case pres stroke
TRANSCRIPT
Far Eastern UniversityInstitute of Nursing
Introduction
Intracranial hemorrhage is the escape of blood within the cranium due to the loss of
integrity of vascular channels and frequently leading to formation of a hematoma.
Intracranial bleeding occurs when a blood vessel within the skull is ruptured or leaks. It
can result from physical trauma (as occurs in head injury) or non-traumatic causes (as occurs in
hemorrhagic stroke) such as a ruptured aneurysm. Anticoagulant therapy, as well as disorders
with blood clotting can heighten the risk that an intracranial hemorrhage will occur.
Objectives
Define the Intracranial hemorrhage.
Know the case of ICH, its possible signs and symptoms, risk factors, and diagnostic and
laboratory exams.
Determine the treatment and to apply appropriate nursing interventions.
Lastly, to use the case as a tool in the improvement of one’s profession in applying
nursing interventions.
I. Biographic Data
Name: A.T.Address: Blk11 L3 SSDM, BulacanAge: 48 y/oGender: MaleReligion: Roman Catholic Admitting date/time: Sept. 04, 2009 8:08AMRoom and Bed No.: 200Chief Complaint: left sided body weakness 3hr. prior to admissionAdmitting Diagnosis: T/C CVA, infarctFinal diagnosis: ICH right basal ganglia score of 1, HCVD, CAD, T2DMAttending Physician: Dr. Boy Saw
II. Nursing History
A. Past Health History
The patient had measles and chickenpox during childhood. He cannot recall his immunization. There are no allergies in food and drugs. There are no foreign travels yet. He is asthmatic since childhood and had his last attack when he was in high school. He also has type 2 Diabetic Mellitus for 10 years and it is being maintained by Diamicron but after 7 years he stopped taking his medication because he assumed that his illness had been already cured.
B. History of Present Illness
The patient has Type 2 Diabetes Mellitus and Hypertension. 3 hours prior to admission, he experienced left sided body weakness. His friend noticed that he walked like tipsy wherein he is not sober that time and his friend decided to accompany him home. In their house, his son accompanied him to urinate when AT is about to fall. AT said to his son “Nanghihina ako” and his son noticed that he has slurring of speech.
C. Family History
Hypertension, diabetes mellitus and asthma runs through the family of AT. There are no other diseases noted.
III. Patterns of Functioning
A. Psychological Health
1. Coping PatternWhen asked about how the patient copes up with life’s problems, he verbalized,
“Naguusap-usap kami tungkol sa problema. Kapag gipit sa pera, tumatawag ako sa mga kapaid ko, humihingi ng pera.”
Interpretation:
The client and his children talk about their problems and if it is about financial problems, they ask money from his sisters.
Analysis:Coping may be described as dealing with problems or contending them successfully.
Short-term coping strategies can reduce stress to a tolerable limit temporarily but are in the long-run ineffective ways to deal with reality. Fundamentals of Nursing research by Kozier 7th
edition p. 1020).
2. Interaction PatternAT’s sister verbalized that “Ayos naman ang pakikitungo niya sa ibang tao,
marami siyang kaibigan sa village namin dahil nga security guard siya ng subdivision eh kilalang kilala siya doon at wala naman siyang kagalit.”
AT’s has slurring of speech during the interview. As verbalized by his son, “Hindi masyadong maintindihan yung sinasabi ni Papa kapag nagsasalita siya.” He also has slow and sluggish movements. He also showed appropritae hand movements.
Interpretation:The client has barriers to effective communication.
Analysis:Human communication is essential for learning, working, and social interaction.
Communication may affect every aspect of a person’s life based on a person’s cognitive level, educational attainment, and health status such as speech, language or hearing problems and disorders. (Fundamentals of Nursing by Taylor et al, 5th ed. Pp466-467)
3. Cognitive PatternWhen we asked about his education, AT said that he is a college graduate.
About his occupation he is an OIC of security guards in their village.
Interpretation:The client finished tertiary education and is a college graduate.
Analysis:COGNITVE DEVELOPMENT (PIAGET): Cognitive thinking culminates with the capacity
for abstract thinking. This stage, the period of formal operations, is Piaget’s fourth and last stage. It is typical of the period of concrete thought. They now think beyond the present. Without having to center attention on the immediate situation, they can imagine a sequence of events that might occur, such as college and occupational possibilities; how things might change in the future, such as relationships with parents; and the consequences of their actions. At this time their thoughts can be influenced by logical principles rather than just their own perceptions and experiences. (Wong’s Essentials of Pediatrics Nursing, by Donna Wong and Marilyn J. Hockenberr-Eaton, 6th Edition, p. 525)
4. Self-ConceptAT said that he is happy and contented even though he had been
separated from his wife for how many years. He lives with his daughter and son. He is also happy because of his job, as an OIC security guard.
Interpretation:
The client does not see any problem with his self-concept and the way how he lives his life with his two children.
Analysis:The self-concept becomes more differentiated as adults acquire a more complex picture
of themselves, one that takes situational factors into account. The self-concept gradually becomes more individualized and more distinct from the concepts of others. The advent of chronic disease or a permanent physical disability has very special significance and creates stress for the person. (Wong’s Essential of Pediatric Nursing by Wong and Eaton, 6 th edition, p. 525) Image of physical self or body image is how a person perceives the size, appearance and functioning of boy and its parts. Body sensation describes “how one feels and experiences oneself as physical being.” Fundamentals of Nursing by Kozier 6th edition p. 804)
5. Emotional PatternRegarding to the emotional pattern of the client, his sister verbalized that
“6 years na simula nung maghiwalay sila ng asawa niya, after 2 years nilang maghiwalay nakapag-move na din siya na wala silang komunikasyon at hindi na rin nasusustentuhan yung mga bata”. She also added that “Tinutuon na lang niya ang atensyon sa pagpapalaki sa mga anak niya at sa trabaho”.
Interpretation:The client’s emotional state is normal.
Analysis:Emotional pattern is the ability to manage stress and to express emotions appropriately.
It also involves the ability to recognize, accept, and express feelings and to accept one’s limitations. (Fundamentals of Nursing by Kozier 7th ed. P. 173)
6. SexualityAT acts appropriate to his gender. He is friendly in both male and female as
verbalized by his sister that he everyone in their village knows him.
Interpretation:The client is able to express his own sexuality.
Analysis:Sexual health is the integration of the somatic, emotional, intellectual, and social aspects
of sexual being, in ways that are positively enriching and that enhance personality, communication and love. (Fundamentals of Nursing by Kozier 7th ed. P. 973)
7. Family coping patternWhen asked about his family, his son verbalized “Ako at si papa po magkasama
sa bahay tapos yung kapatid kong babae nakatira sa tita ko” he added “Close naman po kami kay papa, minsan napapalo ako pag may nagawa akong kasalanan at yung ate ko nasisigawan niya minsan”
Interpretation:The client’s family is open whenever they have problems.
Analysis:
Family roles are especially important to clients, since family relationships are particularly close. All members of the family are empowered to maintain communication with each other. When it comes to decisions, the family members are considered as a whole that functions together and not individually. (Public Health Nursing-DOH book, pg, 118)
B. Socio-cultural PatternThe client’s siblings and his children are considered as significant others as mentioned
by his son.
As for his recreational activities, his son mentioned that he often drinks with his friends and neighbors in their village. He also loves to watch TV when at home.
The client lives in SSDM Bulacan wherein he is also the security guard of the said village. Since they live inside the village, their environment is not exposed to air pollution. Sometimes their house has cockroaches, mouse, and mosquitoes.
AT’s income is not enough for their basic needs and to the education of his children. That’s why sometimes he asks money from his sister.
Interpretation:The significant relationship pattern of the client is normal since the client is able
to regard people around her who are significant. The client’s recreational pattern is similar to others of his age which is interesting and can provide independence. Drinking often is not healthy. The client’s environment has no health hazards. The client’s source of income for their basic needs and the education of his children are not enough for the family.
Analysis:Significant other is an individual or group that takes on a special importance for
the development of self-esteem during a particular life stage. Significant others may include parents, siblings, peers, teachers and the like. (Fundamentals of Nursing by Kozier 6 th ed. p.806)
Recreational activities are often determined by what is popular and what can provide independence. It is a form of relaxation on the part of a person. It is also a time free of obligations and formal duties of paid work, thus an opportunity to pursue at one’s own pace, mental nourishment, enlivenment, pleasure and relief from fatigue of work. (Fundamentals of Nursing by Kozier 7th ed. P. 201)
The environment is all the conditions, circumstances, and influences surrounding and affecting the development of an organism or a person. It should provide physical and psychological comfort. (Fundamentals of Nursing by Kozier 6th ed. p.250)
All individual’s standard of living (reflecting occupation, income, and education) is related to health, morbidity, and mortality. Hygiene, food habits, and the propensity to seek health care advice and follow health care regimens vary among high-income and low-income groups. (Fundamentals of Nursing by Kozier, p. 178)
C. Spiritual PatternAT is a Roman Catholic. He believes in God and he goes to church once a month.
Interpretation:The client has a positive outlook in life and has faith in God.
Analysis:Spirituality refers to that part of human that seeks meaningfulness through intrapersonal,
interpersonal and transpersonal connection. It generally involves a belief with some higher power, creative force, divine being, or infinite source of energy. Spiritual and religious beliefs are important in many people’s lives. They can influence lifestyle, attitudes and feelings about illness and death. (Fundamentals of Nursing by Kozier 6th ed. p.313)
IV. Activities of Daily Living
Before Hospitalization
During Hospitalization
Interpretation and Analysis
Nutrition A.T. usually eats thrice a day. He eats all kind of foods.He is fond of eating pork liempo, barbeque, tokwa’t baboy and sisig. He always drink softdrinks while eating lunch. He has a good appetite. He drinks more than 8 glasses of water. He often drinks beer with his friends and he consumes 4-6 bottles of beer. He loves to eat pulutan such as Dinakdakan and Sisig.
The client maintains a soft low salt, low fat DM diet.
Interpretation:
The client is fond of eating foods with high cholesterol, softdrinks and alcoholic beverages that are bad to his health.During hospitalization the client is following his diet regimen
Analysis:Nutrition is a basic human need that changes throughout the life cycle and along the wellness-illness continuum. Carbohydrates, commonly known as sugars and starches, are organic compounds composed of carbon, hydrogen and oxygen. Tissue growth and repair, helps regulate fluid balance through oncotic pressure, helps regulate acid-base balance, component of body framework are the functions of protein in our body system.(Fundamentals of Nursing by Kozier 6th ed. p.714)
Elimination The client usually voids 6 times per day. His urine is light in color and aromatic in odor.He defecates once a day. His stool is brownish in color and smooth.
The client urinates 4-5 times and defecates once a day.
Interpretation:
patient has a normal elimination pattern
Analysis:A properly functioning urinary system is essential to the body’s physical well-being, to life itself, and to a person’s general sense of well-being. Elimination from the urinary
tract helps to rid the body of waste products and materials that exceed bodily needs. Elimination of the waste products of digestion is a natural process critical for human functioning. Although most people have experienced minor acute bouts of diarrhea or constipation, some patients experience severe or chronic alterations in bowel elimination that affect their fluid and electrolyte balance, hydration, nutritional status, skin integrity, comfort and self-concept.(Fundamentals of Nursing by Kozier 6th ed. p.918-920)
Exercise The client is always walking because of his job (subdivision’s security guard). Sometimes he plays basketball with his neighbors.
A.T. does bed exercises every morning by stretching.The client’s activities/ exercise are very limited due to his illness.
Interpretation: The client’s activities/ exercise are very limited due to his illness.
Analysis:Active exertion of muscles involving the contraction and relaxation of muscle groups is termed “exercise”. The human body was designed for motion, and regular exercise is necessary for its healthy functioning. Individuals who choose inactive lifestyles or who are forced into inactivity by illness or injury place themselves at high risk for serious health problems.(Fundamentals of Nursing by Kozier 6th ed. p.345)
Hygiene A.T. takes a bath 1-2 times a day and brushes his teeth twice a day. He always washes his hands before and after eating.
As for the client’s hygiene, he cannot do his daily routine or hygienic practices.
Interpretation:The patient has a limited movement that’s why he cannot do his daily hygienic practices.
Analysis:Personal hygiene promotes physical and psychological well-being. Various studies have confirmed that improved personal hygiene practices reduce illness rates.(Fundamentals of Nursing by Kozier 6th ed. p.117)
Sleep and Rest
The client usually sleeps 6 hours per day including his naps.
The client has shorter periods of sleep unlike before. There are times that he will be awakened to take his meds, for vital signs monitoring, changing of IV fluids.
Interpretation:The patient has a disturbed sleep and rest pattern related to illness.
Analysis:Rest connotes a condition in which the body is in decreased state of activity with the consequent feeling of being refreshed. Sleep is a state of rest accompanied by altered consciousness and relative inactivity.
Illness that causes physical distress can result in sleep problems, People who are ill require more sleep than normal and the normal rhythm of sleep and wakefulness is often disturbed.(Fundamentals of Nursing by Kozier 6th ed. p.998)
V. Physical Assessment
VITAL SIGNS:
Temperature: 36.7º C
Pulse Rate: 65Beats per minute
Respiration Rate: 20 Breaths per minute
Blood Pressure: 140/90 mmHg (Abnormal BP client is experiencing hypertension)
GCS: 15
APPEARANCE AND MENTAL STATUS:
ASSESSMENT NORMS AND
STANDARDS
ACTUAL FINDINGS ANALYSIS
Body Build: Proportionate, Varies
with Lifestyle
Medium body build,
appropriate for height.
Normal
Posture and Gait Relaxed, Erect
Posture, Coordinated
Movement
The client is relaxed and weak in appearance.He has generalized body weakness with minimal movement.
Asymmetry of movement, in
which only one side of the
body is affected, may occur
with disorders of the central
nervous system, principally
in those patients who had
cerebrovascular accidents.
(Medsurg 10th edi by
Brunners and Suddarths p.
68)
Hygiene and
Grooming
Neat and Clean Looks neat and clean;
clothes are appropriate
for the current condition
Normal
Body and Breath
Odors
No body or breath odor
related to activity.
No body and breath odor Normal
Signs of Distress No signs of distress. No sign of distress Normal
Attitude Cooperative
appropriate to the
situation
Cooperative sometimes Normal
Affect/Mood,
Appropriateness of the
clients responses
Client’s response is
appropriate to the
situation
The client has flat affect and irritable.
Behavior changes after a stroke.The client may exhibit flat affect.(medsurg by Black 7th edi. p.2116)
Quantity, Quality, and
Organization of
Speech
Understandable,
Moderate Pace,
Exhibits thought
association
He can’t verbalize well
for NGT is present.
Slurred speech .
Speech may be slurred
because of CNS disease or
because of damage to
cranial nerves.
(Med-Surg 10th edi. by
Brunners p. 68)
Relevance and
organization of
thoughts
Logical Sequence,
Makes sense, exhibits
thought association
Answers appropriately
but seldom if he can’t
answer the son or the
sister talk.
Normal
AREAS OR
THINGS TO BE
ASSESSED
TECHNIQU
E
NORMS AND
STANDARDS
ACTUAL
FINDINGS
ANALYSIS
INTEGUMENT
Skin Inspect Varies from light to
deep brown; ruddy
pink to light oink;
yellow overtones to
olive
Varies from
light to
deep
brown;
ruddy pink
to light
oink; yellow
overtones
to olive
Normal
Skin color generally
uniform except in
areas exposed to
sun; areas of lighter
pigmentation (palms,
lips, nail beds) in
dark-skinned people
Skin color generally
uniform
Normal
Observe Moisture in skin folds
and the axillae varies
with environmental
temperature, and
activity
Moist Normal
Palpate
Skin temperature of
the two feet and two
hands are uniform
and within the normal
range
Skin temperature of
the two feet and
two hands are
uniform and within
the normal range.
Normal
Note Skin Turgor:
When pinched, skin
springs back to
previous state
Skin Turgor:
When pinched, skin
springs back to
previous state
Normal
Hair Inspect The hair is evenly Thick and evenly Normal
distributed
Thick hair
Silky, Resilient Hair
No infection or
infestation
distributed hair. No
alopecia and other
infections.
Nails Inspect Convex curvature;
angle of nail plate
about 160o
Smooth texture
Highly vascular and
pink in light-skinned
people; dark-skinned
clients may have
brown or black
pigmentation in
longitudinal streaks.
Intact epidermis
Convex curvature;
angle of nail plate
about 160o
Smooth texture
Highly vascular and
pink in light-skinned
people; dark-
skinned clients may
have brown or
black pigmentation
in longitudinal
streaks.
Intact epidermis
Normal
Perform
Blanch test
of capillary
refill
Prompt return of pink
or usual color
(generally less than 4
seconds)
When performed
blanche test
capillary refill
returns back in
seconds in its usual
color.
normal
HEAD
Cranium and Face
Cranium Inspect Rounded
( normocephalic and
symmetrical, with
frontal, parietal and
occipital
prominences);
smooth skull contour
Rounded,
normocephalic and
symmetrical,
smooth skull
contour
Normal
Palpate Smooth, uniform
consistency;
absence of nodules
or masses
Smooth and no
presence of
masses and
nodules
Normal
Face Inspect Facial features are
symmetric or slightly
asymmetric facial
features; palpebral
fissures equal in size;
symmetric nasolabial
folds.
Slightly
Asymmetrical facial
features. Shallow
nasolabial folds to
the left
Almost all clients have some degree of mobility after a stroke. Hemiparesis, these deficit are usually caused by a stroke.(medsurg by Black 7th
edi. p. 2111)
Eyes and Visual Acuity
Eyebrows Inspect Eyebrows’ hair is
evenly distributed;
eyebrows’ skin are
intact;
eyebrows
symmetrically
aligned;
equal movement of
eyebrows
Evenly distributed;
asymmetrically
aligned with equal
movement.
Normal
Eyelashes Eyelashes are
equally distributed
and curled slightly
upward
Eyelashes are
equally distributed,
slightly curved
upward
Normal
Eyelids Eyelids’ skin are
intact; no discharge;
no discoloration;
Lids close
symmetrically;
15 to 20 involuntary
blinks per minute;
bilateral blinking;
When lids open, no
visible sclera above
cornea, & upper &
lower borders of
cornea are slightly
covered
Eyelids are intact .
negative presence
od discharge nor
discoloration.17
involunatary blinks
per minute. When
lids open no visible
sclera above
cornea and upper
and lower borders
of cornea are
slightly covered
Normal
Anterior Chamber Anterior chamber is
transparent no
shadows of light
when lighted
obliquely, and about
3 mm depth.
Transparent Normal
Pupil Pupils are black,
equal in size (3-7mm
in diameter), round,
smooth border, iris is
flat and round.
Equal in size;
round, smooth
Normal
Assess
Illuminated pupil
constricts (direct
response); Non
illuminated pupil
constricts when the
other pupil is
illuminated
(consensual
response)
Constricts when
illuminated. Non-
illuminated eye also
constricts.
Normal
Pupils constrict when
looking at near
objects; pupils dilate
when looking at far
objects; pupils
converge when near
object is moved
toward nose.
Pupils constrict
when looking at
near objects; pupils
dilate when looking
at far objects
Normal
Visual Fields Temporally, object
can be seen at right
angles (90o) to the
central point of
vision;
The upward field of
vision is normally 50o
because the orbital
ridge is in the way;
The downward field
of vision is normally
70o because the
cheekbone is in the
way.
Able to see objects
placed at periphery.
Normal
Extra Ocular
Muscle
Both eyes
coordinated, move in
unison, with parallel
alignment.
Coordinated
movement, eyes
are able to follow
the movement in
unison
Normal
Visual Acuity Able to read
newsprint
Able to read
newsprint
normal
20/20 Vision on
Snellen Chart
Not performed
Ears and Hearing
Auricles Inspect Color same as facial
skin;
Symmetrical;
Auricle aligned with
outer canthus of eye,
about 10o from
vertical
Same color with
facial skin;
symmetrically
aligned with eyes
outer canthus. Size
is appropriate for
the face.
Normal
Palpate Mobile, firm, and not
tender;
pinna recoils after it
is folded
Springs back after
being recoiled
Normal
Gross Hearing
Acuity
Assess Normal voice tones
audible
Able to hear normal
voice tone
Normal
Watch Tick
Test
Able to hear ticking in
both ears
Able to hear ticking
in both ears
Normal
Tuning Fork
Test
(Weber’s
test)
Sound is heard in
both ears or is
localized at the
center of the head
( Negative Weber
Test)
Not performed
Tuning Fork
Test
(Rinne Test)
Air-conducted
hearing is greater
than bone-conducted
hearing
(Rinne Test Positive)
Not performed
Nose and Sinuses
External Nose Inspect Symmetric and
Straight;
No discharge or
discoloration;
Uniform color
At the center of
face; straight and
symmetric. No
discharge. Color
same as facial skin
color.. presence of
NGT
Normal
Palpate Not tender; no
lesions
No tenderness,
masses or lesions
Normal
Patency of both
nasal cavities
Determine Air moves Freely as
the client breathes
through the nares
Patent nares Normal
nasal Cavity Inspect Air moves freely as
the client breathes
through the nares.
Air move freely
from both
nose.Presence of
NGT
Normal
Redness, swelling,
growths, and
discharge.
Mucosa pink; Clear,
watery discharge;
No lesions, Nasal
septum intact & in
midline
Mucosa pink;
Clear, watery
discharge;
No lesions, Nasal
septum intact & in
midline
Normal
Maxillary and frontal
sinuses for
tenderness
Palpate Not tender No tenderness Normal
Mouth and Oropharynx
Outer Lips Inspect Uniform pink color
( darker, e.g. bluish
hue, in
Mediterranean
groups and dark-
skinned people);
Soft, moist, smooth
texture;
Symmetry of contour;
Ability to purse lips
Pinkish color; soft,
moist, smooth. Able
to purse lips.
Normal
Inner Lips and
buccal mucosa
Uniform pink color
(freckled brown
pigmentation in dark-
skinned clients)
Moist, smooth, soft,
glistening, and elastic
texture (drier oral
mucosa in elderly
due to decreased
salivation)
Uniform dark
pinkish color,
Moist, smooth, soft,
glistening, and
elastic texture.
.Normal
Palpate
Teeth Inspect 32 adult teeth;
smooth, white, shiny
tooth enamel
32 adult teeth;
smooth, white,
shiny tooth enamel
Normal
Gums Pink gums (bluish or
dark patches in dark-
skinned clients);
Moist, firm texture of
gums;
No retraction of gums
Pink to bluish gum
color;
Moist, firm texture
of gums;
No retraction of
gums
Normal
Surface of Tongue Central position;
Pink color (some
brown pigmentation
on tongue borders in
dark-skinned clients);
moist; slightly rough,
thin washing coating;
Smooth, lateral
margins; No lesions;
Raised papillae
Pink color; moist;
slightly rough, thin
washing coating;
Smooth, lateral
margins; No
lesions;
Raised papillae
Normal
Tongue Movement Assess Moves freely; no
tenderness
Moves freely Normal
Base of Tongue Inspect Smooth tongue base
with prominent veins
Smooth tongue
base
Normal
Tongue, mouth floor,
and frenulum
Palpate Smooth with no
palpable nodules
smooth Normal
Salivary Gland Inspect Same color of buccal
mucosa and floor of
mouth
Pinkish with
prominent vein.
Normal
Soft Palate Light pink, smooth,
soft palate
Pinkish in color and
smooth
Normal
Hard Palate Lighter pink hard
palate
Light pinkish color Normal
Uvula Positioned in midline
of soft palate
Seen at the
midline
Normal
Oropharynx Pink and smooth
posterior wall
Pinkish in color Normal
Tonsils Pink and smooth; no
discharge; Of normal
size (Grade 1: the
tonsils are behind the
tonsillar pillars)
Pinkish,smooth and
no discharge.
Normal
Glosso- Assess Present Present but weak Normal
Pharyngeal or vagus
nerve
(Elicit Gag
Reflex)
NECK
Neck Muscles Inspect Muscles equal in
size; head centered
Equal in size Normal
Head Movements Observe Coordinated, smooth
movements with no
discomfort;
Head flexes 45
degrees;
Head hyperextends
60 degrees;
Head laterally flexes
40 degrees;
Head laterally rotates
70 degrees;
Coordinated
movement
Normal
Neck Muscle
Strength
Assess Equal Strength Equal strength Normal
Neck Lymph Nodes Palpate Not palpable Not palpable
lymphnodes.
Normal
Trachea Central Placement in
midline of neck;
spaces are equal on
both sides
Seen at the
midline.
Normal
Thyroid Gland Inspect Not visible on
inspection;
Gland ascends
during swallowing but
is not visible
Not visible thyroid
gland
Normal
Palpate Lobes may not be
palpated; If palpated,
lobes are small,
smooth, centrally
located, painless,
and rise freely with
swallowing
Not palpable Normal
THORAX AND LUNGS
Thorax Inspect Anteroposterior to
transverse diameter
in ratio of 1:2;
Chest symmetric;
Symmetrical chest Normal
Spinal alignment The Spine vertically
aligned
Aligned at the
midline
Normal
Posterior Thorax Palpate Skin intact;
uniform temperature
Skin intact Normal
Posterior chest for
respiratory excursion
Full and symmetric
chest expansion
(when client takes a
deep breath, your
thumbs should move
apart an equal
distance and at the
same time; normally,
the thumb separate 3
to 5 cm)
Full and symmetric
lung expansion.
Normal
Posterior Chest for
tactile fremitus
Bilateral Symmetry of
vocal fremitus;
Fremitus is heard
most clearly at the
apex of the lungs;
Low pitched voices of
males are more
readily palpated than
higher pitched voice
of females
Not performed.
Patient doesn’t
want to.
Posterior Thorax Percuss Percussion notes
resonate, except over
scapula;
Lowest point of
resonance is at the
diaphragm;
Percussion on a rib
normally elicits
dullness
Patient doesn’t
want to
Breathing Patterns Inspect Quiet, rhythmic, and
effortless
qiuet Normal
Costal angle and the
angle at w/c the ribs
enter the spine
Costal angle is less
than 90 degrees, and
the ribs inserted to
the spine is
approximately 45
degrees angle
Not performed
Anterior Chest Palpate Skin intact; uniform
temperature
Skin is intact Normal
Anterior Chest for
respiratory excursion
Full and symmetric
chest expansion;
Normally, the thumb
separate 3 to 5 cm
full chest
expansion
Normal
Anterior Chest for
Tactile Fremitus
Fremitus is normally
decreased over heart
and breast tissue
Fremitus is heard. Normal
Anterior Chest Percuss Percussion notes
resonate down to the
sixth rib at the level
of the diaphragm but
are flat over areas of
heavy muscle and
bone, dull on areas
over the heart and
the liver, and
tympanic over the
underlying stomach
Resonance down
to the 6th rib,flat
over the muscle
and bones.and dull
over the heart and
the liver and
underlying
stomach.
Normal
Trachea Auscultate Bronchial and tubular
breath sounds
Sounds like air
moving through a
tube.
Normal
Anterior Chest Bronchovesicular and
vesicular breath
sounds
bronchovesicular
breath sound
Normal
HEART AND CENTRAL VESSELS
Aortic Area Inspect and
Palpate
No pulsations No pulsation Normal
Pulmonic Area
Tricuspid Area No pulsations; No lift
or heave
No pulsations Normal
Apical Area Pulsation is visible in
50% of adults and
palpable in most PMI
in fifth LICS at or
medial to MCL;
Diameter of 1 to 2
cm; No lift or heave
Pulsation heard. Normal
Epigastric Area Aortic pulsations Presence of
pulsation
Normal
Aortic Area Auscultate S1: usually heard at
all sites and usually
louder at apical area;
S2: usually heard at
all sites and usually
louder at the base of
the heart
Systole: silent
interval, slightly
shorter duration than
diastole at normal
heart rate;
Diastole: silent
interval, slightly
longer duration than
diastole at normal
heart rate;
S3 in children and
young adults;
S4 in many older
adults
S1 and S2 heard Normal
Pulmonic Area
Tricuspid Area
Apical Area
Carotid Artery No sounds heard on
auscultation
No sound Normal
Jugular Vein Inspect Veins not visible Not visible Normal
MUSCULOSKELETAL SYSTEM
Muscles Inspect Equal size on both
sides of the body;
No fasciculation or
tremors
Equal size Normal
Palpate Normally form;
smooth coordinated
movements
No contractures Normal
Strength
test
Equal strength on
each body side
Unequal muscle
strength on each
body graded as in left
side is (1/5) weak
than the right side
graded as (4/5) of the
body. Weakness in
face and arms is
greater than the legs
Hemiparesis of one
side of the body may
occur after stroke
(medsurg by black 7th
edi. p.2111)
Joints Inspect No swelling,
tenderness,
crepitation, or
nodules;
Joints move smoothly
No swelling,
tenderness,crepitai
on, or nodules; joint
move smoothly
except for the weak
left side.
Hemiparesis of one
side of the body may
occur after stroke
(medsurg by black 7th
edi. p.2111)
NEUROLOGIC SYSTEM
Cranial nerve Inspect
2 2-3 mm pupils
equally reactive to
light and
accommodation
Normal
3,4,6
11 Symmetrical lifting of
shoulders
Intact extraocular
muscles
Can lift shoulders
Right greater than
Left
Normal
Muscle weakness,
paralysis, abnormal
or lost sensation on
one side of the body
occur after a stroke.
(medsurg by black 7th
edi. p.2112)
VI. LABORATORY EXAMINATIONS
COMPLETE BLOOD COUNTSeptember 4, 2009
Result Normal Findings Interpretation and AnalysisRBC Count 5.50 x
10^12 /LM: 5.5-6.5x1012/L Normal
Hemoglobin 17.00 g/dL 14-16 g/dL HighMay indicate Polycythemia, Dehydration and COPDFundamentals of Nursing by Kozier p.759
Hematocrit 0.50 L/L M:0.42-0.52L/LF:0.37-0.47L/L
Normal
WBC 7.84 x 10^9 /L 5-10 x10 ^ 9/L Normal
MCV (Mean Corpuscular Volume)
91.7 f 82-92 fl Normal
MCH (Mean Corpuscular Hemoglobin)
30.9 pg 27-33 pg Normal
MCHC (Mean Corpuscular Hemoglobin Concentration)
34.0 pg 32-38% Normal
Eosinophils 0.01 0.03-0.05 LowWith stress and certain medications such as epinephrine, thyroxine and ACTHFundamentals of Nursing by Kozier p.759
Segmenters 0.67 0.55-0.65 HighThere might be an acute infection, tissue necrosis, leukemias and drug influences such as aspirin, heparin, digitalis, epinephrine, lithium, histamine, antibioticsFundamentals of Nursing by Kozier p.759
Lymphocytes 0.26 0.25-0.35 Normal
Monocytes 0.06 0.02-0.06 Normal
ROENTGENOGRAPHIC REPORTSeptember 4, 2009
Impression:Atheromatous aorta
Chest:No active lung infiltrate seen. Pulmonary vascular markings are within normal limits. Heart is not enlarged. Aorta is calcified. Diaphragm and bony thorax are unremarkable.
URINALYSISSeptember 4, 2009
Actual Findings Normal Findings AnalysisColor Light Yellow Light straw to dark
amberNormal
Sp. Gravity 1.010 1.005-1.030 NormalCharacter Hazy Clear Bacteria,
Pus, tissueRBCsWBCsPhosphatesProstatic fluid
Urates, uric acidBilirubin Negative Negative NormalProtein Negative Negative NormalGlucose Negative Negative NormalBlood Negative Negative NormalKetone +2 Negative Abnormal
Ketone bodies, a product of the breakdown of fatty acids, normally are not present in the urine. They may, however, be found in the urine of clients with poorly controlled diabetes.Fundamentals of Nursing by Kozier p.771
Nitrite Negative Negative NormalLeukocytes Negative Negative NormalPus Cells Negative 0-2 hpf Normal
RBC Negative 0-3 hpf Normal pH 6.0 4.6-8 Low
Urine is slightly acidic with an average pH of 6.Fundamentals of Nursing by Kozier p.770
Casts None None NormalCrystals None None NormalBacteria Moderate None Abnormal
Bacteria present in stool indicate infection. Bacterial gastroenteritis, sometimes called acute gastroenteritis, is an inflammation of the stomach and intestines caused by the introduction of certain types of bacteria into the
digestive tract.
DIFFUSION WEIGHTED MRI OF THE BRAINSeptember 4, 2009
Indication:The patient presents left-sided body weakness and slurring of speech.
Pertinent MR findings:There is 2.8 x 2.5 x 3.9 cm (APxTxH) abnormal signal, which is ointense on T1W1 slightly hyperintense on T2W1 and shows blooming artifact on GRE, in the R basal ganglia and surrounding capsules extending superiorly into the R corona radiate. These findings are indicative of intracerebral hemorrhage in hyperacute stage. There is an associated perilesional edema with apparent mild compression effect to the right lateral ventricle producing some mild bowing of the midline structures leftwardly. There is also 1.0 x 0.4 (APxT) focal hemorrhage in subacute stage in the left lentiform nucleus and left external capsule. Minimal perilesional edema is likewise present. In addition, there is a probable petechial hemorrhage in the right occipital region.
Other worth mentioning findings include chronic small vessel ischemic changes in the centrum semiovale/coron radiate, left frontal subcorticalwhite matter and both forceps major. There are old lacunar infarcts in the left external capsule and probably also in the anterior portion of both corona radiata.
Remarks:There are finding of bilateral intracerebral hemorrhage of differing ages as described.
SEROLOGYSeptember 5, 2009
Actual Findings Normal Findings AnalysisHgbA1c 10.7% 4-7% % Abnormal
Indicates Diabetes.http://diabetes_basics/what/high_blood_sugar.html
BLOOD CHEMISTRY
September 4, 2009
September 7, 2009
September
8,2009
Normal Findings
Interpretation and Analysis
RBS 358 --- --- 70-100 High
mg/dL mg/dLGreater than normal levels (hyperglycemia) may indicate:
Acromegaly (very rare) Cushing syndrome (rare) Diabetes mellitus Impaired fasting glucose
(also called "prediabetes") Hyperthyroidism Pancreatic cancer Pancreatitis Pheochromocytoma (very
rare) Too little insulin Too much food
http://www.nlm.nih.gov/medlineplus/ency/article/003482.htm
Crea 92 mmol/L
--- --- M: 62-115 mmol/LF: 53-97 mmol/L
Normal
SGPT 166 U/L --- --- 0-55 U/L HighElevations of SGPT, an enzyme found within the liver cells, indicate that the liver cells are either leaky (internal contents are entering the blood) or damaged. A wide array of conditions can cause this problem. For example, viral hepatitis or alcohol can cause elevated SGPT. We know that patients can have elevated liver tests as a result of fatty liver, a condition that does not necessarily mean generalized obesity. Usually fatty liver is not a cause for significant liver problems.http://www.valdezlink.com/pages/SGPT.htm
Na 131.70 mmol/L
--- 147.60 mmol/L
135-148 mmol/L
Normal
K 4.29 mmol/L
3.20 mmol/L
2.83 mmol/L
3.50-5.30 mmol/L
Normal
Glucose 12.71 mmol/L
--- --- 3.90-6.00 mmol/L
HighIndicates diabetes mellitus.
CLINICAL CHEMISTRY RESULT
Capillary Blood Glucose
Actual Findings Normal Findings
Interpretation and Analysis
September 4, 2009
@ 1pm 277 mg/dL@ 2pm 271 mg/dL@6pm 369 mg/dL@ 7pm 237 mg/dL
@ 10pm 346 mg/dL
70-110 mg/dL High*Indicates Diabetes.
Having too much sugar in the blood for long periods of time can cause serious health problems if it's not treated. Hyperglycemia can cause damage to the vessels that supply blood to vital organs, which can increase the risk of heart disease and stroke, kidney disease, vision problems, and nerve problems in people with diabetes. These problems don't usually show up in kids or teens with diabetes who have had the disease for only a few years. However, these health problems can occur in adulthood in some people with diabetes, particularly if they haven't managed or controlled their diabetes properly.http://diabetes_basics/what/high_blood_sugar.html
September 5, 2009
@ 2mn 242 mg/dL@ 6am 190 mg/dL@11pm 150 mg/dL@ 12nn 397 mg/dL@ 1pm 377 mg/dL@ 3pm 382 mg/dL@ 4pm 283 mg/dL@ 5pm 256 mg/dL
70-110 mg/dL High*
September 6, 2009
@ 5am 207 mg/dL@ 11am 167mg/dL@ 5pm 125 mg/dL
70-110 mg/dL High*
September 7, 2009
@ 5am 106 mg/dL@ 5pm 163 mg/dL
70-110 mg/dL High*
September 8, 2009
@ 5am 110 mg/dL@ 5pm 92 mg/dL
70-110 mg/dL Normal
September 9, 2009
@ 5am 204 mg/dL@ 5pm 141 mg/dL
70-110 mg/dL High*
September 10, 2009
@ 5am 105 mg/dL 70-110 mg/dL Normal
VII. Drug Study
Generic/Trade Name
Dosage/ Frequency
Classification Indication Contraindication Side Effects Nursing Responsibilities
Citicholine 1g BID Nootropics & Neurotonics
Parkinson's disease; Cerebrovascular disorders and head injury
Contraindicated to patients with allergy with the drug
elevated body temperature, restlessness, and difficulty sleeping if the supplement is taken in the evening.insomnia, headache, diarrhea, low or high blood pressure, nausea, blurred vision, chest pains,
Assess patient for any allergy of the drug.
Advise patient to seek emergency medical attention if he feels adverse effects of the drug.
Omeprazole 2mg 1 CAP OD
Antacids, Antireflux Agents & Antiulcerants
Eradication of H. pylori infection,Prophylaxis of acid aspiration,to treat symptoms of gastroesophageal reflux disease (GERD) and other conditions caused by excess stomach acid. Omeprazole is also used to promote healing of erosive esophagitis (damage to your esophagus caused by stomach acid).
Contraindicated in patients with known hypersensitivity to any component of the formulation.
Diarrhoea, nausea, fatigue, constipation, vomiting, flatulence, acid regurgitation, taste perversion, arthralgia, myalgia, urticaria, dry mouth, dizziness, headache, paraesthesia, abdominal pain, skin rashes, weakness, back pain, upper respiratory
Assess patient for any allergy of the drug.
Advise patient to seek emergency medical attention if he has chest pain or heavy feeling, dizziness, pain spreading to the arm or shoulder, sweating, nausea or vomiting, and a general ill feeling.
Give each dose of omeprazole with a full glass (8 ounces) of water.
infection, cough.Potentially Fatal: Anaphylaxis.
Do not crush, break, or open a delayed-release capsule. It is specially made to release medicine slowly in the body. Breaking or opening the pill would cause too much of the drug to be released at one time.
Store omeprazole at room temperature away from moisture and heat.
Lactulose 30cc @ HS Laxatives, Purgatives
to treat chronic constipation.
Galactosaemia, intestinal obstruction. Patients on low galactose diet.
Diarrhoea (dose-related), nausea, vomiting, hypokalaemia, bloating and abdominal cramps.Potentially Fatal: Dehydration and hypernatraemia on aggressive treatment.
Assess patient for any allergy of the drug.
Advise patient to seek emergency medical attention if he feels adverse effects of the drug.
Not to be given to patients on a special diet low in galactose (milk sugar).
May be given w/ meals to reduce GI discomfort
Monitor electrolyte
imbalance. Special
prescaution for Lactose intolerance; diabetics.
Measure liquid medicine with a special dose-measuring spoon or cup, not a regular table spoon.
Lactulose powder should be mixed with at least 4 ounces of water.
Store lactulose at room temperature away from moisture and heat.
Mannitol 150cc OD in pm
Diuretics Oliguric phase of renal failure,Raised intracranial pressure; Raised intraocular pressure; Cerebral oedema,to reduce swelling and pressure inside the eye or around the brain.
Pulmonary congestion or oedema; intracranial bleeding; CHF; metabolic oedema with abnormal capillary fragility; anuria due to severe renal disease; severe dehydration.
Fluid and electrolyte imbalance; acidosis (with high doses). Nausea, vomiting, thirst; headache, dizziness, convulsions, chills, fever; tachycardia, chest pain; blurred vision; urticaria and hypotension
Assess patient for any allergy of the drug.
Assess for history of severe or long-term kidney disease, lung swelling or congestion, severe dehydration, bleeding in brain not caused by surgery, or if kidneys have
or hypertension; acute renal failure; skin necrosis; thrombophloebitis.
already shut down and unable to urinate.
Check for signs of fluid and electrolyte imbalance.
Should not be administered with whole blood.
Advise patient to get emergency medical help if he has any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
Losartan 50mg/tab OD in pm
Angiotensin II Antagonists
HTN; Diabetic nephropathy in Type 2 DM;to treat high blood pressure (hypertension).
contraindicated in patients with known hypersensitivity to any component of the formulation.
Headache, dizziness, back pain, myalgia, respiratory tract disorders, asthenia/fatigue, first dose hypotension, rash, angioedema, neutropenia, GI disturbances, transient elevation of liver enzymes, impaired renal function, taste disturbances and
Assess patient for any allergy of the drug.
Assess for history or presence of kidney disease; liver disease; congestive heart failure; or dehydration.
Advise patients to avoid drinking alcohol. It can lower blood pressure and may increase some of
hyperkalaemia. the side effects of losartan.
Do not give potassium supplements or salt substitutes while patient is taking losartan, unless prescribed by doctor.
Check blood pressure on a regular basis.
Monitor serum-potassium concentration.
Kalium durule 1tab x 6 doses TID
Electrolytes Adults & elderly Prophylaxis, hypokalemia
Renal insufficiency, hyperkalemia, untreated Addison's disease, constriction of the esophagus &/or obstructive changes in the alimentary tract.
Nausea and vomiting, ECG changes in hyperkalemia
Assess patient for any allergy of the drug.
Should be taken with food (Swallow whole w/ 1/2 glass of liqd, do not break/chew/crush. Do not administer to a patient in a supine position.).
Report weakness, fatigue, polyuria, polydypsia, as these could be signs of K+ deficit.
Notify physician for persistent vomiting as K= loss may occur.
Humulin 70/30 25 units @ am
15 u @pm
Insulin Preparations
Treatment of IDDM.
Hypoglycemia, IV administration & hyperglycemic coma.
Lipodystrophy, insulin resistance. Local & generalised allergic reactions.
Correct Syringe: Doses of insulin are measured in units. Use only U-100 insulin syringe.
Failure to use the proper syringe can lead to a mistake in dosage, causing serious problems eg, a blood glucose level that is too low or too high.
Syringe Use: To help avoid contamination and possible infection, follow these instructions exactly:
Disposable syringes and needles should be used only once and then discarded. Needles and syringes must not be shared.
Preparing the Dose: Wash hands. Carefully shake or rotate the insulin bottle several times to completely mix the
insulin.
Inspect the insulin. Humulin 70/30 should look uniformly cloudy or milky. Do not use it if anything unusual in the appearance is noticed.
If using a new bottle, flip off the plastic protective cap, but do not remove the stopper. When using a new bottle, wipe the top of the bottle with an alcohol swab.
Draw air into the syringe equal to the insulin dose. Put the needle through the rubber top of the insulin bottle and inject the air into the bottle.
Turn the bottle and syringe upside down. Hold the bottle and syringe firmly in 1 hand and shake
gently.
Making sure the tip of the needle is in the insulin, withdraw the correct dose of insulin into the syringe.
Before removing the needle from the bottle, check the syringe for air bubbles which reduces the amount of insulin in it. If bubbles are present, hold the syringe straight up and tap its side until the bubbles float to the top. Push them out with the plunger and withdraw the correct dose.
Remove the needle from the bottle and lay the syringe down so that the needle does not touch anything.
Administration: Injection: Cleanse the skin with alcohol
where the injection is to be made. Stabilize the skin by spreading it or pinching up a large area. Insert the needle as instructed by the doctor. Push the plunger in as far as it will go. Pull the needle out and apply gentle pressure over the injection site for several seconds.
Do not rub the area. To avoid tissue damage, give the next injection at a site at least ½ inch from the previous site.
Always examine the appearance of the insulin before administering a dose. The vial must be carefully shaken or rotated injection, and the cartridge rolled between the palms 10 times and inverted 180° 10 times before each injection so that the contents are uniformly mixed.
Humulin should look uniformly cloudy or milky after mixing. Do not use if the insulin substance (the white material) remains visibly separated from the liquid after mixing.
Do not use if there are clumps in the insulin after mixing.
Do not use if solid white particles stick to the bottom or wall of the vial/cartridge, giving it a frosted appearance. Always check the appearance of the vial/cartridge of insulin before using, and note anything unusual in the appearance of the insulin or a marked change in the insulin requirements.
VIII. PathophysiologyAneurysm Severe Hypertension AV Malformation
Rupture of cerebral vessel
Intracerebral bleeding occursBleeding in the Right basal ganglia
Contralateral hemiplegia, with initial flaccidity progressing to spasticity
Sudden severe headache
Nausea and vomiting
Coma
DEATH
Increased ICP
Risk factors DM HPN Smoking Obesity High cholesterol
levels Heart Disease Age Gender Race Family history
Decreased insulin production
Diminished insulin action
Hyperglycemia
S/Sx: Generalized weakness and malaise, excessive urine production, excessive thirst, blurred vision, unexplained weight loss
Imbalance bet. The blood supply and the demand of the heart for oxygenated
Limitations to coronary blood flow with vasospasm and thrombosis
Increased metabolic demands of the heart and everyday activities Perfusion pressure may be insufficient to
provide adequate blood flow
X. Ecologic Model
A. Hypothesis
The condition of the client might have been resulted from the interrelationship of the risk factors that the client gained overtime. Factors like diet, familial history, and the client’s lifestyle aggravates the condition of the client.
B. Predisposing Factors
The host, male 48 years of age, with a nationality of Filipino and is residing at Barangay San Manuel SSMD, Bulacan.Working as a security guard in the subdivision. With familial history of hypertension and Diabetes Mellitus.He engages in drinking alcohol often with friends consumes 4-6 bottles of beer. He is fond of eating pork foods which is high in cholesterol. Client is known to be hypertensive and with DMT2
Last September 4, 2009 the client experienced left side body weakness 3 hours PTA.
.
C. Ecologic Model,
D. Analysis
There are several factors of CVA. The modifiable factors are hypertension, sedentary lifestyle, obesity, increase salt, cholesterol, and fatty foods intake, smoking, stress, diabetes mellitus. The non-modifiable factors are sex (women are more likely to die from a stroke), age (two-thirds of strokes occur in people over age 65), race (affect blacks more often than whites, and are more likely to be fatal among blacks) and heredity.
CVA
MALE
FAMILY HISTORYHPN, DM
HYPERTENSION
CAD
DMT2
HIGH-CHOLESTEROL DIET
ENVIRONMENTDRINKING ALCOHOL
OCCUPATION SECURITY GUARD
In this case, factors contributing to the client’s attack are FAMILIAL HISTORY,GENDER,HPN,DMT2,LIFESTYLE, DIET,AGE,OCCUPATION.GENDER As in all diseases, a genetic predisposition increases one’s risk of having the disease. His advancing age also cause a lot of physiologic changes in his body. As a person ages, his blood vessels become less elastic and covered by atheroma or fat plaques which narrows or obstructs the passage of blood causing an infarct to the area. Present illness HPN,DM2 aggreviates the disease. Food habits and alcohol consumption, also intensified his risk because such acts increase the deposition of fat in the vessels and its hardening. Lastly, the incidence of stroke is higher in men than that of women.
E. Conclusion and Recommendations
The factors contributing to the disease are Familial history, Lifestyle, DM2, HPN, Occupation. Such factors that are not modifiable; thus, care must be focused on ensuring client comfort and wellness and decreasing further complications and worsening of the disease. The body becomes weaker and vulnerable to a lot of diseases as it matures. Remind the family to be in constant monitor of the client in case of an attack. Also, always be in assistance with the client because with this disease, the client becomes too weak with sensory and motor impairments
Lifestyle should also be modified. His food habits must be corrected. His alcohol consumption . Though this may not reverse the problem, such actions may prevent worsening of the disease.
XI. Prioritization
NURSING PROBLEM CUES JUSTIFICATION Impaired Tissue Perfusion (cerebral) related to bleeding
Subjective: “Nanghihina ako.”
Changes in BP (BP): 140/90 mmHg
slurring of speech left sided body weakness flat affect and irritable
Cerebral perfusion of the cerebrum is critical for survival and long term outcome; therefore it should be the first priority in the care of the client. Decrease in cerebral blood flow may be secondary to thrombus, embolus, hemorrhage, edema or spasm
(p.1858 Medical Surgical Nursing by Joyce Black)
Impaired physical mobility related to neuromuscular
left sided body weakness slow and sluggish
movements
Almost all clients have some degree of immobility after a stroke.
impairmentPressure ulcers are common problem for anyone with a lower than normal level of activity. It can be deadly for a patient who can’t turn or move by him/herself. Infected pressure ulcers are one of the primary causes of death in a patient with neurological diagnosis, even when not infected, pressure ulcer still cause prolonged distress and adversely affect the patient’s ability to function and his/her quality of life.
(p.1859 Medical Surgical Nursing by Joyce Black; p. 122 Medical Surgical Nursing by Lippincott Williams & Wilkins)
Impaired verbal communication related to decrease in circulation to brain
“Hindi masyadong maintindihan yung sinasabi ni Papa kapag nagsasalita siya.”
slurred speech showing of hand
movements
The inability to speak is frustrating for clients. Early recognition of this problem decreases some of the frustration in meeting everyday needs and the ability to effectively communicate and express feelings and sensations to other people.
(p.1860 Medical Surgical Nursing by Joyce Black)
XII. Nursing Care Plan
NURSING PROBLEM
ANALYSIS GOAL AND OBJECTIVES
INTERVENTIONS RATIONALE EVALUATION
Impaired Tissue Perfusion (cerebral) related to intracranial hemorrhage as evidenced by left sided body weakness
Cues:Subjective:“Nanghihina ako, ” as verbalized by the client.
Objectives: slurring of
speech left sided
body weakness
flat affect and irritable
Measurement:VITAL SIGNS:Temp: 36.7º CPR: 65 BPMRR: 20 BPMBP: 140/90 mmHg
Immediate Cause:Ineffective tissue perfusion
Intermmediate Cause:Intracranial hemorrhage
Root Cause:Cerebrovascular Accident(stroke)
The cerebral hemisphere of our bicameral (two-chambered) brain is known as the seat of thought, memory, awareness, motor function, sensory function, and speech -- i.e., the higher brain. When a hemorrhage (bleeding from traumatic injury or arterial damage) occurs inside the brain in one or both of the hemispheres,
Goal:After 5 hours of nursing interventions, the client will have no further deterioration as mainifested by improved cerebral tissue perfusion and stabilized neurological deficits.
Objectives:
IndependentAfter 1 hour of nursing intervention the client will be able to:
a. maintain adequate oxygenation
b. maximize tissue perfusion
Administer oxygen therapy
Assess heart rate and rhythm; auscultate for murmurs;
O2 therapy may be required to maintain adequate airway and to improve cerebral tissue perfusion.
Changes in rate, especially bradycardia, can occurbecause of the brain damage. Dysrhythmias and murmursmay reflect cardiac disease, which may have precipitated
Goal met as the client had adequate and improved cerebral perfusion as evidenced by stable vital signs, improved cognition, motor and sensory function, and appropriate affect and mood.
Symptoms depend on distribution of the cerebral vessel(s) involved.
Hypertension (High Blood Pressure) is one of the prime causes. It is also suspected that the underlying blood vessels of the brain may be abnormal with microaneurysms (i.e., tiny outpouchings of the arterial walls which are weak and subject to bursting).
Bleeding commonly occurs in the basal ganglia, and less commonly in the pons, thalamus, cerebellum, and cerebral white matter. The hemorrhage (bleeding) may extend into the ventricular system or subarachnoid space of the brain. The bleeding, in some cases, may compress the brain
b. maintain blood pressure within normal range
c. maintain head/ neck in neutral position.
Assess respirations, noting patterns and rhythm
Evaluate pupils, noting size, shape, equality, lightreactivity.
Assess higher functions, including speech, if patient isalert.
Frequently monitor blood pressure
Position with head slightly elevated and in neutralposition.
CVA.
Irregularities can suggest location of cerebralinsult/increasing ICP and need for further intervention, including possible respiratory support.
Response to light reflects combined functionof the optic (II) and oculomotor (III) cranial nerves and is useful in determining whether thebrainstem is intact.
Changes in cognition and speech content are an indicator of location/ degree of cerebral involvement and may indicate deterioration/ increased ICP.
To maintain perfusion without promoting cerebral edema.
Reduces arterial pressure by promoting venous drainageand may improve cerebral circulation/perfusion.
stem (lower part of the brain). If brain stem compression occurs, the death rate is very high.
d. maintain normo-thermia.
CollaborativeAfter 1 hour of intervention the client will be able to:
a. Engage in pharmacologic therapy.
Monitor client’s temperature.
Administer medications (eg. anticoagulants, antihypertensives, stool softeners) as prescribed by the physician.
Normo- thermia reduces cerebral glucose and oxygen consumption.
Will aid in the recovery of the patient and help prevent further complications
XIII. Discharge Plan
Medications Exercise Treatment/Therapy Health Teaching Outpatient Diet Support System
Medicines may be needed in addition to lifestyle changes.
Statins to help lower choleste-rol.
Beta-
Get regular exercise on most, if not all, days of the week. Your doctor can suggest a safe level of exercise
Procedures may be done to improve blood flow to the heart.
Angioplasty is used to open blocked arteries. It isn't major surgery. During angioplasty, the
Treatment focuses on taking steps to manage your symptoms and reduce your risk for heart attack and stroke.
Lifestyle changes are the first step for anyone with coronary artery
See the doctor for regular follow-up appointments. This lets the doctor keep track of the risk factors and adjust his
Lowering of LDL cholesterol by reducing saturated fat intake.
Lowering of Triglyceride levels by reducing consumption of sugary and
Get the support you need to succeed in making lifestyle changes. Ask family or friends to share a healthy meal or join a stop-
blockers or ACE inhibitors to lower blood pressure.
Aspirin or other medicines to reduce the risk of blood clots.
Nitrates to relieve chest pain.
for you. Walking is great exercise that most people can do. A good goal is 30 minutes or more a day.
doctor guides a thin tube (called a catheter) into the narrowed artery and inflates a small balloon. This widens the artery to help restore blood flow. Often a small wire-mesh tube called a stent is placed to keep the artery open. The doctor may use a stent that is coated with medicine, called a drug-eluting stent. When the stent is in place, it slowly releases a medicine that prevents the growth of new tissue. This helps keep the artery open.
Bypass surgery, which is major surgery, may
disease. These changes may stop or even reverse coronary artery disease. To improve your heart health:
Don't smoke. This may be the most important thing you can do. Quitting smoking can quickly reduce the risk of heart attack or death.
Eat a heart-healthy diet that includes plenty of fish, fruits, vegetables, beans, high-fiber grains and breads, and olive oil. See a dietitian if you need help making better food choices.
Lower your stress level. Stress can huzrt your heart.
Changing old habits may not be easy, but it is
treatment as needed.
Take medicines exactly as prescribed. Do not stop or change medicines without talking to the doctor.
Instruct to keep nitroglycerin with him at all times, if the doctor prescribed it for chest pain.
processed foods.
Reduction of Homocysteine levels by supplementation with Vitamins B6 and B12, and folic acid.
Increased antioxidant activity by higher consumption of fruits and vegetables.
Lowering of fibrinogen and growth factors by cutting back on foods such as red meat, dairy products, poultry and eggs.
smoking program with you. Or ask your doctor about a cardiac rehab program. In cardiac rehab, a team of health professionals provides education and support to help you make new, healthy habits
be used if more than one coronary artery is blocked. It uses healthy blood vessels to create detours around narrowed or blocked arteries.
very important to help you live a healthier and longer life. Having a plan can help. Start with small steps. For example, commit to eating five servings of fruits and vegetables a day. Instead of having dessert, take a short walk. When feeling stressed, stop and take some deep breaths
Far Eastern UniversityInstitute of Nursing
Case Study
Intracranial Hemorrhage
Submitted to:Pepito B. Ruzol JR., PT, RN, RM, MSN
Submitted by:
BSN117Group 67
GALINATO, Maria JunelsiaGAMBOA, Jessedith AnnGAMBOA, Michael BrianGANCENIA, Bettina Rose
GARCIA, JaniceGARCIA, Kimberly Ann
BSN117Group 68
MATULAC, Famela JeanTEOVISIO, Jessely
TUY, Barry VASQUEZ, Neil