa” and lupa” and slurring of speech, she then had an idea that it may be a stroke. They planned planned to bring bring Kitty Kitty to a private private hospital, hospital, but Mrs. Sanrio Sanrio disagre disagreed ed 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. Physic Physical al Examina Examinatio tion n January 27, 2009 (lifted from chart)

Patient has chief complaints of left sided body weakness, conscious, alert, (+) faci facial al asym asymme metr try y, norm normal al rate rate and and regu regula larr rhy rhythm, thm, clea clearr brea breath th soun sounds ds,, normoactive bowel sounds, GCS= 15, BP= 200/100 mmHg, PR= 85, RR= 16 R 5/5

5/5

L 1/5

1/5

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

8

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.

Patient has the following vital signs:

T= 35.8 ° C

R

L

5/5

0/5

5/5

4/5

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  norm normal al find finding ings s char charact acteri erized zed by pupil pupils s which which are are equall equally y round round in shape shape,, reactive to light and accommodation, with her right eyebrows evenly distributed and and symme symmetri trical cally ly align aligned. ed. With With eyelas eyelashe hes s of norma normall grow growth, th, there there are 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. Furthe Furtherr more more upon upon the asse assessm ssmen entt of the the throa throatt and and the the mouth mouth,, the the researchers have noted the following manifestations: lips that are dark and dry, 9

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 extremity 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 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

R 5/5

L 1/5

P= 63 bpm R= 18 cpm

5/5

4/5

BP= 170/60 mmHg

10

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  norm normal al find finding ings s char charact acteri erized zed by pupil pupils s which which are are equall equally y round round in shape shape,, reactive to light and accommodation, with her right eyebrows evenly distributed and symmetrically symmetrically aligned. aligned. Patient has has eyelashes eyelashes of normal growth, growth, with dried exudates exud ates,, with a pres prescrib cribed ed eyeg eyeglass lasses es “200 ya gradu ing salamin na” . na” . No periorbital edema noted, cornea is transparent and shiny. Ears are of normal findings. Nose is also of normal findings. Furthe Furtherr more more upon upon the asse assessm ssmen entt of the the throa throatt and and the the mouth mouth,, the 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 extremity 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

RESULTS

NORMAL VALUES

ANALYSIS AND INTERPRETATION

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. gy.

CLINICAL CHEMISTRY

Date Ordered: 1/27/09 FBS

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  117mg/dL overnight. It is a test that is routinely done in all clients with possible cardiovascula r disorders to determine blood glucose levels.

FBS, Blood:  Pre-test: 1. Info Inform rm the the pati patien entt that that the the test test is used used to assi assist st in the the eval evalua uati tion on of fast fastin ing g hypoglycemia 2. Obtain Obtain a history of the patient patient’s ’s complain complaints, ts, including including a list of known allerge allergens ns such as allergy to latex. 3. Obta Obtain in a hist histor ory y of the the pati patien ent’ t’s s endo endocr crin ine e syst system em and and resu result lts s of prev previo ious usly ly performed laboratory tests, surgical procedures, and other diagnostic procedures.

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4. Note any any procedu procedures res that that can interfe interfere re with the the test result results. s. 5. Obta Obtain in a list list of medi medica cati tion ons s pati patien entt is taki taking ng,, incl includ udin ing g herb herbs, s, and and nutr nutrit itio iona nall supplements. 

1. 2. 3. 4. 5.

Intra-test; Ensure that that the patient has has complied complied with dietary or medication restrictions and other  other  pretesting preparations. Instru Instruct ct the the patie patient nt to coope cooperat rate e fully fully and to follow follow direct direction ions. s. Direct Direct patien patientt to breathe normally and to avoid unnecessary movement. If the patient patient has has a history of severe severe allergic allergic reactio reaction n to latex, latex, care should should be taken taken and to avoid the use of equipment containing latex. Obse Observe rve Stan Standa dard rd preca precauti ution ons. s. After obtaining obtaining the the specimen, specimen, promptly promptly transport transport to the the laboratory laboratory for processing processing and and analysis.

Post-test: 1. Observe Observe venipunc venipuncture ture site site for bleeding bleeding or hematom hematoma a formation. formation. 2. Instruct the patient patient to report signs signs and symptoms symptoms of hypoglycemia hypoglycemia or hyperglycemia. hyperglycemia. 3. Emphasize Emphasize that good good glycemic glycemic control control delays the the onset of and slows the progression of diabetic retinopathy, nephropathy, and neuropathy. 4. Reinforc Reinforce e informatio information n regarding regarding the test results results and address address concern concerns s voiced by the family or the patient. It is checked in order to assess Date a known and requested The potassium suspected : 3.6 3.5 – 5.3 electrolyte level disorder  1/27/09 mmoL/L mmoL/L is within normal associated with Potassium range. renal disease, Date glucose results in: metabolism, 1/28/09 trauma or  burns. Potassium, blood,  Before 



1. Check Check the docto doctor’s r’s order  order  2. Expl Explai ain n the the proc proced edur ure e 3. Explain Explain the purpose purpose and and what what to to expec expectt 4. No foo food d or or fluid fluid restri restricti ction ons s During 1. 2. 3. 4. 5.

Do not take take the blood blood sampl sample e from hand hand or arm with with receiving receiving IVF IVF The tourniqu tourniquet et shou should ld be less on a minute minute Do not not squee squeeze ze the the punctu punctured red site site right rightly ly Wipe Wipe away away the the firs firstt drop drop of bloo blood d Collect Collect 2ml 2ml venous venous blood blood in a lavend lavender er top top tube tube

13



After  1. 2. 3. 4. 5.

Obse Observe rved d and and record record vital vital signs. signs. Check injection sites for for bleeding, bleeding, infection, infection, tenderness tenderness or thrombosis. thrombosis. Report Report untowa untoward rd reacti reaction on to to the the physicia physician. n. Apply Apply warm warm compres compress s to ease ease discomf discomfort, ort, as as ordered. ordered. Encou Encourag rage e relaxa relaxatio tion n by allow allowing ing client client to discu discuss ss experi experien ences ces and verba verbaliz lize e feelings. 6. Interpret results and and provide provide counsel counsel appropriately appropriately.. Provide health teachings teachings regarding proper lifestyle changes and symptoms that may warrant immediate medical attention. The creatinine level is The creatinine Date significantly test is used to requested above the diagnose : normal limits impaired kidney 1/27/09 41mg/dL which is a 0.6 – 1.2 Creatinine function and to result of renal mg/dL determine renal impairment Date (kidney) related to the results in: damage. client’s active 1/28/09 renal disease.

BUA

Date requested : 1/27/09 Date results in: 1/28/09

BUN

Date requested : 1/27/09 Date

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. Blood urea nitrogen (BUN) measures the amount of urea nitrogen, a waste product

8.5 mg/ dL

64 mg/dL

2.0 – 6.0 mg/dL

The uric acid level is significantly above the normal limits this also gives  justification  justification to the deteriorating function of the renal system.

7-18 mg/ dL

The BUN level is significantly above the normal limits which denotes an impairment

14

results in: 1/28/09

of protein metabolism, in the blood. Urea is formed by the liver and 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.

in renal function

Creatinine, BUN, BUA, Blood, 



Prior: 1. Select Select vein for for venipunctu venipuncture re (usually (usually antecub antecubital ital space). space). 2. Apply Apply tournique tourniquett several several inches above above intende intended d venipunctu venipuncture re site 3. Clean venipunctu venipuncture re site (with povidone povidone iodine iodine or alcohol, allow area area to dry). dry). During: 1. Perform venipuncture venipuncture by entering entering the skin with needle needle at approximately approximately a 15-degree

15



angle to the skin, needle bevel up. 2. If using a Vacutainer, acutainer, ease tube forward in holder holder once once in the vein. If using using a syringe, syringe, pull back on the barrel with slow, even tension as blood fills the syringe. 3. Release Release tourniq tourniquet uet when when the blood blood begin begins s to flow. flow. After: 1. After the blood is drawn, drawn, place place cotton ball over site; site; withdraw the needle needle and exert exert pressure. Apply bandage if needed. 2. Properly Properly dispose dispose contami contaminate nated d materi materials. als. 3. Record the date and time of blood blood collection. collection. Attach a label to each each blood blood tube. 4. Relay Relay res result ults s to the the doct doctor or.. LIPID PROFILE This is a blood test that measures a kind of fat (lipid) in the Date requested blood. The HDL The LDL level is test helps : within the check your risk 1/27/09 30mg/dL > HDL normal range for heart 87mg/dL disease or  Date atherosclerosis, results in: which is a 1/28/09 hardening, narrowing, or  blockage of the arteries.

CHOLESTEROL

Date requested : 1/27/09 Date results in: 1/28/09

LDL

Date requested :

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. The LDL test measures how much lowdensity

351 mg/dL

140250mg/dL

219 mg/dL

<178 mg/dL

The client has an increased cholesterol level which is one of the precipitating factor of the client’s Hypertension.

This is also one of the factors that aggravates or  16

1/27/09 Date results in: 1/28/09

Triglycerides

lipoprotein (LDL) you have in your blood. Too much LDL in the blood can clog arteries.

triggers the client’s hypertensive episodes.

A test to determine the cholesterol level circulating in the bloodstream

This is also one of the factors that aggravates or  triggers the client’s hypertensive episodes.

209 mg/dL

10190mg/dL

Total Cholesterol Test: (NSG. Implications)  Pretest: 1. Inform Inform the patient patient that that the test test is used to assess assess and monito monitorr risk for coronary coronary artery artery disease. 2. Obtain history history of the patient’s patient’s past past health health history and previously previously performed performed laboratory laboratory tests, surgical procedures, and other diagnostic procedures. 3. Instruct the the patient patient to withhold withhold drugs and alcohol alcohol known to alter cholesterol cholesterol levels for  12 to 24 hours before specimen collection. 4. Fast Fastin ing g 6 to 12 hour hours s befo before re spec specim imen en coll collec ecti tion on is requ requir ired ed if trig trigly lyce ceri ride de measure measuremen ments ts are included included;; it is recomme recommende nded d if choleste cholesterol rol levels levels alone alone are measured for screening. 

1. 2. 3. 4. 5. 6. 

1. 2.

3. 4. 5.

Intratest: Ensure that the patient has complied with the dietary restrictions and pre testing precautions. If the patient has a history history of severe severe allergic allergic reaction to latex, care should should be taken to avoid the use of equipment containing latex. Instruct Instruct the client client to coope cooperate rate fully fully and to follow follow directio directions. ns. Obse Observe rve Stan Standa dard rd Preca Precauti ution ons. s. Remove the needle needle and and apply pressure dressing over over the puncture site. Immediately Immediately transport transport the specimen to the laboratory for processing processing and and analysis. analysis. Post-test: Observe Observe venipunc venipuncture ture site site for bleeding bleeding or hematom hematoma a formation. formation. Instruct Instruct the patient patient to reduce reduce intake intake of foods foods high in saturated saturated fats fats and cholester cholesterol ol and triglyceride levels. (E.g. red meats, eggs, and dairy products are major sources of saturated fats and cholesterol. Consider Consider social social and cultur cultural al beliefs beliefs and practice practices s of the client. client. Recogniz Recognize e anxiety related related to test results. results. Discuss Discuss the implicatio implications ns of abnormal abnormal test results on the patient’s lifestyle. Provide teaching and information information regarding the clinical clinical indications indications of the test test results.

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BLOOD HEMATOLOGY

Hemoglobin (Hgb)

Date requested : 1/27/09 Date results in: 1/28/09

Hematocrit (Hct)

Date requested : 1/27/09

Date results in: 1/28/09

WBC

Date requested : 1/27/09 Date results in: 1/28/09

Neutrophils/ Segmenters

Date requested : 1/27/09

- to monitor  Hgb value in the RBC - to suggest the presence of  body fluid deficit due to elevated Hgb level To aid diagnosis of  abnormal states of  hydration, polycythemia and anemia.

8.0mg%

27.0 vol%

- It measures the concentration of RBC within the blood volume and is expressed as a percentage. 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 To detect presence of  infection in the body

4900/ cu. mm

76%

12-16 mg%

37-47 vol%

5-10 x 103mm

50-70%

The patient having a decreased hemoglobin level with accompanying signs of pallor  indicates that the client has anemia.

The hematocrit level is below the normal range, which denotes a decreased concentration of RBC in the blood or  hemodilution.

The WBC count is below the normal limits a decrease or  increase in the WBC count denotes infection or  inflammation.

The Neutrophils is above the normal limits indicating infection.

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Lymphocytes

Date results in: 1/28/09 Date requested : 1/27/09 Date results in: 1/28/09

Eosinophils

Date requested : 1/27/09

To detect presence of  infection within the body.

To detect presence of  infection within the body.

24%

1%

25-40%

1-4%

The number of  lymphocytes is slightly decreased which indicates infection

The eosinophils count is within the normal range

Date results in: 1/28/09 Nursing Implications Implicati ons for Blood Hematology Test:  Pretest: 1. Inform the the patient patient that the test is used used to evaluate evaluate numerous numerous conditions conditions inflammat inflammation, ion, infection, and response to chemotherapy. 2. Obtain a history of the patient’s patient’s complaints complaints (such (such as allergies allergies and sensitivity sensitivity to latex. 3. Obta Obtain in a histor history y of the patie patient’ nt’s s gastr gastroin ointe testi stina nal, l, hemato hematopo poiet ietic, ic, immun immune, e, and and respirat respiratory ory systems, systems, as well as results results of previous previously ly performe performed d laborato laboratory ry tests, tests, surgical procedures, and other diagnostic procedures. 4. Obta Obtain in a list list of medi medica cati tion ons s the the pati patien entt is taki taking ng,, incl includ udin ing g herb herbs, s, nutr nutrit itio iona nall supplements, and nutraceuticals. 5. Review Review the procedu procedure re with the patient patient.. Explain Explain the duration duration of the proced procedure ure and inform the client that there may be some discomforts during the procedure. 6. Consid Consider er the the patie patient nt’s ’s cultural cultural beliefs beliefs and practice practices s and and it is impor importa tant nt to provid provide e psychological support before, during, and after the procedure. 

1. 2. 3. 4. 5.

Intratest: Avoid using equipmen equipmentt containing containing latex latex if the patient has allergy allergy to it. Instruct Instruct the patient patient to cooperat cooperate e fully and to follow directi directions. ons. Direct Direct the patient patient to breathe normally and to avoid unnecessary movement. Obse Observe rve Stan Standa dard rd preca precauti ution ons. s. Remove the needle, needle, and and apply apply a pressure pressure dressing dressing over over the puncture site. Promptly transport the specimen specimen to to the laboratory laboratory for processing processing and and analysis. analysis.

19

Post-test: 1. Observe Observe venipunct venipuncture ure site for bleeding bleeding or hematoma hematoma formatio formation. n. Apply Apply paper paper tape or  other adhesive to hold pressure bandage in place. 2. Instruct the patient patient to limit salt intake, alcohol alcohol intake intake and cut down down smoking. smoking. 3. Reinforce information information regarding regarding the test test results and address address any concerns voiced by the patient or family. 

IMAGING

CXR APL

Date requested : 1/27/09 Date results in: 1/30/09

Chest Roentgen ogram reveals X-rays a minimal diagnost diagnostic ic test hazy which uses infiltrates invisible on both electromagneti lower  c energy lung beams to fields. produce images of   Heat and great internal tissues, vessels bones, and are of  organs onto normal film film.. Ches Chestt size and radiographs configurat may depict ion. segm segmen enta tall or  loba lobarr infi infilt ltra rate te but but they they more more Hemidiag phragms, commonly reveal a sulci, and other  diff iffuse, se, fin fine, visualized reticulogranular  patt patter ern, n, much much including chest like what is observed in structures are RDS. RDS. Pleu Pleura rall effus effusion ions s may unremark able. also be observed. Remarks: Pneumon itis , bilateral

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

The chest xray denotes abnormal features of the patient lungs, it shows that her  both lung parenchyma are inflamed.

Nursing Implication 

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

20

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

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

Consistency:

Soft

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 Consiste ncy: Soft Trichiuris: 0-1/hpf 

Trichiuris: none Amoeba: None Hookworm: None

Fecalysis shows that the patient has a positive parasitic infestation specifically trichiuris

Pus Cells: None RBC: None Bacteria: None

Nursing Implication 

1. 2. 3. 4.

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

During: 1. Prov Provid ide e pri priva vacy cy.. 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. 



 After:

21

1. Continue taking the the medications medications that were were stopped stopped prior to the procedure. procedure. URINALYSIS Urinalysis Color: shows that Yellow Color: patient is Yellow manifesting Appearance: pyuria Clear  Appearance: This was done indicating Clear  to the patient infection as a screening Ph: Acidic Date within the Ph: Acidic for  requested urinary tract. Pus abnormalities : She also Cells: Pus Cells: within the 1/27/09 manifests red 4-6/HPF none urinary system URINALYSIS blood cells on as well as for  her urine Date Red Red Cells: system indicating a results in: Cells: none problems that problem on 1/29/09 6-8/HPF may manifest the kidney Albumin: through the filtration; this Albumin: negative urinary tract. is supported 4 by Glucose: albuminuria Glucose: negative and rare glucosuria. Nursing Implication 

5. 6. 7. 8.

Prior: Explain Explain the the procedu procedure re to the the client client in order order to to gain her  her  Inform Inform the the client client that that there there is is no need need for for NPO. NPO. Educate the patient patient on the proper proper way of collecting collecting urine (clean catch catch midstream midstream specimen). Prepare Prepare the containe containerr for for the the urine urine..

During: 4. Prov Provid ide e pri priva vacy cy.. 5. Assist Assist the patien patientt if unable unable to get her her urine urine sample sample on her 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. Refrig Refrigera erate te the the spe specim cimen. en. 2. Continue taking the the medications medications that were were stopped stopped prior to the procedure. procedure. 

22

III. ANATOMY AND 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 body thro throug ugh h a comp comple lex x netw networ ork k of arte arteri ries es,, arterioles, arterioles, and capillaries. capillaries. Blood is returned to the heart through venules and veins. The The one-w one-way ay circu circulat latory ory syste system m carrie carries s blood to all parts of the body. This process of  blood blood flow within the body is called called circulat circulation. ion. 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 pulmonary artery that brings oxygen-poor blood into the lungs and the pulmonary vein

23

that brings oxygen-rich blood back to the heart. (Rod R. Seeley et. al, Essentials of  Anatomy and Physiology 5 th edition, McGraw-Hill Int. NY 10020 2005) Twenty major arteries make a path through the tissues, where they branch into smaller smaller vessels vessels called called arteriol arterioles. es. Arterioles Arterioles further further branch branch into capillar capillaries, ies, 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 form vein veins, s, which hich deli delive verr the the bloo blood d back back to the the hear heartt to pick pick up oxy oxygen. gen. 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 5 th 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 blood cells cells (also (also called called erythrocy erythrocytes tes)) are shaped shaped like slightly indented, 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 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 24

red blood cell has a life span of about 4 months. Each day, 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) 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 affected tissues. The blood contains far fewer white blood cells than red cells, although the body can increase increase producti production on of white white blood blood cells cells to fight fight infectio infection. n. 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 granulocytes and lymphocytes 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 5 th edition, McGraw-Hill Int. NY 10020 2005) Certain Certain types types of white white blood blood cells cells produce produce antibodies antibodies,, special special proteins 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 well becau because se more more white white blood blood cells cells are are bein being g prod produc uced ed or are are ente enterin ring g the the blood bloodstr stream eam to battl battle e the infec infectio tion. n. After After the the body body has has been been challe challenge nged d by some 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 temporarily stop or slow bleeding, the action of clotting factors is needed to produce a strong, stable clot. 25

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 addi additio tion n to the cells cells and and clott clotting ing facto factors, rs, blood blood cont contain ains s other other impo importa rtant nt 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 5 th 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 also carrie carries s carbo carbon n dioxi dioxide de and and other other wast waste e mate materia rials ls to the lungs lungs,, kidn kidneys eys,, and and digestive system, from where they are removed from the body. (Rod R. Seeley et. al, Esse Essenti ntial als s of Anato Anatomy my and and Physio Physiolog logy y 5 th 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, meta metabo boli lism sm (the (the phys physic ical al and and processes

of

the

body) dy),

and

chem chemic ical al sexual

develop development ment and functio function. n. The hormone hormones s are released into the bloodstream and may affect one or several organs throughout the 26

body. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5 th edition, McGrawHill 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. Horm Hormone ones s are are chemic chemical al mess messen enger gers s create created d by the body body. They They transf transfer  er  information information from one set of cells to another to coordinate coordinate the functions functions of different 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 Physiology 5 th edition, McGrawHill 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 selects and removes removes materials materials from the blood, blood, process processes es them, them, and secretes 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) 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 27

cell cells s of the the hypo hypoth thal alam amus us,, caus causin ing g eith either er stim stimul ulat atio ion n or inhi inhibi biti tion on of horm hormon one e produ producti ction. on. Secre Secretio tion n of horm hormone ones s by the the PPG PPG is contr controll olled ed by nervo nervous us syste system m 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 thymu thymus s glan gland d secre secretes tes thymo thymosi sin n which which aids aids in the the synth synthesi esis s of WBC WBC for fight fighting ing 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 5 th edition, McGraw-Hill Int. NY 10020 2005) The pancreas is also part of the body's hormone-secreting hormone-secreting system, even though it is also also assoc associat iated ed with with the the diges digestiv tive e syste system m becau because se it produ produce ces s and and secre secretes tes diges digestiv tive e enzym enzymes. es. The pancr pancreas eas produ produce ces s two impor importan tantt hormo hormone nes, s, insuli insulin n and 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. 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

28

(exte (extends nds toward toward the the splee spleen) n).. (Rod (Rod R. Seel Seeley ey et. al, al, Esse Essenti ntial als s of Anato Anatomy my and and Physiology 5 th 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 5 th 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) Langerhans) embedded between the exocrine units of the pancreas. Beta cells of the islands secrete insulin, which helps control 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 29

their secretion: Beta cells secretes Insulin and Amylin lower blood sugar, Alpha Cells secre secretes tes Gluca Glucago gon n raise raise blood blood suga sugarr, Delta Delta Cells Cells secret secretes es Somas Somasto totat tatin in inhib inhibit it 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 direct appo apposit sitio ion. n. Ther There e are two main main types types of exocr exocrin ine e pancr pancreat eatic ic cells cells,, responsible responsible for two main classes of secretions: Centroacinar Centroacinar cells secretes bicarbonate ions, ions, Basoph Basophilic ilic cells cells secr secretes etes

digestive digestive enzymes enzymes

such as pancre pancreatic atic amyl amylase, ase,

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 nervou vous sys system is a netw netwo ork of  special specialized ized cells cells that communi communicate cate informat information ion abou aboutt an anim animals als surrou surround nding ings s and and its self, self, it processes this information and causes reactions in othe otherr part parts s of the the body body.. It is comp compos osed ed of  neurons and other specialized cells called glia, that aid in the function of the neurons. The nervous nervous system is divided divided broadly broadly into into two two cate catego gori ries es;; the the peri periph pher eral al nerv nervou ous s system and the central nervous system. Neurons gene generat rate e and and cond conduct uct impu impulse lses s betwe between en and and within the two systems. The peripheral nervous system is composed of sensory neurons and the neuro neurons ns that that conn connect ect them them to the nerve nerve cord, cord, spina spinall cord cord and and brain brain,, which which make make up the the centr central al nervo nervous us syste system. m. In respo respons nse e to 30

stimuli, sensory neurons generate and propagate signals to the central nervous system which which then then proces process s and and condu conduct ct back back signa signals ls to the musc muscles les and and glan glands ds.. (Rod (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 arrangem arrangement ents s and use electro electrochem chemical ical signals signals and neurotr neurotransm ansmitte itters rs to transmit transmit impulses from one neuron to the next. The interaction of the different neurons form neural circuits that regulate an organism’s perception perception of the world and what is going on with with its body body, thus thus regula regulatin ting g its behav behavior ior.. Nervo Nervous us syste systems ms are are found found in many 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, 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 5 th edition, McGraw-Hill Int. NY 10020 2005) Brain Brain is a part part of the Centr Central al Nervou Nervous s System System,, it plays plays a centr central al role in the contr control ol of most most bodil bodily y funct function ions, s, inclu includin ding g aware awarenes ness, s, move moveme ments nts,, sensa sensatio tions, ns, 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 5 th 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. The The convo convolu lutio tions ns of the corte cortex x give give it a wormy wormy appe appeara aranc nce. e. Each Each convo convolut lution ion 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 31

corpus callosum links the hemispheres. The right hemisphere controls voluntary limb movements movements on the left side of the body, body, and the left hemisphere controls voluntary limb move moveme ment nts s on the right right side side of the body body.. Almos Almostt every every perso person n has has one one domi dominan nantt hemi hemisp sphe here re.. Each Each hemi hemisp sphe here re is divi divide ded d into into four four lobe lobes, s, or area areas, s, whic which h are 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 touc touch. h. In addi additi tion on,, the the proc proces essi sing ng incl includ udes es info inform rmat atio ion n abou aboutt numb number ers, s, 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 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 5 th edition, McGraw-Hill McGraw-Hill Int. NY 10020 2005)

The The

urin urinar ary y

syst system em

is

system system of organs organs that

produ produce ces s and and excre excretes tes urine urine from from the body body. Urine 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-sh bean-shaped aped organs organs that continu continuously ously filter filter substan substances ces 32

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 average adult adult produces produces about about 1.5 liters liters of urine urine each each day, 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 5 th edition, McGraw-Hill Int. NY 10020 2005)

Kidney s

are

paired or

gans w

hose fun

ctions

include

removing waste products products from the blood and regulating regulating the amount of fluid in the body. 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 33

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 5

th

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

A primary function 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 occur when when too many many of these these waste waste produ products cts accu accumu mulat late e in the the blood bloodst strea ream. m. Fortunately, a healthy kidney can easily rid the body of these substances.

In additio addition n to cleaning cleaning the blood, blood, the kidneys kidneys perform perform several several other other essenti essential al functions. functions. One such activity is regulation of the amount of water contained in the blood. This process is influenc influenced ed by antidiur antidiuretic etic hormone hormone (ADH), (ADH), also called called vasopres vasopressin sin,, which is produced in the hypothalamus 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 34

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 5 th edition, McGraw-Hill Int. NY 10020 2005) The hormon hormone e aldoster aldosterone one,, produce produced d by the adrenal adrenal glands, glands, interact interacts s with the kidney kidneys s to regu regulat late e the the blood blood’s ’s sodi sodium um and and potas potassi sium um conte content. nt. High High amou amounts nts of  aldosterone cause the nephrons to reabsorb more sodium ions, more water, and fewer  potas potassiu sium m ions; ions; low level levels s of aldos aldoste teron rone e have have the the revers reverse e effe effect. ct. The The kidney 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 5 th 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 kidney also adjusts adjusts the body's body's acid-ba acid-base se balance balance to prevent prevent such blood 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 5 th edition, McGraw-Hill Int. NY 10020 2005) Several Several hormone hormones s are produced produced in the kidney kidney.. One of these, these, erythro erythropoie poietin, tin, influen influences ces the producti production on of red blood cells cells in the bone marrow marrow.. When When the kidney dete detect cts s that that the the numb number er of red red bloo blood d cell cells s in the the body body is decl declin inin ing, g, it secr secret etes es erythropoietin. This hormone travels in the bloodstream to the bone marrow, stimulating the the produ producti ction on and release release of more more red red cells cells.. (Rod (Rod R. Seele Seeley y et. al, al, Esse Essent ntial ials s of  Anatomy and Physiology 5 th edition, McGraw-Hill Int. NY 10020 2005) 35

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 resp re spir irat atory ory mu musc scle les s th that at me medi diat ate e th the e movement of air into and out of the body. Within the alveolar system of the lungs, molecules of oxygen and carbon dioxide are ar e pa passi ssivel vely y exc excha hang nged, ed, by di diff ffus usion ion,, betwe be tween en the ga gaseo seous us env enviro ironm nmen entt and the bloo blood. d. Thu Thus, s, the res respira piratory tory sys system tem facilitates oxygenation of the blood with a conco co ncomi mitan tantt re remo moval val of ca carb rbon on di dioxi oxide de and other gaseous metabolic wastes from the circulation. The system also helps to maintain the acid-base balance of the body through the efficient removal of carbon dioxide from the blood. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5 th 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 temperature and humidity of air breathe breathed d in, as well as to lighten the bone structure of the head and to give resonance to the voice. 36

2. The NOSE (nasal cavity) is the preferred entrance for outside air into the respirat respiratory ory 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 he lps to res resist ist bo body dy in infec fectio tion n by fil filter terin ing g ou outt fo forei reign gn ma matte tterr, inc includ luding ing ger germs ms,, 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 THROA THROAT T (pharynx) collects incoming air from the nose and mouth and passes it downward to the windpipe (trachea). 7. Th The e EPIGLOTTIS is a fl flap ap of tis tissu sue e tha thatt gua guard rds s th the e en entra tranc nce e to th the e wi windp ndpip ipe e (trachea), closing when anything is swallowed that should go into the esophagus and stomach. 8. The VOICE BOX (larynx) contains the vocal chords. 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. 10. The WINDPIP WINDPIPE E (trache (trachea) a) 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. 37

13. The windpipe divides into the two main BRONCHIAL TUBES, 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, 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. LOBES. 16. The PLEURA are the two membranes, membranes, actually one continuo continuous us 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 swallowe swallowed. d. 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. 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 5 th edition, McGraw-Hill Int. NY 10020 2005)

38

Mechanics of Breathing To take a breath in, the t he 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 membrane membranes s , 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  ( pneumothorax ). ). (Rod R. Seeley et. al, Essentials of  Anatomy and Physiology 5 th edition, McGraw-Hill Int. NY 10020 2005) Physiology of Gas Exchange Each branch of the bronchi bronchial al tree eventua eventually lly sub-divides to form very narrow terminal bronchioles, bronchioles, which termina terminate te in the alveoli alveoli.. There are many millions of alveloi in each lung, and these are the th e ar areas eas res respo ponsi nsible ble for ga gase seous ous exc excha hange nge,, pr pres esent enting ing a massive surface area for exchange to occur over. Each Ea ch alv alveol eolus us is ver very y clo close sely ly ass assoc ociat iated ed wi with th a ne netw twork ork of  capillaries containing deoxygenated blood from the pulmonary artery. The capillary and alveolar walls are very thin, allowing rapi ra pid d ex exch chan ange ge of ga gase ses s by pas passive sive dif diffusi fusion on alo along ng con concent centrati ration on grad gradient ients s. CO2 moves into the alveolus as the concentration is much lower in the alveolus than in the blood, and O 2 moves out of the of  the alveolus as the continuous flow of blood through the capillaries prevents saturation of the blood with O 2 and allows maximal transfer across the membrane. (Rod R. Seeley et. al, Essentials Essentials of Anatomy and Physiology 5 th edition, McGraw-Hill Int. NY 10020 2005)

39

IV. IV. THE PATIENT PATIENT AND HIS ILLNESS ILLNES S A. PATHOPHYS THOPHYSIOL IOLOGY OGY (BOOK (BOOK BASED) BASED)

Modifiable Factors

Non Modifiable Factors

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

Age, Family History of CVA, Family History of DM, Sex (Men), Race

Weight Loss

Destruction of alpha and beta cells of the pancreas

Polydipsia

Polyuria

Polyphagia

Failure to produce insulin Production of  excess glucagon

Inc. osmolarity due to glucose

Inc. serum glucose level

Inc. Ketones

Production of  glucose from protein and fat stores

Acidosis

Acetone breath

Glycoprotein cell wall deposits

Wasting of lean body mass

Fatigue Weight loss

40

Impaired immune function (decrease level of  morphonuclear  leukocytes)

Small vessel disease

Diabetic Nephropathy Neuropath

Infection

Delayed wound healin

Diabetic Retinopathy

Symmetri cal loss of  protective sensation

Accelerated atherosclerosis

Renal Disease Hypertension

Loss of vision Blindness Increase LDL levels

Numbness and tingling in the extremities

Autonomic neuropathy

Dry cracked skin

Wasting of  intrinsic

Gastro paresis CEREBROVASCULAR ACCIDENT Impotence

Thrombus

Emboli Charcot changes in  joints

Hemiparesis Decreased Tissue perfusion (brain) Neurogenic bladder 

Loss of speech Hemisensory loss

Cerebral Hypoxia Syncope/ Vertigo th

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

Short term Eschemia (<1015mins)

MID CEREBRAL

Long term Eschemia (>1015mins)

Temporary Deficit

Permanent Deficit

No permanent damage

Irreversible damage

ANTERIOR

41

POSTERIOR

VERTEBROBASILAR

Hemiparesis/ Hemiplegia

Aphasia

Agnosia

Ataxia

Visual Changes

Dysphagia

Dysarthia

Horner’s S ndro ndrom me

Apraxia

Hemisensor y loss

Unilarteral Neglect

42

Incontinence

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

B. PATHOPHYSIOLOGY PATHOPHYSIOLOGY ((CLIENT CLIENT BASED) B ASED)

Non Modifiable Factors

Modifiable Factors

Smoking (23 pack years)

Pneumonitis- radiology re ort 01-3001-30-09 09

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,

Destruction of alpha and beta cells of the pancreas

Failure to produce insulin

Production of  excess glucagon

43

Inc. osmolarity due to glucose

Polyuria

Inc. serum glucose level Production of  glucose from protein and fat stores

FBS: 117 mg/dl (01/28/09) 01/29/09 -01/31/09 Glycoprotein cell wall deposits

01/29/09 -01/31/09 Wasting of lean body mass

Impaired immune function (decrease level of  morphonuclear  leukocytes)

Small vessel disease

Diabetic Nephropathy

Infection

Fatigue

Delayed wound healin

Accelerated atherosclerosis

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

Diabetic Retinopathy

Lab results: WBC: 4,900 Normal: (5-10x103) (01/28/09)

Hypertension

Blurred Vision Renal Affectation

Pus Cell

Urinalysis Albumin: high Sugar: rare Pus cells: 46 /hpf  RBC: 68 /hpf  (01/29/09)

Glucosuria

01/27/09 -01/31/09 Increase LDL levels

Decreased Production of  Erythropoeitin

Lab results: Total Chol: 351 HDL: 87 LDL: 219 Triglycerides: 209 (1/28/09)

Proteinuria

Decreased RBC production in the bone marrow

Lab results: Hemoglobin: 8 (F: 12-16) Hematocrit: 27 (F: 3747) Anemia

44

Thrombus CEREBROVASCULAR ACCIDENT Emboli

01/27/09 Hemiparesis Decreased Tissue perfusion (brain)

01/27/09 Slurred speech

01/27/09

Hemisensory loss Cerebral Hypoxia Ve rt rt i o

01/27/09

Cerebral ischemia

Short term Eschemia (<1015mins)

Temporary Deficit

No permanent damage

MID CEREBRAL ARTERY

ANTERIOR CEREBRAL A.

POSTERIOR CEREBRAL A.

VERTEBROBASILAR ARTERY

45

01/29/09 -01/31/09

Dysphagia

Apraxia 01/29/09 -01/31/09

Ataxia

01/29/09 -01/31/09

Dysarthia

01/29/09 -01/31/09

Hemisensory loss Left upper extremities

Hemiparesis (left upper  extremities) Hemiplegia (left lower extremities)

01/29/09 -01/31/09

01/29/09 -01/31/09

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. brain. Blee Bleedin ding g into into the the brain brain tissu tissue e or the suba subarac rachno hnoid id space space caus causes es a hemo hemorrh rrhag agic ic stroke stroke.. Ische Ischemic mic stroke strokes s accou account nt for abou aboutt 83% 83% of all all strok strokes. es. The The remaining 17% of strokes are hemorrhagic. 46

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 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 the Unite United d State States. s. Along Along with with a high high morta mortalit lity y rate, rate, strok strokes es produ produce ce sign signifi ifica cant nt morbidity in people who survive them. (Joyce M. Black Black et al Medic Medical al Surg Surgica icall Nursi Nursing ng 7 th edition Elsevier Suanders 2005) Vascular Disease which includes C.V.A. is the second leading ing cause of deat eath in the Phili Philipp ppine ines s with with a total total of 51,6 51,680 80 acco accord rding ing to DOH DOH 2004 2004.. Alon Along g with ith this this are are 37,0 37,092 92 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  manif manifest estati ation, on, and and early early treat treatme ment nt of brain brain attac attack. k. (Joy (Joyce ce M. Black Black et al Medic Medical al Surgical Nursing 7 th edition Elsevier Suanders 2005) Diabe Diabetes tes Mellit Mellitus us is a chron chronic ic syste systemi mic c dise disease ase char charact acteri erized zed by eith either er 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, 47

but people with diabetes can take preventive measures measures to reduce the likelihood of such occur occurren rence ces. s. (Joyc (Joyce e M. Black Black et al Medica Medicall Surg Surgica icall Nurs Nursing ing 7 th edition edition Elsevier  Elsevier  Suanders 2005) 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 Hypertension –this is due to plaque deposits on the wall of the arteries which causes narro narrowin wing g of the blood blood vess vessel el there thereby by causin causing g hype hyperte rtensi nsion on which which may lead 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.

48

f. Excessive alcohol consumption –heavy alcohol consumption 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 7 th edition Elsevier Suanders 2005) 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 with diab diabete etes s melli mellitu tus. s. There There is an incre increase ase visco viscous usity ity of blood blood whic which h may cause 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 7 th 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.

49

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

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 7 th edition Elsevier Suanders 2005)

SIGNS AND SYMPTOMS (Book Based)

DIABETES MELLITUS HYPERGLYCEMIA HYPERGLYCEMIA (INCREASED BLOOD SUGAR LEVEL) Diab Diabete etes s Mellit Mellitus us type type II may be due due to lack lack of physio physiolog logic icall ally y active active insu insulin lin that that stimu stimulat lates es gluco glucose se uptak uptake e in the the muscl muscles es and and tissu tissues. es. There Therefor fore, e, it leads 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.

50

POLYURIA 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 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 thirst center center in the hypotha hypothalamu lamus s resultin resulting g from from the intracel intracellula lularr dehydra dehydration tion 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 7 th edition Elsevier Suanders 2005)

51

GLYCOSURIA 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 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. 52

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 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 53

2. loss of speech 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 Hemianopsia – a defective vision 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. 54

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

55

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 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 HYPERGLYCEMIA (INCREASED BLOOD SUGAR LEVEL) (01/28/09) Diab Diabete etes s Mellit Mellitus us type type II may be due due to lack lack of physio physiolog logic icall ally y active active insu insulin lin that that stimu stimulat lates es gluco glucose se uptak uptake e in the the muscl muscles es and and tissu tissues. es. There Therefor fore, e, it leads 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 POLYURIA (01/29/09 -01/31/09) -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 Your kidneys are forced to work overtime to filter and absorb the excess sugar. If your kidneys can't

56

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 GLYCOSURIA (01/29/09) (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 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.

57

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 fight infectio infections. ns. This This is due to low morphon morphonucle uclear ar leukocytes leukocytes which which decreas decreases es 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 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 58

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

59

V. The Patient and His Care A. Medical Management a. IVF’s, BT, NGT Feedings, Nebulization, TPN, Oxygen Therapy.etc. Medical Management/ Treatment D5 LRS (5% Dextrose Lactated Ringer’s Solution) 1L

D5 0.3 NaCl (5% Dextrose 0.3 Sodium Chloride) 500cc

Date ordered/ Date Performed 01-27-09

Jan. 27-31, ‘09

General Description

Indication or  purpose

Client’s Response

Hypertonic solution solution that has higher osmolarity than the serum. It pulls fluid and electroly electrolytes tes from the the intr intrac acel ellu lula lar  r  and int inters erstitia itiall compartments into the intravascular  compartment. It is a sterile, nonpyrogenic solut solution ion for for fluid fluid and electrolyte replenishment and caloric supply administered intravenously.

Since the patient patient was on NPO upon upon admi admissi ssion, on, she was given D5 LRS LRS as her her IVF IVF administered intr intrav aven enou ousl sly y to serve as a source of water, elect electrol rolyt ytes, es, and and calo calori ries es.. It also also serves as a route for medication administration.

The patient was

To

Hypotonic solution solution that has

concen concentra tratio tion n

molec lecule ules

of 

water   that hat

are found found inside inside the cell.

rehydration and to replace fluid loss,

greater 

free

maintain

patient was given this IVF. Also, for  medication administration.

able to maintain normal hydration status

and

electrolyte balance

AEB

patient

had

mois moistt skin skin and and good skin turgor.

Patient respo respond nded ed

well well

as she she did did not manifest

any

signs

and

symptoms

of 

dehydration such as dry skin 60

and

mucous

membranes.

Nursing Implication Implication:: 

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



During: 1. Main Maintena tenance nce of of Asept Aseptic ic Tech Techniqu nique e 2. Prop Proper er procedu procedure re and step steps s in infusing infusing IV IV solution solution 3. Count Count drops drops per minut minute e in drip drip cham chamber ber..



After: 1. Mon Monitor itor IV infusi infusion on at at least least every every 2 hou hour  r  2. Adju Adjust st IV clamp clamp as needed needed and and recount recount drop drop per minut minute. e. 3. Mo Monit nitor or clien clientt for for fluid fluid overf overflow low 4. More frequent frequent check maybe prn if a medication(s medication(s)) are being infused. 5. In Inspe spect ct site for pain, pain, swe swellin lling, g, coolnes coolness s or pallor pallor at th the e sit site e of inserti insertion on,, wh which ich may indicate infiltration of IV 6. Inspect site for redness, swelling, heat heat and and pain which may may indicate indicate phlebitis phlebitis

61

b. Drugs

Name of  Drugs

Date Ordered/ Date Perform ed/ Date Given

Dosage, Route, Frequenc y of  Administr  ation

Piracetam

01-27-09

800mg 1 tab PO q6 hrs then BID on 01-28-09

General Action

Indication or  Purpose

Client’s Response

Nursing Responsibilities

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 system

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 drug to the body.

62

without any toxicity or  addictive properties

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. 2731, ‘09

25mg SL TID

Captopril lower blood pressure by inhibiting the formation of  angiotensin II, thus relaxing

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

without any toxicity or  addictive properties

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. 2731, ‘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 pressure, but also improves the pumping efficiency of a

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: Explain the procedure to the

63

failing heart and improves cardiac output in patients with heart failure.

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

failing heart and improves cardiac output in patients with heart failure.

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 IV q8 then d/c on Jan. 30,’09

It is a competitive, reversible inhibitor of the action of 

This is indicated for the patient as she manifested abdominal pain

The patient improved condition as she did not manifest

Prior to: Wash hands thoroughly. Ask the patients

64

histamine at the histamine H2 receptors, including receptors on the gastric cells

abdominal pain.

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.

histamine at the histamine H2 receptors, including receptors on the gastric cells

abdominal pain.

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  its administration (charting). Observe the patients for possible untoward

65

reaction.

Simvastatin

01-28-09

40mg 1tab OD

Simvastatin is a hypolipidemic drug belonging to the class of  pharmaceutic als called "statins". statins". It is used to control hypercholeste rolemia (elevated cholesterol levels) and to prevent cardiovascula r disease. 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 

reaction.

Simvastatin

01-28-09

40mg 1tab OD

Simvastatin is a hypolipidemic drug belonging to the class of  pharmaceutic als called "statins". statins". It is used to control hypercholeste rolemia (elevated cholesterol levels) and to prevent cardiovascula r disease. 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).

Observe the patients for possible untoward reaction.

66

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 isoproterenolinduced tachycardia, and reduces reflex

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:

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 isoproterenolinduced tachycardia, and reduces reflex orthostatic tachycardia.

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  its administration (charting). Observe the patients for possible untoward reaction.

67

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 concentration s 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

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 concentration s 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. After: Record the drug after  its administration (charting).

68

Observe the patients for possible untoward reaction. Instruct to take the medication exactly as directed. Ferrous Sulfate

01-30-09

1 ca cap OD 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

Observe the patients for possible untoward reaction. Instruct to take the medication exactly as directed. Ferrous Sulfate

01-30-09

1 ca cap OD 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 patient/SO. After: Record the drug after  its administration (charting).

69

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  smooth muscle,

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

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  smooth muscle, vasodilators act to decrease peripheral resistance, thereby lowering blood pressure.

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 Check the patency of  the IV site During: Explain the procedure to the patient/SO.

70

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

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

71

c. Diet Date Type ordered Of  Date given diet Date changed Noth Nothin ing g per  per  01-27-09 Orem (NPO)

Soft Diet

01-28-09

General description A type of Diet where the patient cannot eat or  drink anything

Indication

Specific Foods Taken

It is for the None purpose of   observation precaution

Very similar   This to regular diet ordered t th t id

was to

Client’s response The patient participated with the Doctor’s order 

Boiled Boiled Eggs, Eggs, The client Sopas, enjoyed Lugaw ti h

c. Diet Date Type ordered Of  Date given diet Date changed Noth Nothin ing g per  per  01-27-09 Orem (NPO)

Soft Diet

01-28-09

General description

Indication

Specific Foods Taken

Client’s response

A type of Diet where the patient cannot eat or  drink anything

It is for the None purpose of   observation precaution

The patient participated with the Doctor’s order 

Very similar   to regular diet exce xcept that the the text textur ures es of foods have been modified.

This was Boiled Boiled Eggs, Eggs, The client ordered to Sopas, enjoyed provide a Lugaw eating her   transitional food and diet diet betw betwee een n manifested liquids and feeling of   regu regula larr food fulln fullnes ess s after  after  for patients the meal. She who have did not difficult in manifest swallo swallowin wing g or  dysphagia. who undergone surgery.

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.

72

d. Activity/ Exercise Type Of  exercise High Rest

Back

Date ordered Date given Date changed 01-27-09

General description A type of   activity or   exercise where herein in the the patient is kept on bed with ith the head of  bed held at at least 45° with limita limitatio tions ns to other  activities.

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

Client’s response Patient shows gradual incr increa ease se strength.

in

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

73

B. Nursing Management NURSING CARE PLAN Problem No:1 Acute Pain

ASSESSMENT

NURSING DIAGNOSIS Acute Pain

SCIENTIFIC

PLANNING

EXPLANATION Lots of medicine has the Short Term

INTERVENTIONS Establish rapport

RATION ALE

EXPECTED

To gain pt’s

OUTCOME Short Term

S=” Masakit ku

side side effe effect ct of gast gastri ric c Objective:

therapeutic

Objective:

atsan”

upset

relationship

After the nsg int the

causing

abdominal

pain

to

pati patien entt afte afterr inta intake ke of  The patient

medication specially PO

manifested the

drug drugs. s. It has a side side

following:

effect

of

causing

abdominal cramps, and

After 2 hr of  nursing intervention the pt

pt shall verbalized a Monitor v/s

8/10 to 4/10

relief of pain.

data

will verbalized rlieve of pain from

To obtain baseline

Assess pt’s

To note for the

general condition

etiology or 

pain.

precipitating

O= with facial

factors that can

Long Term

grimace, with

lead to fever.

Objective:

guarding

Long Term

behaviors, pain

Objective:

scale of 8/10, at abdominal area, with quality of dull pain, after intake

After the nsg int the Encourage rest

To overcome pain

pt shall

opportunities

at rest

demonstratetechniq

After 3 days of NI, pt will demonstrate

ue to alleviate pain Ecourage

to divert the pt’s

diversional

attention

74

of meds, left side

technique to

activities such as

paralysis

alleviate pain

talking to S.O.

Encourage deep

Helps to lessen

The patient may

breathing

the feeling of 

also manifest he

exercises

pain.

Provide comfort

To let pt feel safe

measures and

and comfortable

following:

>discomfort >anxiety >irritable

safety

Provide Health

To lessen the pt’s

information

feeling of anxiety

regarding the >Fatigue

occurring problem

>headache Provide

To promote rest and pt’s wellness

of meds, left side

technique to

activities such as

paralysis

alleviate pain

talking to S.O.

Encourage deep

Helps to lessen

The patient may

breathing

the feeling of 

also manifest he

exercises

pain.

Provide comfort

To let pt feel safe

measures and

and comfortable

following:

safety

>discomfort >anxiety >irritable

Provide Health

To lessen the pt’s

information

feeling of anxiety

regarding the >Fatigue

occurring problem

>headache Provide

To promote rest

conducive

and pt’s wellness

environment for  resting

75

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

ASSESSMENT

NURSING

SCIENTIFIC

PLANNING

DIAGNOSIS Impaired cerebral

EXPLANATION In cerebral tissue

Short term

tissue perfusion

perfusion, there is a

The patient

r/t vascular 

manifested the ff:

INTERVENTIONS

RATIONALE

EXPECTED

> To gain pt’s

OUTCOME Short term

objective:

therapeutic

objective:

decrease in oxygen

After 5hrs. of 

relationship

After 5hrs. of 

occlusion

supply which results in

Nursing

secondary to

the failure to nourish the

intervention, the

Monitor Vital

> To identify any

intervention, the pt.

disease condition

tissues at the capillary

pt. will

signs

other deviations

shall be able to

O= without signs

level. Blood vessels

demonstrate

from normal.

demonstrate

of IV infiltration, w/

which function is to

increased

contralateral

supply blood to the

perfusion as

Assist pt. in

>To aid with

as individually

hemiparesis,

different parts of the

individually

assuming

proper perfusion

appropriate

sensory loss,

brain are impaired.

appropriate

semifowler’s

or flow of blood

muscle weakness,

Thus, the O2 supply

position w/ head

(circulation or 

Long Term

slurred speech,

going to the brain is also

Long Term

midline.

venous drainage).

Objective:

with GCS=15

impaired. Proper 

Objective:

S= 0

Establish Rapport

Nursing

increased perfusion

After 2-3 days of 

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

ASSESSMENT

NURSING

SCIENTIFIC

PLANNING

DIAGNOSIS Impaired cerebral

EXPLANATION In cerebral tissue

Short term

tissue perfusion

perfusion, there is a

The patient

r/t vascular 

manifested the ff:

INTERVENTIONS

RATIONALE

EXPECTED

> To gain pt’s

OUTCOME Short term

objective:

therapeutic

objective:

decrease in oxygen

After 5hrs. of 

relationship

After 5hrs. of 

occlusion

supply which results in

Nursing

secondary to

the failure to nourish the

intervention, the

Monitor Vital

> To identify any

intervention, the pt.

disease condition

tissues at the capillary

pt. will

signs

other deviations

shall be able to

O= without signs

level. Blood vessels

demonstrate

from normal.

demonstrate

of IV infiltration, w/

which function is to

increased

contralateral

supply blood to the

perfusion as

Assist pt. in

>To aid with

as individually

hemiparesis,

different parts of the

individually

assuming

proper perfusion

appropriate

sensory loss,

brain are impaired.

appropriate

semifowler’s

or flow of blood

muscle weakness,

Thus, the O2 supply

position w/ head

(circulation or 

Long Term

slurred speech,

going to the brain is also

Long Term

midline.

venous drainage).

Objective:

with GCS=15

impaired. Proper 

Objective:

perfusion is needed in

After 2-3 days of 

Administer 

>To probably

Nursing

order to give adequate

Nursing

medications as

decrease cardiac

Intervention, the pt.

The patient may

nourishment to he

Intervention, the

ordered such as

workload and in

shall be able to

also manifest the

different parts of the

pt. will be able o

antihypertensive

maximizing tissue

demonstrate

ff:

brain in order for it to

demonstrate

or diuretics.

perfusion

behaviors which

function well.

behaviors which

S= 0

>Change in

may improve

Establish Rapport

Nursing

increased perfusion

After 2-3 days of 

may improve proper  >Encourage quiet

circulation such as

76

pupillary reactions

proper circulation

and restful

>To conserve

compliance to

>Change in

such as

atmosphere.

energy which

health management

Mental Status

compliance to

could aid in

& therapies

>Behavioral

health

lowering the O2

provided.

Changes

management &

>Exercise caution

tissue demand.

>Capillary refill

therapies

in using hot or 

>The t issues

longer than 3

provided.

cold pads.

may have

secs.

decreased >Encourage use

sensitivity due to

of relaxation

ischemia.

techniques or  exercises.

>To >To decrease the tension level

>Discuss the importance of  preventing

>To retain heat or  warmth efficiently

pupillary reactions

proper circulation

and restful

>To conserve

compliance to

>Change in

such as

atmosphere.

energy which

health management

Mental Status

compliance to

could aid in

& therapies

>Behavioral

health

lowering the O2

provided.

Changes

management &

>Exercise caution

tissue demand.

>Capillary refill

therapies

in using hot or 

>The t issues

longer than 3

provided.

cold pads.

may have

secs.

decreased >Encourage use

sensitivity due to

of relaxation

ischemia.

techniques or  exercises.

>To >To decrease the tension level

>Discuss the importance of  preventing

>To retain heat or 

exposure to cold

warmth efficiently

or extreme cold temp

>Discuss to the patient’s SO the importance of 

>To promote

77

care of dependent

wellness

limbs, body hygiene, and foot care when circulation is impaired.

Problem No: 3 Impaired Physical Mobility Neuromuscular and Musculoskeletal Impairment NURSING

SCIENTIFIC

DIAGNOSIS Impaired physical

EXPLANATION The nervous system is

Short Term

>Establish

> To gain pt’s

OUTCOME Short Term

mobility

made up of nerve cells

Objective:

Rapport

therapeutic

Objective:

The patient

neuromuscular 

call called ed

neur neuron ons s

relationship

After 4 hrs. Of 

manifested the

and

serve

as

following:

musculoskeletal

communicatio communication n system Intervention, the

>Monitor Vital

> To identify any

Intervention, the pt.

impairment as

of the body. They carry

signs

other deviations

shall be able to

evidence by

messages in the form of  maintain

from normal.

maintain increased

ASSESSMENT S= 0

O= w/ pale

PLANNING

INTERVENTIONS

that that After 4 hrs. Of 

RATIONALE

the Nursing

pt. will be able to

EXPECTED

Nursing

care of dependent

wellness

limbs, body hygiene, and foot care when circulation is impaired.

Problem No: 3 Impaired Physical Mobility Neuromuscular and Musculoskeletal Impairment NURSING

SCIENTIFIC

DIAGNOSIS Impaired physical

EXPLANATION The nervous system is

Short Term

>Establish

> To gain pt’s

OUTCOME Short Term

mobility

made up of nerve cells

Objective:

Rapport

therapeutic

Objective:

The patient

neuromuscular 

call called ed

neur neuron ons s

relationship

After 4 hrs. Of 

manifested the

and

serve

as

following:

musculoskeletal

communicatio communication n system Intervention, the

>Monitor Vital

> To identify any

Intervention, the pt.

impairment as

of the body. They carry

signs

other deviations

shall be able to

O= w/ pale

evidence by

messages in the form of  maintain

from normal.

maintain increased

palpebral

limited motor 

electrical impulses. The

>Assess patient

>To determine

strength and

conjunctiva, w/

skills.

messag messages es move from from strength and

condition

any other 

function of affected

ASSESSMENT S= 0

PLANNING

INTERVENTIONS

that that After 4 hrs. Of 

RATIONALE

the Nursing

pt. will be able to

increased

EXPECTED

Nursing

pale nail beds, w/

one neuron to another  another  function of 

underlying cause

or compensatory

capillary refill

to

of manifestations

part.

time, <3sec. pt. is

functi functioni oning. ng.

able to feel deep touch, raise his

keep

the

body affected or  >Provide

> To prevent

neuron neurons s have, have, limite limited d part.

adequate rest

further stress &

ability

periods as well as

fatigue

to

Becaus Because e compensatory

repair  

Long Term

78

right arm and leg,

themselves unlike other 

w/ slurred speech,

body tissues that is why

Long Term

w/ left sided

nerve nerve cells cells cannot cannot be

Objective:

weakness, with

repa repair ired ed

After 2-3 days of 

>Turn pt. slowly

> To provide

intervention, the pt.

limited ROM on

due to injury or disease.

nursing

from side to side

proper circulation

shall be able to

if

dama damage ged d

comfort & safety

Objective:

measures

After 2-3 days of  nursing

upper and lower 

intervention, the

of blood flow on

demonstrate

extremities,

pt. will be able to

both sides

behaviors that

afebrile, (-) DOB,

demonstrate

(-) chest pain.

behaviors that

>Determine pt.

>To assess

enable

level of mobility

functional ability

>Assist pt. in his

>To promote

activities

optimal level of 

enable resumption

resumption of  The patient may also manifest he

activities.

following:

function

>Slowed

>Encourage

>Promotes well-

movement,

adequate intake

being and

of fluids &

of activities.

right arm and leg,

themselves unlike other 

w/ slurred speech,

body tissues that is why

Long Term

w/ left sided

nerve nerve cells cells cannot cannot be

Objective:

weakness, with

repa repair ired ed

After 2-3 days of 

>Turn pt. slowly

> To provide

intervention, the pt.

limited ROM on

due to injury or disease.

nursing

from side to side

proper circulation

shall be able to

if

dama damage ged d

comfort & safety

Objective:

measures

After 2-3 days of  nursing

upper and lower 

intervention, the

of blood flow on

demonstrate

extremities,

pt. will be able to

both sides

behaviors that

afebrile, (-) DOB,

demonstrate

(-) chest pain.

behaviors that

>Determine pt.

>To assess

enable

level of mobility

functional ability

>Assist pt. in his

>To promote

activities

optimal level of 

enable resumption of activities.

resumption of  The patient may

activities.

also manifest he following:

function

>Slowed

>Encourage

>Promotes well-

movement,

adequate intake

being and

>Postural

of fluids &

maximizes

instability during

Nutritious foods

energy

performance of 

production.

ADLs >Movement

>Involve client’s

>To assist in

induced shortness

SO in care

learning ways of 

of breath.

managing

79

problems of  immobility.

Problem: 4 Activity Intolerance r/t immobility

Assessment

Nursing

Scientific

Objective

Nursing

Expected

Diagnosis Activity

Explanation Infarction on the

Intolerance r/t

right hemisphere

immobility

has a contra

nursing

lateral

intervention the

O>The Patient

manifestation of 

patient will use

Manifests:

either left side

identified

paralysis and/or 

techniques to

>Assess General

>To note for 

techniques to

weakness due to

enhance activity

Condition

signs and

enhance activity

left hemisphere

tolerance.

symptoms

tolerance.

S>O

>with Paralysis

Short Term:

Intervention >Establish Rapport

Rationale

After 3 hrs of 

>To gain patient’s Trust

Outcome Short Term: After the nursing

>Assess V.S.

>To gain

intervention the

baseline data

patient shall use identified

problems of  immobility.

Problem: 4 Activity Intolerance r/t immobility

Assessment

Nursing

Scientific

Objective

Nursing

Expected

Diagnosis Activity

Explanation Infarction on the

Intolerance r/t

right hemisphere

immobility

has a contra

nursing

lateral

intervention the

O>The Patient

manifestation of 

patient will use

Manifests:

either left side

identified

paralysis and/or 

techniques to

>Assess General

>To note for 

techniques to

weakness due to

enhance activity

Condition

signs and

enhance activity

>with Paralysis

left hemisphere

tolerance.

symptoms

tolerance.

of the Left Body

affectation

Side

causing the

>with Left side

immobility

weakness

because of 

>with Blurred

stiffness of 

Vision

muscle and

>with infraction

unability to

S>O

Short Term:

Intervention >Establish Rapport

Rationale

After 3 hrs of 

>To gain patient’s Trust

Outcome Short Term: After the nursing

>Assess V.S.

>To gain

intervention the

baseline data

patient shall use identified

>Adjust Activity

>To prevent overexertion

Long Term: After 3 days

>Provide positive

>to minimize

atmosphere

frustration

of nursing

Long term: After the nursing

80

on right

mobilize due to

intervention the

>Promote comfort

>to enhance

intervention the

hemisphere

the

patient will

measure and

ability to

patient shall

>requires

manifestation of 

demonstrate

provide for relief of 

participate in

demonstrate

assistance and

the disease

increase in

pain

activities

increase in

guidance from

condition.

activity

S.O.

tolerance.

activity >Provide ROM

>to promote circulation

>Give client

>to sustain

The Patient may

information that

motivation

Manifest:

provides evidence/difference

>headache >pain

>Assist client in

>to prevent

>irritable

learning and

injuries

>discomfort

demonstrating

>cold clammy

appropriate safety

tolerance.

on right

mobilize due to

intervention the

>Promote comfort

>to enhance

intervention the

hemisphere

the

patient will

measure and

ability to

patient shall

>requires

manifestation of 

demonstrate

provide for relief of 

participate in

demonstrate

assistance and

the disease

increase in

pain

activities

increase in

guidance from

condition.

activity

S.O.

tolerance.

activity >Provide ROM

>to promote

tolerance.

circulation

>Give client

>to sustain

The Patient may

information that

motivation

Manifest:

provides evidence/difference

>headache >pain

>Assist client in

>to prevent

>irritable

learning and

injuries

>discomfort

demonstrating

>cold clammy

appropriate safety

skin

measures

>dehydration

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

81

ASSESSMENT

NURSING

SCIENTIFIC

PLANNING

DIAGNOSIS impaired verbal

EXPLANATION There is an affectation

and/or written

of

communication

lobe lobes s that that caus caused ed by After 3 hrs of nsg

The patient

r/t impaired

im pa pa ir ired

manifested the

cerebral

circulation circulation that affects affects able to verbalize

following:

circulation

its proper functions that or indicate

S= 0

the the

lead leads s

cert certa ain

O= w/ pale

de la la ye yed

palpebral

ab ililit y

conjunctiva, w/

Establish rapport

brai brain n Objective:

cerebral

to

Short Term

INTERVENTIONS

RATIONALE To gain pt’s

OUTCOME Short Term

therapeutic

Objective:

relationship

After the nrsing

int. the pt will be

intervention the pt Monitor v/s

To obtain

shall verbalize ir 

baseline data

indicate

decr decrea ease sed, d, understanding of  To note for the

communication

general condition

etiology or 

difficulty and plans

process process,, transm transmit it and difficulty and

precipitating

for ways of 

pale nail beds, w/

use

o plans for ways of 

factors that can

handling

capillary refill

symbols

in handling.

lead to fever.

time, <3sec., pt.

communicating

is able to feel

resu resulti lting ng

deep touch, raise

verbal communication.

to

a

abs en ent

receive, communication

system

in

the

understanding of  Assess pt’s

his right arm and

or

EXPECTED

impa impair ired ed

Note results of 

To assess

Long Term

neurological

causative/contrib

Long Term

Objective:

testing such as

uting factors

Objective:

ASSESSMENT

NURSING

SCIENTIFIC

PLANNING

DIAGNOSIS impaired verbal

EXPLANATION There is an affectation

and/or written

of

communication

lobe lobes s that that caus caused ed by After 3 hrs of nsg

The patient

r/t impaired

im pa pa ir ired

manifested the

cerebral

circulation circulation that affects affects able to verbalize

following:

circulation

its proper functions that or indicate

S= 0

the the

lead leads s

cert certa ain

O= w/ pale

de la la ye yed

palpebral

ab ililit y

conjunctiva, w/

Establish rapport

brai brain n Objective:

cerebral

to

Short Term

INTERVENTIONS

RATIONALE To gain pt’s

OUTCOME Short Term

therapeutic

Objective:

relationship

After the nrsing

int. the pt will be

intervention the pt Monitor v/s

To obtain

shall verbalize ir 

baseline data

indicate

decr decrea ease sed, d, understanding of  or

To note for the

communication

general condition

etiology or 

difficulty and plans

process process,, transm transmit it and difficulty and

precipitating

for ways of 

pale nail beds, w/

use

o plans for ways of 

factors that can

handling

capillary refill

symbols

in handling.

lead to fever.

time, <3sec., pt.

communicating

is able to feel

resu resulti lting ng

deep touch, raise

verbal communication.

a

receive, communication

system

in

the

understanding of  Assess pt’s

to

abs en ent

EXPECTED

impa impair ired ed

Note results of 

To assess

Long Term

neurological

causative/contrib

Long Term

his right arm and

Objective:

testing such as

uting factors

Objective:

leg, w/ slurred

After 3 days of 

EEG/CTscan EEG/CTscan and

After the nursing

speech, w/ left

nursing

the likes

intervention the pt

sided weakness,

intervention the

with limited ROM

pt will establish

Assess

To assess

establish methods

on upper and

method of 

environment

causative/contrib

of communication

lower extremities,

communication in

factors that may

uting factors

in which can be

which needs can

affect ability to

shall be albe to

expressed.

82

The patient may

be expressed.

communicate

also manifest he following:

Establish

To assist c lient to

relationship with

establish a

>weakness

the client ,

means of 

>headache

listening carefully

communication to

>dyspnea

and attending to

express needs,

>unable to speak

clients

wants, ideas and

>discomfort

verbal/nonverbal

questions

>irritability

expressions

>low self esteem >Difficulty in

Maintain a calm,

Individuals may

expressing needs

unhurried

talk more easily

manner, provide

when they are

sufficient time for 

rested and

the client to

relaxed

responds

The patient may

be expressed.

communicate

also manifest he following:

Establish

To assist c lient to

relationship with

establish a

>weakness

the client ,

means of 

>headache

listening carefully

communication to

>dyspnea

and attending to

express needs,

>unable to speak

clients

wants, ideas and

>discomfort

verbal/nonverbal

questions

>irritability

expressions

>low self esteem >Difficulty in

Maintain a calm,

Individuals may

expressing needs

unhurried

talk more easily

manner, provide

when they are

sufficient time for 

rested and

the client to

relaxed

responds Anticipate needs until effective

To attend pt’s

communication is

needs

reestablished

immediately

Administer due

For pt’s recovery

meds

and to treat

83

underlying conditions

Problem No: 6 Risk for Aspiration ASSESSMENT S= 0 The patient manifested the ff: O= Dysphagia, impaired swallowing The patient may also manifest the ff:

NURSING DIAGNOSIS Risk Risk for for Aspira Aspiration tion

SCIENTIFIC EXPLANATION When When there 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.

PLANNING Short term objective: After 5hrs. of  Nursing intervention, the pt. demonstrate techniques to prevent aspiration. Long Term Objective: After 1-2 days of 

INTERVENTIONS

RATIONALE

>Established Rapport

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

>Monitored Vital signs

> To identify any other deviations from normal.

>Note level of  consciousness of  surroundings, and cognitive impairment.

>To assess if  there is gag reflex or difficulty of  swallowing.

EXPECTED OUTCOME Short term objective: The patient shall have demonstrated techniques to prevent aspiration. Long Term Objective: The patient shall have experienced no aspiration aeb noiseless

underlying conditions

Problem No: 6 Risk for Aspiration ASSESSMENT S= 0 The patient manifested the ff: O= Dysphagia, impaired swallowing The patient may also manifest the ff: >Depressed gag reflex. >Reduced level of  consciousness

NURSING DIAGNOSIS Risk Risk for for Aspira Aspiration tion

SCIENTIFIC EXPLANATION When When there 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.

PLANNING Short term objective: After 5hrs. of  Nursing intervention, the pt. demonstrate techniques to prevent aspiration. Long Term Objective: After 1-2 days of  Nursing Intervention, the pt. will experience no aspiration aeb noiseless respirations, and clear breath sounds.

INTERVENTIONS

RATIONALE

>Established Rapport

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

>Monitored Vital signs

> To identify any other deviations from normal.

>Note level of  consciousness of  surroundings, and cognitive impairment.

>To assess if  there is gag reflex or difficulty of  swallowing.

>Suction as needed

>To clear  secretions

>Auscultate lung sounds

>to determine presence of  secretions

>Give semisolid

>To prevent

EXPECTED OUTCOME Short term objective: The patient shall have demonstrated techniques to prevent aspiration. Long Term Objective: The patient shall have experienced no aspiration aeb noiseless respirations, and clear breath sounds.

84

foods; avoid pureed that may increase risk of  aspiration.

aspiration and to aide swallowing effort.

>Provide very warm or cold liquids

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

>Refer to speech therapist

>To strengthen muscles and techniques to enhance swallowing.

foods; avoid pureed that may increase risk of  aspiration.

aspiration and to aide swallowing effort.

>Provide very warm or cold liquids

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

>Refer to speech therapist

>To strengthen muscles and techniques to enhance swallowing.

Problem no: 7 Risk for impaired skin integrity 85

ASSESSMENT

S= 0

The patient manifested the following:

O= with dysphagia, with reports of body malaise, increased urine output indwelling Foley catheter, pallor, cold skin, physical immobility.

NURSING DIAGNOSIS

Risk for Impaired skin integrity

SCIENTIFIC EX EXPLANATION

The skin is the baseline defe defens nse e of the the body body agains againstt infecti infection. on. Any brea break k in the the skin skin may harbor microorgani microorganisms sms tha that may may inva invade de the the norm normal al proc proces essi sing ng of  the the body body,, whic which h may may inflict inflict or aggrav aggravate ate the pt’s disease condition.

PLANNING

Short Term Objective: After 4 hr of  nursing intervention the pt will take actions regarding minimizing the risk

INTERVENTIONS

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

EXPECTED OU OUTCOME

Establish therapeutic relationship

To gain pt’ and SO’s trust and cooperation

The pt shall have

Monitor v/s

To obtain baseline data

minimizing the risk

Assess pt’s general condition

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

Monitor I&O Long Term Objective:

RATIONALE

Encourage To maintain increase OFI to al hydration status least 2-3 liters per 

took actions regarding

The pt shall have been free from risk.

ASSESSMENT

S= 0

The patient manifested the following:

O= with dysphagia, with reports of body malaise, increased urine output indwelling Foley catheter, pallor, cold skin, physical immobility.

NURSING DIAGNOSIS

Risk for Impaired skin integrity

SCIENTIFIC EX EXPLANATION

The skin is the baseline defe defens nse e of the the body body agains againstt infecti infection. on. Any brea break k in the the skin skin may harbor microorgani microorganisms sms tha that may may inva invade de the the norm normal al proc proces essi sing ng of  the the body body,, whic which h may may inflict inflict or aggrav aggravate ate the pt’s disease condition.

PLANNING

Short Term Objective: After 4 hr of  nursing intervention the pt will take actions regarding minimizing the risk

INTERVENTIONS

EXPECTED OU OUTCOME

Establish therapeutic relationship

To gain pt’ and SO’s trust and cooperation

The pt shall have

Monitor v/s

To obtain baseline data

minimizing the risk

Assess pt’s general condition

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

Monitor I&O Long Term Objective: After 3 days of NI, pt will be free of  the risk.

RATIONALE

took actions regarding

The pt shall have been free from risk.

Encourage To maintain increase OFI to al hydration status least 2-3 liters per  . day Arrange bed linens

To prevent increase pressure

Encourage and assist client to active and passive ROM

To maintain blood flow

86

exercises Encourage rest opportunities

To promote optimum level of  functioning

Provided comfort measures and safety

To let pt feel safe and comfortable

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

To maintain skin moisture

Assist client in changing positions every

To prevent pressure ulcer 

exercises Encourage rest opportunities

To promote optimum level of  functioning

Provided comfort measures and safety

To let pt feel safe and comfortable

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

To maintain skin moisture

Assist client in changing positions every two hours

To prevent pressure ulcer 

Provided Health information regarding the occurring problem

To lessen the pt’s feeling of anxiety

Provided conducive

To promote rest and pt’s wellness

87

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 promote adequate nourishment.

For proper  replacement of  fluid losses.

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 promote adequate nourishment.

For proper  replacement of  fluid losses.

Problem: 8 Risk for deficient fluid volume

88

Assessment S> O>the patient manifested:  Fatigue 

Weakness



Polyuria



Pale to pink palpebral conjunctiva Change in mental status



 

T he he pat ie ient may manifests: Hemoconcentr  ation



Pale skin



Poor skin

Nursing Diagnosis Risk for Deficient Fluid Volume AEB polyuria

Scientific Explanation 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.

Objectives

Interventions

Rationale

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

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

> Assess causative factors leading to deficit

Long Term: After 2-3 days of  nursing interventions, patient will demonstrate management to prevent fluid volume deficit

>Assess vital signs; note strength of  peripheral pulses. Measure blood pressure. Note presence of  physical signs. Monitor I/O, color  measure amount and specific

>Evaluate degree of deficit

Expected Outcome Short Term: Patient shall have demonstrated behaviors and techniques to correct deficit

Long Term: Patient shall have demonstrated management to prevent fluid volume deficit.

Assessment S> O>the patient manifested:  Fatigue 

Weakness



Polyuria



Pale to pink palpebral conjunctiva Change in mental status



 

T he he pat ie ient may manifests: Hemoconcentr  ation



Pale skin



Poor skin turgor  Capillary refill time of less than 3 secs.



Nursing Diagnosis Risk for Deficient Fluid Volume AEB polyuria

Scientific Explanation 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.

Objectives

Interventions

Rationale

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

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

> Assess causative factors leading to deficit

Long Term: After 2-3 days of  nursing interventions, patient will demonstrate management to prevent fluid volume deficit

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

>Evaluate degree of deficit

>Establish 24-hour  replacement needs and routes to be used. >Note client preference

> Prevent peaks and valleys in fluid level

Expected Outcome Short Term: Patient shall have demonstrated behaviors and techniques to correct deficit

Long Term: Patient shall have demonstrated management to prevent fluid volume deficit.

>Encourage the client to increase

89

concerning fluids and foods with high fluid content

intake of foods high in fluid content

>Provide nutritious diet via appropriate route

>Correct/Replace fluid losses to reverse pathophysiologic mechanism

>Weigh daily

>Assess progress or status of efforts

>Bathe less frequently using mild cleanser/soap and provide optimal skin care

>Maintain skin integrity and prevent excessive dryness

>Provide frequent oral and eye care

>Prevent injury from dryness

>Change position

>Promote comfort

concerning fluids and foods with high fluid content

intake of foods high in fluid content

>Provide nutritious diet via appropriate route

>Correct/Replace fluid losses to reverse pathophysiologic mechanism

>Weigh daily

>Assess progress or status of efforts

>Bathe less frequently using mild cleanser/soap and provide optimal skin care

>Maintain skin integrity and prevent excessive dryness

>Provide frequent oral and eye care

>Prevent injury from dryness

>Change position frequently

>Promote comfort and safety

>Discuss factors related to occurrence of the deficit as individually appropriate. Instruct client how

>Promote wellness

90

to measure and record I/O

Problem: 9 Risk for imbalanced nutrition: less than body requirements Assessment S> O> The patient manifested: -muscle weakness - with contralateral hemiparesis - pale to pink palpebral conjunctiva - sensory loss > The patient may manifest: - loss of weight - capillary fragility - decreased in

Nursing Diagnosis Risk for  imbalanced nutrition: less than body requirements AEB inability to ingest adequate nutrition

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

Objectives SHORT TERM: After 4 hours of  NI, the patient will verbalize understanding of  causative factors when known and necessary interventions. LONG TERM: After 4 days of  NI, the patient will demonstrate behaviors to regain or  maintain

Nursing Interventions >Establish therapeutic relationship

Rationale

Expected Outcome

>To obtain trust and cooperation of the pt.

>Assess and monitor vital signs

>To obtain baseline date

>Identify clients at risk for malnutrition

>To assess causative factors

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

>Determine ability to chew, swallow and taste

>Factors that can affect ingestion or  digestion of  nutrients

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

to measure and record I/O

Problem: 9 Risk for imbalanced nutrition: less than body requirements Assessment S> O> The patient manifested: -muscle weakness - with contralateral hemiparesis - pale to pink palpebral conjunctiva - sensory loss > The patient may manifest: - loss of weight - capillary fragility - decreased in subcutaneous fats and muscle mass

Nursing Diagnosis Risk for  imbalanced nutrition: less than body requirements AEB inability to ingest adequate nutrition

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

Objectives SHORT TERM: After 4 hours of  NI, the patient will verbalize understanding of  causative factors when known and necessary interventions. LONG TERM: After 4 days of  NI, the patient will demonstrate behaviors to regain or  maintain appropriate weight.

Nursing Interventions >Establish therapeutic relationship

Rationale

Expected Outcome

>To obtain trust and cooperation of the pt.

>Assess and monitor vital signs

>To obtain baseline date

>Identify clients at risk for malnutrition

>To assess causative factors

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

>Determine ability to chew, swallow and taste

>Factors that can affect ingestion or  digestion of  nutrients

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

>To appeal to clients likes/desires

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

>Provides comparative baseline

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

91

>Note total daily intake

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

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

>To establish a nutritional plan that meets individual needs

>Increase oral fluid intake

>To prevent dehydration and liquefy respiratory secretions

>Encourage client to choose foods that are appealing

>To stimulate appetite

>Limit fiber/bulk if  indicated

>May result to early satiety

>Note total daily intake

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

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

>To establish a nutritional plan that meets individual needs

>Increase oral fluid intake

>To prevent dehydration and liquefy respiratory secretions

>Encourage client to choose foods that are appealing

>To stimulate appetite

>Limit fiber/bulk if  indicated

>May result to early satiety

>Promote pleasant, relaxing environment

>To enhance intake

>Provide oral care before/after meals

>To keep mouth clean

>Emphasize importance of wellbalanced, nutritious

>To promote wellness

92

intake >Give supplemental humidification as needed (oxygen supply)

>To humidify airways and supplement need for oxygen

Problem no: 10 Risk for Infection ASSESSMENT

NURSING DIAGNOSIS

Risk for Infection S= 0

The patient manifested the following:

O= with dysphagia, with

SCIENTIFIC EX EXPLANATION

An infect io ion is t he he detrimental detrimental colonizatio colonization n of a host organism by a forei foreign gn spec specie ies. s. In an infecti infection, on, the infect infecting ing organism seeks to utilize the host's resour resources ces to multip multiply ly.. The infecting organism, or pathogen, pathogen, interferes interferes with the normal functio functionin ning g of the host host

PLANNING

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

INTERVENTIONS

RATIONALE

Establish therapeutic relationship

To gain pt’ and SO’s trust and cooperation

Monitor VS

To obtain baseline data

Assess pt. general condition

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

EXPECTED OU OUTCOME

The patient shall have demonstrated appropriate hygienic measures such as hand washing, oral care, and perineal care

intake >Give supplemental humidification as needed (oxygen supply)

>To humidify airways and supplement need for oxygen

Problem no: 10 Risk for Infection ASSESSMENT

NURSING DIAGNOSIS

Risk for Infection 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.

SCIENTIFIC EX EXPLANATION

An infect io ion is t he he detrimental detrimental colonizatio colonization n of a host organism by a forei foreign gn spec specie ies. s. In an infecti infection, on, the infect infecting ing organism seeks to utilize the host's resour resources ces to multip multiply ly.. The infecting organism, or pathogen, pathogen, interferes interferes with the normal functio functionin ning g of the host host and can lead to chronic wounds, gangrene, loss of an infected limb, and even death.

PLANNING

Short Term Objective:

INTERVENTIONS

RATIONALE

Establish therapeutic relationship

To gain pt’ and SO’s trust and cooperation

Monitor VS

To obtain baseline data

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

Assess pt. general condition

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

Long Term Objective:

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

To have a baseline data regarding client’s risk

After 3 days of NI, pt will maintain

EXPECTED OU OUTCOME

The patient shall 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

93

white blood cell (WBC) count and differential within normal limits.

normal limits. Assess skin for  color, moisture, texture, and turgor (elasticity). Keep accurate, ongoing documentation of  changes. Preventive skin assessment protocol, including documentation, assists in the prevention of skin breakdown. Carefully wash and pat dry skin, including skinfold areas. Use hydration and

To note f or degree of deficiency

To promote optimum level of  functioning

To prevent s kin impariment

white blood cell (WBC) count and differential within normal limits.

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

To note f or degree of deficiency

To promote optimum level of  functioning

To prevent s kin impariment

To promote pt’s wellness

94

vitamins listed below. Encourage fluid intake. Use appropriate "hand hygiene" (i.e., hand washing or use of  alcohol-based hand rubs). Use careful technique when changing and emptying urinary catheter bags. Ensure the client's appropriate hygienic care with

To maintain hydration status To prevent nosocomial infection

To avoid cross contamination

To prevent good source of  bacterial multiplication

vitamins listed below. Encourage fluid intake. Use appropriate "hand hygiene" (i.e., hand washing or use of  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

To maintain hydration status To prevent nosocomial infection

To avoid cross contamination

To prevent good source of  bacterial multiplication

To pharmacologically manage the

95

antibiotics sparingly as per  doctor’s order 

problem.

Problem No: 11 Risk for Injury ASSESSMENT

S= 0 The patient manifested the following: O= with limited range of motion. contralateral hemiparesis, sensory loss,

NURSING DIAGNOSIS Risk for Injury

SCIENTIFIC EXPLANATION Because of limited rang range e of moti motion on and and slightl slightly y paraly paralyze ze body body the patient is unable to mobilize properly which maybe a risk for injury.

PLANNING

INTERVENTIONS

RATION ALE

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

>Establish rapport

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

>Monitor v/s

>To obtain baseline data

>Assess pt’s general condition

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

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

antibiotics sparingly as per  doctor’s order 

problem.

Problem No: 11 Risk for Injury ASSESSMENT

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

NURSING DIAGNOSIS Risk for Injury

SCIENTIFIC EXPLANATION Because of limited rang range e of moti motion on and and slightl slightly y paraly paralyze ze body body the patient is unable to mobilize properly which maybe a risk for injury.

PLANNING

INTERVENTIONS

RATION ALE

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

>Establish rapport

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

>Monitor v/s

>To obtain baseline data

>Assess pt’s general condition

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

>Assess mood, coping abilities, personality styles

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

>Identify

>To promote safe

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

EXPECTED OUTCOME 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

>Dizziness

interventions and safety devices

physical environment and individual safety

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

>To enhance self  esteem. sense of  worth

>raise the side rails of the bed

>To promote safe physical environment and individual safety

>Frequent skin inspection

> To assess if  there is presence of pressure ulcers.

>Use effective

>To promote

>Dizziness

interventions and safety devices

physical environment and individual safety

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

>To enhance self  esteem. sense of  worth

>raise the side rails of the bed

>To promote safe physical environment and individual safety

>Frequent skin inspection

> To assess if  there is presence of pressure ulcers.

>Use effective lighting

>To promote safety and easy scanning of the environment.

>Remind client to walk slowly

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

97

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

>To >To prevent injury and promote safety.

Problem No: 12 Self Care Deficit: Bathing/Hygiene

ASSESSMENT

NURSING

SCIENTIFIC

PLANNING

INTERVENTION

RATIONALE

EXPECTED

DIAGNOSIS Self Care deficit

EXPLANATION Body Body move moveme ment nts s are are Short Term

S >Established

> To gain trust of 

OUTCOME Short Term

r/t

possible because of the Objective:

Rapport

the patient and

Objective:

The patient

neuromuscular,

movement movement of impulses impulses After 4 hrs. Of 

SO in order to

After

manifested the

musculoskeletal

elicited elicited by such stimuli Nursing

acquire

Nursing

following:

impairment

wh ic ich

pas se ses Intervention, the

compliance with

Interve Interventio ntion, n,

ner nerves ves

pt. will be able to

appropriate

pt. shall be able to

O= w/ pale

goin going g to our our neur neuron ons s

identify personal

treatments or 

identi identify fy

palpebral

which

resources which

teachings

reso resour urce ces s

conjunctiva, w/

interpreted by our brain.

S= 0

thro throug ugh h

t he hen our

are

then

can help in

can

4

hrs.

Of  

the

person personal al

help

whic which h in

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

>To >To prevent injury and promote safety.

Problem No: 12 Self Care Deficit: Bathing/Hygiene

ASSESSMENT

NURSING

SCIENTIFIC

PLANNING

INTERVENTION

RATIONALE

EXPECTED

DIAGNOSIS Self Care deficit

EXPLANATION Body Body move moveme ment nts s are are Short Term

S >Established

> To gain trust of 

OUTCOME Short Term

r/t

possible because of the Objective:

Rapport

the patient and

Objective:

The patient

neuromuscular,

movement movement of impulses impulses After 4 hrs. Of 

SO in order to

After

manifested the

musculoskeletal

elicited elicited by such stimuli Nursing

acquire

Nursing

following:

impairment

wh ic ich

pas se ses Intervention, the

compliance with

Interve Interventio ntion, n,

ner nerves ves

pt. will be able to

appropriate

pt. shall be able to

O= w/ pale

goin going g to our our neur neuron ons s

identify personal

treatments or 

identi identify fy

palpebral

which

resources which

teachings

reso resour urce ces s

conjunctiva, w/

interpreted by our brain.

can help in

pale nail beds, w/

Nerv Nerves es

providing

capillary refill

serve as messengers. If  assistance.

time, 1-3sec., pt.

these are impaired, the

is able to feel

affectation affectation to the brain

deep touch, raise

function

his right arm and

decr decrea ease sed d

leg, w/ slurred

wh ic ich

speech, w/ left

cause impairment also

sided weakness,

to othe otherr stru struct ctur ures es of  intervention, the

with limited ROM

the body and this could

on upper and

S= 0

t he hen

thro throug ugh h

our

are

and and

then

Neur Neuron ons s

Of  

the

person personal al whic which h

help

>Monitored Vital

> To identify any

providing

signs

other deviations

assistance.

in

from normal.

>To determine

Long Term

patient condition

any other 

Objective:

underlying cause

After After 2-3 days of  98

of manifestations

nursing

>Provided

> To prevent

inte interve rventi ntion on,,

adequate rest

further stress &

pt. shall be able to

affect affect the performance performance demonstrate

periods as well as

fatigue

demonstrate

lower extremities,

of ADLs. An example of  techniques or 

comfort & safety

techniques

afebrile, (-) DOB,

that that is Impair Impaired ed ability ability changes to meet

measures

change changes s to meet meet

(-) chest pain.

to

also manifest he

ma y

be

can

hrs.

>Assessed

The patient may

would

4

Long Term

func functi tion on Objective: lat er er

on After 2-3 days of 

perform

nursing

pt. will be able to

self care needs.

self care needs.

bathing/hygiene,

>Turned pt.

> To provide

dressing or grooming.

slowly from side

proper circulation

to side

of blood flow on

following:

both sides of he body

>Inability to get bath supplies

>Determined pt.

>To assess

>Inability to wash

strengths and

degree of 

body parts

skills

disability

>Inability to pick

the

or  

speech, w/ left

cause impairment also

of manifestations

nursing

sided weakness,

to othe otherr stru struct ctur ures es of  intervention, the

>Provided

> To prevent

inte interve rventi ntion on,,

with limited ROM

the body and this could

adequate rest

further stress &

pt. shall be able to

on upper and

affect affect the performance performance demonstrate

periods as well as

fatigue

demonstrate

lower extremities,

of ADLs. An example of  techniques or 

comfort & safety

techniques

afebrile, (-) DOB,

that that is Impair Impaired ed ability ability changes to meet

measures

change changes s to meet meet

(-) chest pain.

to

The patient may also manifest he

perform

nursing

pt. will be able to

self care needs.

self care needs.

bathing/hygiene,

>Turned pt.

> To provide

dressing or grooming.

slowly from side

proper circulation

to side

of blood flow on

following:

both sides of he body

>Inability to get bath supplies

>Determined pt.

>To assess

>Inability to wash

strengths and

degree of 

body parts

skills

disability

appropriate

>Assisted pt. in

>To promote

clothing

his activities

optimal level of 

>Inability to pick

>Inabiliy to

function

replace articles or  clothing on own

>Encouraged

>Promotes well-

>Inability to

adequate intake

being and

maintain

of fluids &

maximizes

99

appearance at a

the

Nutritious foods

satisfactory level

energy production.

>Provided time

>To >To assist with

for listening to

the patient’s

patient and SO,

current disability

and provided

or condition.

privacy during personal care activities. >Involved client’s

>To assist in

SO in care

learning ways of  managing problems of  immobility and for  providing appropriate nursing care.

or  

appearance at a

Nutritious foods

satisfactory level

energy production.

>Provided time

>To >To assist with

for listening to

the patient’s

patient and SO,

current disability

and provided

or condition.

privacy during personal care activities. >Involved client’s

>To assist in

SO in care

learning ways of  managing problems of  immobility and for  providing appropriate nursing care.

> Provided health

>To provide

teachings and

clarification

support o the SO

Reinforcement

for care options

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, 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

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, 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’ Client’s s Daily Progre Progress ss Chart Chart (From admis admission sion to dischar discharge) ge) Days

01-27-09

01-28-09

01-29-09

01-30-09

*

*

01-31-09

(Admission) Nursing Problems: 1.) 1.) Acut Acute e Pai Pain n 2.) 2.) Impa Impair ired ed cerebral tissue

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

perfusion 3.) 3.) Impa Impair ired ed physical mobility 4.) 4.) Acti Activi vity ty Intolerance 5.) 5.) Impa Impaire ired d verbal verbal and/or written communication 6.) 6.) Risk Risk for  for  Aspiration 7.) 7.) Risk Risk for  for  impaired skin integrity

103

8.) 8.) Risk Risk for  for 

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

36.2c

36.5c

37c

36c

36c

Pulse Rate

84 bpm

88 bpm

76 bpm

71 bpm

69 bpm

Respiratory rate

18 bpm

22 mmHg

19 bpm

17 bpm

18 pbm

Blood Pressure

170/100

140/50

180/90

180/90

170/90

mmHg

mmHg

mmHg

mmHg

mmHG

deficient fluid volume 9.) 9.) Risk Risk for  for  imbalanced nutrition: less than body requirements 10.)Risk for  Infection 11.)Risk for Injury 12.)Self care Deficit

Vital Signs: Temperature

Diagnostics Procedures:

*

1.) 1.) CXR CXR APL APL

*

2.) 2.) Feca Fecaly lysi sis s 3.) 3.) Urin Urinal alys ysis is

*

*

4.) 4.) Pota Potass ssiu ium mK 5.) CBC

*

104

*

Drugs: 1. Piracetam 2. Captopril 3. Ranitid itidin ine e

*

*

*

*

*

*

*

D/C

*

*

*

*

*

*

*

*

4. Simva imvas stat tatin

*

5. Metop toprolo rololl 6. Ketoste steril ril 7. FeSo4

*

8. Hyd Hydrala ralazi zine ne * *

Hold

*

*

*

*

*

*

*

*

*

*

*

*

Medical managements: 1. D5 LRS 1L 2. D5 0. 0.3 Na NaCl

*

500cc Diet: 1. NPO

*

2. Soft Di Diet Activity/Exercises: 1. High Back Rest

*

VII. Conclusion Stro Stroke ke is a term term used used to desc descri ribe be the the neur neurol olog ogic ic chan change ges s caus caused ed by an interruption in the blood supply to a part of the brain. The incidence of stroke and stroke

105

mortalities has gradually declined in many industrialized countries in recent years as a resul resultt of incre increase ased d recog recognit nition ion and and treatm treatment ent of risk risk factor factors, s, whic which h may inclu include de 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 controlled and reducing heavy alcohol consumption. consumption. The best intervention is to stop smoking cigarettes. As nursing students, this study showed us the importance of early detection of  diseases diseases such as stroke since it may lead to more serious conditions 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

VIII. Bibliography Joyce M. Black et al (2005) Medical Surgical Nursing 7 th edition Elsevier Suanders Smelt Smeltze zerr, S. et. al. (2008 (2008). ). Brun Brunner ner and and Sudd Suddart arth’ h’s s Textbo extbook ok of Medic Medicalal-Su Surgi rgical cal th Nursing 11 edition. Philadelphia: Philadelphi a: Lippincott-Williams Lippinco tt-Williams & Wilkins Spratto Spratto,, G. and Woods, Woods, A. (2008). (2008). 2008 Edition 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 edition. New York: McGraw-Hill.

th

Van Leeuwen, A., Kranpitz, T., Smith, L., (2006) Davis’s Comprehensive Handbook of  Laboratory and Diagnostic Test with Nursing Implication 2 nd edition editi on, U.S.A, U.S.A , F.A Davis Company Nurse’s Nurse’s Quick Check - Signs and Sympto S ymptoms ms (2006) Philadelphia, Philadelphia, Lippincott Williams & Wilkins Nurse’s 5- minute Clinical Consult – Diseases, (2007) Philadelphia, Lippincott Williams & Wilkins Hansel, D., Dintzis, R. (2006) Lippincott’s Lippincott’s Pocket Pathology, Philadelphia, Lippincott Lippincott Williams & Wilkins Stew Stewar art, t, Jose Joseph ph (198 (1989) 9) Clin Clinic ical al Anat Anatom omy y and and Path Pathop ophy hysi siol olog ogy y for for the the Heal Health th Professional, Miami, MedMasters Inc. Web information retrieved at: http://en.wikipedia.org/wiki/Nervous_system accessed on January 30, 2009 10:58pm http://www.emedicinehealth.com/anatomy_of_the_endocrine_system/article_em.htm accessed on January 20, 2008 10:00pm http://en.wikipedia.org/wiki/Cardiovascular_system accessed on January 31, 2009 5:00pm http://www.enotes.com/nursing-encyclopedia/cerebrovascular-accident accessed on January 31, 2009, 9:46 pm

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http://www.emedicinehealth.com/anatomy_of_the_central_nervous_system/page2_em. htm accessed on February 1, 2009 9:00am http://www.mims.com/ accessed on February 1, 2009 09:00pm http://www.virtualneurocentre.com/diseases.asp?did=823 accessed on February 2, 2009, 8:26 pm http://www.mayoclinic.com/health/transient-ischemic-attack/DS00220 accessed on February 2, 2009 9:14 pm http://www.mayoclinic.com/health/stroke/DS00150/DSECTION=symptoms accessed on February 2, 2009 10:25 pm http://www.mayoclinic.com/health/type-2-diabetes/DS00585 accessed on February 3, 2009, 12:30 am http://www.mayoclinic.com/health/high-blood-pressure/DS00100 accessed on February 2, 2009, 1:46 pm http://www.webmd.com/hypertension-high-blood-pressure/guide/blood-pressure-basics accessed on February 2, 2009, 2:30 pm http://www.google.com.ph/search?hl=tl&q=creatinine&btnG=Maghanap&meta = accessed on February 2, 2009, 8:25pm

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