compilation for mgt 3

8/9/2019 Compilation for Mgt 3

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I. INTRODUCTION

A cerebrovascular accident is the medical term for a stroke. A stroke is when

blood flow to a part of your brain is stopped either by a blockage or a rupture of a blood

vessel. There are important signs of a stroke that you should be aware of and watch out

for. A left-side stroke happens when the blood supply to the left side of the brain is

interrupted. Without oxygen and nutrients from blood, the brain tissue quickly dies. The

cerebrum is the largest part of the brain. t is made of a left and a right hemisphere. n

most people, the left hemisphere is in charge of the functions on the right-side of the

body. t is also involved in abilities such as the ability to speak, or use language. There

are two main types of stroke! ischemic and hemorrhagic.

"emorrhagic stroke accounts for about #$ percent of stroke cases. t results from

a weakened vessel that ruptures and bleeds into the surrounding brain. The blood

accumulates and compresses the surrounding brain tissue. The two types of

hemorrhagic strokes are intracerebral %within the brain& hemorrhage or subarachnoid

hemorrhage.

Globally, measurements undertaken by the W"' revealed an up to ten-fold

difference in age-ad(usted and sex-ad(usted mortality rates and burden %measured in

disability-ad(usted life year loss rates %)A*+s&& among countries. oth were

considerably higher in low-income countries % orth Asia, astern urope, /entral Africa,

and 0outh 1acific& compared to high-income countries %Western urope, orth

America&. 234,555 new or recurrent strokes occur per year in the 60, accounting for

approximately # in #7 deaths. n urope, the incidence of stroke varies from #5#.# to

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8$3.$ per #55,555 in men and 9$.5 to #47.2 per #55,555 in women. Within 4 years of a

stroke, over half of patients aged : ;4 years will die! 48< of men and 49< of women.

0troke is the second leading cause of death above the age of 95 years, and the

fifth leading cause of death in people aged #4 to 43 years old. very year, #4 million

people worldwide suffer a stroke. early six million die and another five million are left

permanently disabled. 0troke is the second leading cause of disability, after dementia.

)isability may include loss of vision and = or speech, paralysis and confusion. 0troke is

less common in people under ;5 years, although it does happen. n young people the

most common causes are high blood pressure or sickle cell disease. n many developed

countries the incidence of stroke is declining even though the actual number of strokes

is increasing because of the ageing population. n the developing world, however, the

incidence of stroke is increasing. n /hina, #.$ million people have a stroke each year

and 24< live with varying degrees of disability as a result of stroke. The predictions for

the next two decades suggest a tripling in stroke mortality in *atin America, the >iddle

ast, and sub-0aharan Africa.

Nationally, according to the latest W"' data published in April 85## 0troke

)eaths in 1hilippines reached ;5,8;4 or 3.44< of total deaths. The age ad(usted )eath

?ate is 78.22 per #55,555 of population ranks 1hilippines @#59 in the world.

Locally , there are no records of incidence of stroke published online for )avao)el orte. "owever, in )avao /ity, /ouncilor ?ene lias *ope said stroke is now the

top cause of morbidity in the city, with #,755 people dying from the disease in 8557.

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OBJECTIVES

The study aims to present all the information we have gathered about the case of

our patient who has an admitting diagnosis of T=/ /erebrovascular accidentB /A1->?.

>oreover, this intends to share the knowledge based on information gathered to the

patient, the significant others and to our fellow nursing students.

0pecifically, this study intends to!

• 'btain sufficient and relevant information regarding our patientCs condition.• 1resent personal data of our patient.• Trace the past medical history affecting the patientCs present health condition.• 1resent factual information by conducting a thorough head-to-toe assessment

with our chosen sub(ect serving as our baseline data.• 0how and discuss the anatomy and physiology of the involved organ and system

basing from our patientCs diagnosis.• *ist down the actual laboratory results of our patient.• 1resent the medical interventions done to the patient including the different drugs

ordered with their action in alleviating the underlying causes of present condition.• dentify the needs of the patient and formulate effective nursing care plans

appropriate for the patientCs case.• mpart suitable and realistic health teachings to the patient himself and to his

significant others %watcher&.• valuate the outcome of the condition of the patient.

II. ASSESSMENT

A Biogra !ical Dataame! 1atient Dowowo

Age! 94 years oldirthdate! Euly #5, #3;3

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irthplace! ohol0ex! >ale0tatus! >arried

Address! 1urok 58A, >agdum, Tagum /ityationality! Filipino

?eligion! ?oman /atholic)ate of Admission! )ecember 2, 85#;Time admitted! 9!84 pm

Attending 1hysician! )r. Dintanar B C!i"# Co$ laint

?ight 0ided WeaknessC %i&tory o# r"&"nt illn"&&

1atient Dowowo was admitted on )ecember 2, 85#; at ishop Eoseph

?egan >emorial "ospital. Few minutes 1TA, had sudden onset of ?ight 0ided

Weakness associated with /hest pain, %G& cough.

D 'a&t M"(ical %i&toryt is the first time for the patient to be admitted due to cerebrovascular

accident. "e has not done a regular 1 check-up even though heCs aware that he

has a high 1 especially that he has family history of hypertension. "e did not seek

any medical attention therefore he has no maintenance medications.E '"r&onal, )a$ily an( Socio*Econo$ic %i&tory

1atient Dowowo belongs to the middle class family. "e is currently a

pensioner. The patientCs father was hypertensive and died because of it. The patient

has ten siblings and they also died due to hypertension and /HA. The client himself

was a smoker during his young age and stopped when he was older. "owever, heCs

a habitual alcoholic drinker and has no limit in eating foods that are not good for him.

"e has also a sedentary lifestyle and not doing regular exercises.

) 'ati"nt N""( A&&"&&$"nt

)ate! )ecember 3, 85#;

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ame of patient! 1atient Dowowo

Age! 94 years old 0ex! > 0tatus! >arried

)ate= Admission Time! )ecember 2, 85#;= 9!84 1>

Arrived on 6nit by! 0tretcher From! mergency ?oom

Admitting weight=H0! Weight! 25kg.Temp! $4.2 I/ 1! 895=#$5 mm"g

??! 88cpm 1?! 77 bpm

/lientCs ?eason for Admission! J ikalit ra pagnaog niya sa motor namurag

nawad-an na og kusog og dili na kalihok ang right side sa iyang lawasK as

verbali ed by the watcher."ow was problem been managed by client at homeL 1atient was immediately

brought to the hospital.

Allergies! o known allergies

>edication %at home&! o medications at home

1hysiologic eeds

I. O+yg"nation 1 M #;5=#55 mm"gB 1? M 74bpmB ?? M 85cpm %regular

respiration&.*ungs %per auscultation! sound, character, chest pain&! With symmetrical

chest expansion upon inhalation and distress not noted upon assessment.

With crackles heard upon lung auscultation./ardiac 0tatus %per auscultation! sound, character, chest pain&! With

normal cardiac sound of J*ubb dubbK heard upon auscultation and no

complains of chest pain upon assessment./apillary ?efill! With capillary refill of 8 seconds upon blanching.

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0kin /haracter and /olor! rownish skin complexion, warm to touch.

Nood skin turgor noted.*ife 0upporting Apparatus! With ' 8 inhalation O 8*1> via nasal cannula.

With HF @8 1 00 #* O DH' rate infusing well O * metacarpal vein.'ther 'bservations! o other observationsII. T"$ "rat-r" Maint"nanc"

Temperature! $2.# o /0kin /haracter! rownish, warm to touch and with good skin turgor.

III. N-tritional )l-i("eight! 4C2KWeight! 25 kg.

Amount of Food /onsumed! Able to consume meal served.1rescribed diet! )AT

ating pattern! $x a day

ating problems! eeds assistance and aspiration precaution should beconsidered.

HF=Fluid ntake! HF- 855cc, Water P $55 ccIV. Eli$ination

*ast bowel movement! 6nable to defecate within the shift.ormal pattern! once a day

6rination! Able to urinate ;55 cc, yellow in color, within the shift.'ther observations! With Foley catheter attached to urobag

V. R"&t an( Sl""ed time! 2!55 1.> Waking up! 7!55 A.>

0leep %pattern, amount of sleep&! Able to sleep at long intervals and onlywakes up to attend needs.

VI. 'ain A oi(anc"?ate of pain %using scale 5-#5&! o complains of pain upon assessment./haracter! =A*ocation! =AFrequency! =A)uration! =A

ehavior! =A'ther 'bservations! one

VII. Sti$-lation/ Acti ityWork! "e was once a laborer in a anana 1lantation before and is

currently retired, a pensioner.?ecreation or past time! "eCs doing household chores."obbies or vices! 0topped smoking several years from now but is still and

alcoholic drinker.

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VIII. Sa#"ty 0 S"c-rity n""(&euro H0! score of #4 out of #4

>ental status! /onsciousB 0lurred speech.motional 1roblems! one

'ther ob(ective cues! ? hand grip and ? leg movement is absent

I1. Lo " an( b"longing"e feels very secure and happy living with his wife, they were gifted with

four loving children. "e feels grateful toward his familyCs loving and caring

support, especially in terms of his current condition.1. S"l#* "&t""$

The client has a low self-esteem at present because of his current

condition that would really limit or make him unable to perform A)* and

total assistance of significant others is highly needed.1I. S"l#*act-ali2ation

The client was able to raise their four children successfully with the help of

his loving wife. "e was successful in his previous (ob as heCs now

receiving his pension every month. "owever, the client has no limit in

eating foods and is continuously drinking alcoholic beverages that

aggravated his current condition.Eric3&on4& D" "lo $"ntal Ta&3

rickson envisions life as a sequence of levels of achievement. ach stage

signals a task that must be achieved. The resolution of the task can be complete,

partial, or unsuccessful. rickson believes that the greater the task achievement, the

healthier the personality of the person! failure to achieve a task influences the personCs

ability to achieve the next task. These developmental tasks can be viewed as a series of

crises, and successful resolution of these crises is supportive to the personCs ego.

Failure to resolve the crises is damaging the ego.

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G"n"rati ity &. Stagnation

1atient Dowowo, 94 years old, falls under the >id Adulthood from $4-94 years

old which has the central task of Nenerativity versus 0tagnation. This stageCs ma(or task

is creativity, productivity and concern for others. 0elf-indulgence, self-concern, lack of

interests and commitments are the indicators of negative resolution. n the case of our

patient, 1atient Dowowo, he attained the Nenerativity for he was able to achieve and

reali e the ma(or task successfully by showing concern to his family especially to his

wife and children despite of the condition he has. "e always thinks of whatCs best for his

family, willing to give the excellent care and love that he can.

'%5SICAL ASSESSMENT

Neneral 0urvey

1atient Dowowo, 94 years old, male, stands 4 feet and 2 inches tall and weighs

25kg. With the following H0 as monitored and recorded upon admission Temp M $4.2 o /B

1M 895=#$5 mm"gB 1? M 77 bpmB ?? M 88cpm. With HF bottle @ # 1 00 #* O DH'

rate infusing well. "e is conscious and his words were hard to understand due to slurred

speech.

Vital Sign& Monitoring S!""t

ame! 1atient Dowowo 0ex! > Age! 94 +.'

Ward! 0t. Francis ?oom= ed! ;54-8

Date/Shift Time Temperatur Blood Respirator Cardiac

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e Pressure y Rate Rate12/07/201

4

3 11

!2" P# 3"$7 2 0/130 22 %%

!30 P# 1%0/100%!00 P# 3&$3 1%0/1&0 21 %712/0%/201

4

11 7

12!00 '# 3 $% 200/140 22 &

1!00 '# 200/110 2" &%2!00 '# 3 $7 1%0/100 2% &2!30 '# 1"0/%0 2" &73!00 '# 3 1"0/100 2" &%4!00 '# 37 1"0/%0 24 %

12/0%/2014

7 3

%!00 '# 37 1"0/100 20 &0

10!00 '# 140/&012!00 (( 37$1 1"0/100 1& %&1!00 P# 170/100

12/0%/201

4

3 11

4!00 P# 37$3 140/&0 21 %

!00 P# 37$4 1"0/&0 21 %7%!00 P# 3 $" 1"0/&0 22 %3

12/0&/201

4

11 7

12!00 #( 3 $7 1"0/&0 22 %%

4!00 '# 37$1 1 0/100 22 %0!00 '# 1%0/&0 22 %&

12/0&/201

4

7 3

%!00 '# 3 $% 1"0/%0 20 %

10!00 '# 3 $ 1%0/100 21 %412!00 (( 37$1 140/100 20 %"2!00 P# 37$3 1&0/&0 20 %1

12/0&/201

4

4!00 P# 37 1 0/&0 22 7

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3 11%!00 P# 37$4 1 0/%0 20 7"

12/10/201

4

11 7

12!00 #( 37 1%0/100 20 7

4!00 '# 37 1 0/&0 20 7%12/10/201

4

7 3

%!00 '# 3 $& 1 0/100 21 &0

10!00 '# 3 $% 170/100 20 &112!00 (( 37$2 130/100 20 %%2!00 P# 37$1 1 0/&0 21 %&

REVIE6 O) S5STEMS

Int"g-$"ntary Sy&t"$

Nenerally, patient Dowow has brownish skin that is warm to touch, with the

presence of hair, with good skin turgor and capillary refill of 8 seconds.

%EENT

" A)

• "ead is normocephalic, can lift head fully and turn them from side to side. "air is

short, thick and evenly distributed. o dandruff, head and scalp lesions not

noted.

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• yes are symmetrical and black in colorB o eye discharges noted. The pupil is

brisk and constricted at 8mm when diverted to light and dilated when the patient

looks into the distanceB 1ale and palpebral con(unctivae not noted, with white and

anicteric sclera. yelashes are equally distributed.

A?0

• oth symmetricalB with no discharges noted within both ears. There were no

lesions, wounds or discoloration noted upon inspection, and there were no

problems in hearing.

/D

• 0hort and mobile. Able to perform the different neck ?'> exercises or

maneuvers. o tracheal deviations felt upon placing a finger along one side of

the trachea, noting the space and comparing with the opposite side. o swollen

lymph nodes upon palpation.

T"?'AT

• Nums are in good condition. Tongue midline and mobile with visible papillae.

Tonsils are not inflamed. 1inkish hard and soft palate. Nag reflex is present.

'-l$onary Sy&t"$

• With crackles heard upon auscultationB regular breathing pattern and symmetrical

chest expansion. ThereCs an equal rise and fall of the chest with normal depth of

respiration.

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Car(io a&c-lar Sy&t"$

• ormal JlubbdubbK heard upon auscultation and apical pulse heard per

auscultation. o heaves and thrills heard. o murmurs, regular cardiac rate andrhythm heard upon auscultation.

Ga&troint"&tinal Sy&t"$

• Abdomen is distended, and has the same color as the rest of the body. 4-#4 clicks

per minute heard upon auscultation.

M-&c-lo&3"l"tal Sy&t"$

6nable to perform A)* alone and assistance is really needed. ?ight "and grip and

?ight *eg movement is absent.

G"nito*-rinary Sy&t"$• Was able to urinate ;55 cc, yellow in color. With Foley catheter attached to

urobag.

III. LABORATOR5 AND DIAGNOSTIC E1AMINATION

%EMATOLOG5

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Dat" 78/9:/897;

LABORATORY

EXAMINATIONS/

DETERMINATION

RESULT NORMAL

VALUE

UNIT IMPLICATION

)emo*lo+i, 137 134$00-

1 0$00

*/. (ormal

)ematocrit 0$41 0$40-0$"4 (ormal.eu ocytes (o$ of

Co,ce,$

%$& "-

10 10 &

. (ormal

Se*me,ters 0$32 0$40-0$ 0 .o $ t may i,dicate

iral i,fectio,s5

autoimmu,e diseases$.ymphocytes 0$"2 0$2"-0$40 )i*h$ t may i,dicate

'cute i,fectio,$#o,ocytes 0$0% 0$01-0$12 (ormal6osi,ophils 0$0 0$01-0$0" )i*h$ t may i,dicate

'ller*y5 asthma5

parasitic i,fectio,s$Basophils - 0$00"Sta+s - 0$01-0$0"

Throm+ocytes 333$" 1"0-

440 10 &

. (ormal

Blood type -Rh type -

URINAL5SIS

Dat" 78/9


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S/

DETERMINATI

ON

Color .i*ht

yello

.i*ht yello to a

dar am+er color

- (ormal

Su*ar ,e*ati e 0 to trace

amou,ts$

- (ormal

'l+umi, ,e*ati e (e*ati e - (ormalReactio, "$0 4$" - 7$2 - (ormal

Sp *ra ity 1$020 1$00" to 1$02" - (ormalCrystlas - 8e - -

Casts - (e*ati e - -6pithellial cells - 8e - (ormal#ucous threads - - - -Pus cells 3- 0-2 )pf '+,ormal!

,fectio,R+c 0-2 0-2 - (ormalBacteria - (e*ati e - -Pus i, clumps - (e*ati e hpf -

CT CRANIAL

Dat" 78/9ultiple plain axial tomographic sections of the head were taken and reveal the

following findings!

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There is an irregular intraparenchymalhyperdensity focus in the left capsule-thalamic

area, extending up to the corona radiate with an approximate volume of #8.5 cc.

0urrounding hypodense edema noted. "yperdense bleed extensions into the ventricular

system %lateral and $ rd ventricles&. There is slight midline shift to the right with a distance

of 5.4cm from midline. o other abnormal density changes in the brainstem nor brain

parenchyma.

The ventricles, cortical sulci, tissues and cisterns are prominent.

The sella, orbits, petromastoids and the paranasal sinuses are not unusual.

1hysiologic calcifications are seen in the pineal gland and basal ganglia.

o other significant findings.

>1? 00 ' !

Acute bleed %#8.5cc& in the left capsulo-thalamic areas with parenchymal and

intraventricular bleed extensions, edema and slight mass effect as described.

/erebral atrophy, age related.

C%EST 'A

Dat" 78/9


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>inimal spurrings are seen in the lateral edges of the thoracic spines.

o other significant interval chest findings

>1? 00 ' !

/ompatible with bibasal pneumonia.

*eft ventricular cardiomegaly with atherosclerotic aorta.

>inimal hypertrophic degenerative spurs, thoracic spines.

ECG

cg no. 4874 A.?.! 24=min

?hythm! 0inus H.?.! 24=min

1.?.! .#9sec. Q.T.! .$8sec.

Q.?.0.! .57sec. Q?0 Axis! G#4 o

mpression!

onspecific 0T segment. ?=' myocardial ischemia

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IV. REVIE6 O) ANATOM5 AND '%5SIOLOG5

NERVOUS S5STEM

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The brain is a spongy organ made up of nerve and supportive tissues. t is

located in the head and is protected by a bony covering called the skull. The base, or

lower part, of the brain is connected to the spinal cord. Together, the brain and spinal

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cord are known as the central nervous system %/ 0&. The spinal cord contains nerves

that send information to and from the brain.

The / 0 works with the peripheral nervous system %1 0&. The 1 0 is made up

of nerves that branch out from the spinal cord to relay messages from the brain to

different parts of the body. Together, the / 0 and 1 0 allow a person to walk, talk, and

throw a ball and so on.

The brain is the bodyCs control centre. t constantly receives and interprets nerve

signals from the body and responds based on this information. )ifferent parts of the

brain control movement, speech, emotions, consciousness and internal body functions,

such as heart rate, breathing and body temperature.

The brain has $ main parts! cerebrum, cerebellum and brain stem.

C"r"br-$

The cerebrum is the largest part of the brain. t is divided into 8 parts %halves&

called the left and right cerebral hemispheres. The 8 hemispheres are connected by a

bridge of nerve fibres called the corpus callosum.

The right half of the cerebrum %right hemisphere& controls the left side of the

body. The left half of the cerebrum %left hemisphere& controls the right side of the body.

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The outer surface of the cerebrum is called the cerebral cortex or grey matter. t

is the area of the brain where nerve cells make connections, called synapses, that

control brain activity. The inner area of the cerebrum contains the insulated %myelinated&

bodies of the nerve cells %axons& that relay information between the brain and spinal

cord. This inner area is called the white matter because the insulation around the axons

gives it a whitish appearance.

The cerebrum is further divided into ; sections called lobes. These include thefrontal %front&, parietal %top&, temporal %side& and occipital %back& lobes.

ach lobe has different functions!

• The frontal lobe controls movement, speech, behaviour, memory, emotions and

intellectual functioning, such as thought processes, reasoning, problem solving,

decision making and planning.

• The parietal lobe controls sensations, such as touch, pressure, pain and

temperature. t also controls spatial orientation %understanding of si e, shape and

direction&.

• The temporal lobe controls hearing, memory and emotions. The left temporal

lobe also controls speech.

• The occipital lobe controls vision.

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C"r"b"ll-$

The cerebellum is the next largest part of the brain. t is located under the

cerebrum at the back of the brain. t is divided into 8 parts or hemispheres and has grey

and white matter, much like the cerebrum.

The cerebellum is responsible for!

• movement

• posture

• balance

• reflexes

• complex actions %walking, talking&

• collecting sensory information from the body

Brain &t"$

The brain stem is a bundle of nerve tissue at the base of the brain. t connects

the cerebrum to the spinal cord and sends messages between different parts of the

body and the brain.

The brain stem has $ areas!

• midbrain

• pons

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• medulla oblongata

The brain stem controls!

• breathing

• body temperature

• blood pressure

• heart rate

• hunger and thirst

/ranial nerves emerge from the brainstem. These nerves control facial

sensation, eye movement, hearing, swallowing, taste and speech.

Ot!"r i$ ortant art& o# t!" brain

C"r"bro& inal #l-i( =CS)>

The cerebrospinal fluid %/0F& is a clear, watery liquid that surrounds, cushions

and protects the brain and spinal cord. The /0F also carries nutrients from the blood to,

and removes waste products from, the brain. t circulates through chambers called

ventricles and over the surface of the brain and spinal cord. The brain controls the level

of /0F in the body.

>eninges

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The brain and spinal cord are covered and protected by $ thin layers of tissue

%membranes& called the meninges!

•

dura mater P thickest outer layer

• arachnoid layer P middle, thin membrane

• pia mater P inner, thin membrane

/0F flows in the space between the arachnoid layer and the pia mater. This

space is called the subarachnoid space.

The tentorium is a flap made of a fold in the meninges. t separates the cerebrum

from the cerebellum.

• The supratentorial area of the brain is the area above the tentorium. t contains

the cerebrum, the first and second %lateral& ventricles, the third ventricle, and glands and

structures in the centre of the brain.

• The infratentorial area is located at the back of the brain below the tentorium. t

contains the cerebellum and brain stem. This area is also called the posterior fossa.

Cor -& callo&-$

The corpus callosum is a bundle of nerve fibres between the 8 cerebral

hemispheres. t connects and allows communication between both hemispheres.

T!ala$-&

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The thalamus is a structure in the middle of the brain that has 8 lobes or

sections. t acts as a relay station for almost all information that comes and goes

between the brain and the rest of the nervous system in the body.

%y ot!ala$-&

The hypothalamus is a small structure in the middle of the brain below the

thalamus. t plays a part in controlling body temperature, hormone secretion, blood

pressure, emotions, appetite, and sleep patterns.

'it-itary glan(The pituitary gland is a small, pea-si ed organ in the centre of the brain. t is

attached to the hypothalamus and makes a number of different hormones that affect

other glands of the bodyCs endocrine system . t receives messages from the

hypothalamus and releases hormones that control the thyroid and adrenal gland, as

well as growth and physical and sexual development.

V"ntricl"&

The ventricles are fluid-filled spaces %cavities& within the brain. There are ;

ventricles!

• The first and second ventricles are in the cerebral hemispheres. They are called

lateral ventricles.

• The third ventricle is in the centre of the brain, surrounded by the thalamus and

hypothalamus.

• The fourth ventricle is at the back of the brain between the brain stem and the

cerebellum.

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The ventricles are connected to each other by a series of tubes. The fluid in the

ventricles is cerebrospinal fluid %/0F&. The /0F flows through the ventricles, around the

brain in the space between the layers of the meninges %subarachnoid space& and down

the spinal cord.

'in"al glan(

The pineal gland is a very small gland in the third ventricle of the brain. t

produces the hormone melatonin, which influences sleeping and waking patterns and

sexual development.

C!oroi( l"+-&The choroid plexus is a small organ in the ventricles that makes /0F.

Cranial n"r "&

There are #8 pairs of cranial nerves that perform specific functions in the head

and neck area. The first pair starts in the cerebrum, while the other ## pairs start in the

brain stem. /ranial nerves are indicated by number %?oman numeral& or name.

Ty "& o# c"ll& in t!" brain

The brain is made up of neurons and glial cells!

• neurons• These cells carry the signals that make the nervous system work.• They cannot be replaced or repaired if they are damaged.• glial cells %neuroglial cells&• These cells support, feed and protect the neurons.• The different types of glial cells are!• astrocytes• oligodendrocytes• ependymal cells• microglial cells

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Str-ct-r" an( #-nction o# t!" & in"

The spine is made up of!

•

vertebrae, sacrum and coccyx P bony sections that house and protect the spinalcord %commonly called the spine&

• The vertebral body is the biggest part of a vertebra. t is the front part of the vertebra,

which means it faces into the body.• spinal cord P a column of nerves inside the protective vertebrae that runs from the

brain to the bottom of the spine• disc P a layer of cartilage between each vertebra that cushions and protects the

vertebrae and spinal cord

T!" & in" i& (i i("( into ? &"ction&

• cervical P the vertebrae from the base of the skull to the lowest part of the neck

• thoracic P the vertebrae from the shoulders to mid-back

• lumbar P the vertebrae from mid-back to the hips

• sacrum P the vertebrae at the base of the spine

• The vertebrae in this section are fused and do not flex.

• coccyx P the Jtail boneK at the end of the spine

• The vertebrae in this section are fused and do not flex.

S inal n"r "&

The spine relays messages between the body and the brain. These nerve

messages control body functions like movement, bladder and bowel control and

89


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28/65

"emorrhagic stroke accounts for

about #$ percent of stroke cases. t results

from a weakened vessel that ruptures and

bleeds into the surrounding brain. The blood

accumulates and compresses the

surrounding brain tissue.

V. ETIOLOG5 O) T%E DISEASE

Etiology Actual Rationale)i*h +lood

pressure

9,co,trolled i,crease of +lood pressure

ca, cause a essel to e plode or +urst$

Thus: causes hemorrha*ic

stro ehttp!// $stro eassociatio,$or*/S

TR;9C#>30%"3&>Su+)omePa*e$?sp@

87


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30/65

e,t/30/11/2307$full

Race 'frica,-'merica,s Hope,s i, ,e

i,do I ha e a much hi*her ris of

death from a stro e tha, Caucasia,s

do$ This is partly +ecause +lac s ha e

hi*her ris s of hi*h +lood

pressure: dia+etes a,do+esity$http!// $stro eassociatio,$or*/

STR;rd ssl@

ratio,aleGforG "GyearsGoldGperso,GithGstro e

8amilyhistory of stro e

+our stroke risk may be greater if a parent,

grandparent, sister or brother has had a

stroke. 0ome strokes may be symptoms of

$5


31/65

genetic disorders like /A)A0 * %/erebral

Autosomal )ominant Arteriopathy with 0ub-

cortical nfarcts and *eukoencephalopathy&,

which is caused by a gene mutation that

leads to damage of blood vessel walls in the

brain, blocking blood flow. >ost individuals

with /A)A0 * have a family history of the

disorder R each child of a /A)A0 * parent

has a 45< chance of inheriting thedisease.http!==www.strokeassociation.org=0T

?'D '?N=About0troke=6nderstanding?isk=

VI. S5M'TOMATOLOG5

Sy !to " Actual RationaleMea ,ess

or ,um+,ess of

the face: arm: or

le* o, o,e side of

the +ody

(um+,ess ca, occur from dysfu,ctio,

a,y here alo,* the path ay from the

se,sory receptors up to a,d i,cludi,*

the cere+ral

corte http!// $merc ma,uals$com/pr

ofessio,al/,eurolo*ic>disorders/approac

h>to>the>,eurolo*ic>patie,t/,um+,ess$h

tml

.oss of speech:

diNculty tal i,*:

commu,icatio, deKcits are

characteriOed +y diNculty i,

$#


32/65

or u,dersta,di,*

hat others are

sayi,*

u,dersta,di,* or produci,* speech

correctly HaphasiaI: slurred speech

co,se ue,t to ea muscles

HdysarthriaI: a,d/or diNculty i,

pro*rammi,* oral muscles for speech

productio, Hapra iaI$ These deKcits ary

i, ,ature a,d se erity depe,di,* o, the

e te,t a,d locatio, of the dama*e$

Some i,di iduals may also ha e

diNculty i, social commu,icatio,: such

as diNculty ta i,* tur,s i, co, ersatio,

a,d pro+lems mai,tai,i,* a topic of

co, ersatio,$http!// $asha$or*/pu+lic

/speech/disorders/Stro e/

.oss of isio, or

dimmi,* Hli e a

curtai, falli,*I i,

o,e or +oth eyes

isio, loss ca, +e +oth a symptom a,d

result of a stro e$ Temporary isio, loss

ca, +e a si*, of impe,di,* stro e a,d

re uires immediate medical atte,tio,$

.ear, a+out ho stro e may a ect

isio, a,d hat to do a+out

ithttp!// $stro e$or*/stro e-

resources/li+rary/stro e-a,d- isio,-lossSudde,: se ere

headache ith ,oPai, ca, also accompa,y a stro e$

(um+,ess a,d pai, ca, also alter,ate i,

$8


33/65


34/65

haemorrhage is the accumulation of blood anywhere within the brain, i.e. P

intraparenchymal haemorrhage, intraventricular haemorrhage. This will form a gradually

enlarging haematoma %blood pool&. ntracerebral "aemorrhages can be caused by local

vessel abnormalities %hypertension, vasculitis, vascular malformation& or systemic

factors %drugs, trauma, tumours and sickle cell anaemia=leukaemia&. "aemorrhaging

directly damages brain tissue and raises intracranial pressure giving headaches,

vomiting nausea and eventually coma and death.0ubarachnoid haemorrhage is the

gradual collection of blood in the subarachnoid space of the )ura. These can be

traumatic or spontaneous. 0pontaneous haemorrhages occur through saccular %berry&aneurysms and through extensions of intracranial haemorrhaging or due to similar

causes. Approximately one third of those who suffer a subarachnoid haemorrhage die.it

is the subarachnoid space which can pathologically fill with blood.

Diagra$ o# 'at!o !y&iology

Age

$;

1recipitating Factors!

- xcessive alcohol intakeB had beendrinking in the past days.

- "istory of smoking

1redisposing Factors!

- Age of 94 years old- Family "istory of 0troke- 0edentary *ifestyle

"emorrhagic- mpaired tissueperfusion


35/65

$4

nfarction of cerebral vessels

known as stroke

0pace-occupying blood clotsput more pressure on the braintissues

The regulatory mechanisms ofthe brain attempt to maintainequilibrium by increasing 1and /1

The ruptured cerebral vesselsmay constrict to limit blood losshowever, the vasospasm willresult to further ischemia andnecrosis of brain tissues.

0 N 0 A ) 0+>1T'>0!

-*oss of alance - 0udden or severe headache - *oss of vision-*oss of 0peech -Weakness or umbness of face and extremities

/omplications

*oss of >uscle

/ontrol=1aralysis

0peech 1roblems

0wallowing )ifficulties

/ognitive mpairments

1ersonality and >ood

/hanges

)epression

1harmacological >anagement

Furosemide

/eftriaxone

/iticoline

'mepra ole

Amlodipine

*osartan

>annitol

ursing >anagement!

#. ?eposition client q8

8. 0upport dependent body

parts with pillows

$. 1rovide safety measures

including environmental

management

;. ncourage 0'Cs

involvement in activities S

decision making

4. 1eroform passive range

of motion exercises daily

9. ncrease functional

activities as strength

improves N'') 1?'N '0 0 A) 1?'N '0 0


36/65

VIII. 'LANNING

A NURSING CARE 'LAN

Date /Ti e

A""e"" ent Nee# Nu$"ingDiagno"i"

O%&ecti'eo( Ca$e

Nu$"ingInte$'ention"

E'aluation

Decem+er 10:20147-3shift

Su+?ecti e cues!Q=i-u+o sya sir:dili sya

a*i,ha a aauas er+aliOed +ythe atcher$

;+?ecti e cues!- S! BP- 1 0/100 PR- &0 RR- 27 Temp- 3 $&

;2 sat &7

-producti ecou*h-crac les heardupo,auscultatio,$-HGI use ofaccessorymuscle he,

P)

ES

;.;=

C'.

(eed

; y*e,atio

,patter

,

neffectivereathing 1attern

r=ttracheobronchialinflammation andincreased sputumproductionsecondary to/A1->?

?ationale!

1neumonia is inflammation of theterminal airwaysand alveolicaused by acuteinfection byvarious agents./ommunity

Acquired

Mithi, theshift: ill+e a+le to!

a$ de,tifyordemo,strate+eha iorsto achie eair aycleara,ce$

+$ Displaypate,tair ay

ith+reathsou,dscleari,*$

-#o,itored S$R! To mo,itorpatie,t s co,ditio,a,d compared ith+aseli,e data$-Placed o, #)BRpositio,$R! t promotesrela atio, a,d helpsi, promoti,*e ecti e air aycleara,ce$-'ssisted i, tur,i,*to sides e ery 30mi,utes$R! To promotecirculatio, as ellas to pre e,tfurthercomplicatio,s i, thepulmo,ary system$-6,coura*ed toi,crease ;8 $

Mithi, theshift: =;'.P'RT '..E#6T: ase ide,ced+y!

a$ +ei,* a+letoide,tify/demo,strate+eha iors toachie eair aycleara,cesuch as deep+reathi,*a,d cou*hi,*e ercises$

+$ crac leslu,* sou,dstill heard

$9


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+reathi,*- ith ; 2i,halatio, U2.P# ia ,asalca,,ula-lyi,* Vat o, +ed

1neumonia%/A1& is adisease in whichindividuals whohave not recentlybeen hospitali eddevelop aninfection of thelungs. t is anacuteinflammatorycondition thatCsresult fromaspiration oforopharyngealsecretions orstomach contentsin the lungs.Therefore, airway

clearance is noteffective.

?eference!

http!==nursingcrib.com=

R! t helps to softe,a,d e pectoratio,of secretio,s$-6,coura*ed to dodeep +reathi,* a,dcou*hi,* e ercises$R! Deep +reathi,*

e ercises facilitatema imume pa,sio, of thelu,*s a,d smallerair ays$ Cou*hi,*is a reVe a,d a,atural self-clea,i,*mecha,ism thatassists the cilia tomai,tai, pate,tair ays$-Demo,stratedproper +ac a,dchest tappi,* to

atchers$R! t ca, aid tomo+iliOatio, a,de pectoratio, ofsecretio,s$

Depe,de,t!-'dmi,ister meds as

upo,auscultatio,$

$2


38/65

)ate ?etrieved!)ecember ##,85#;

prescri+ed$R! To co,ti,uouslytreat u,derlyi,*causes a,dsymptoms$

Colla+orati e!

-6,coura*edatchers to assistpatie,t i, tur,i,* tosides as ell as i,performi,* 'D.$R! To pre e,tfurthercomplicatio,s a,dto pre e,t accide,tsthat may lead toi,?ury$

Date /Ti e

A""e"" ent Nee# Nu$"ingDiagno"i"

O%&ecti'eo( Ca$e

Nu$"ingInte$'ention"

E'aluation

Decem+er 10:20147-3shift

Su+?ecti ecues!QMala +aya ?ud

uso* iya,*tuo ,*a partesa la as sir

P)

ES

;

0elf-caredeficit r=t rightsided bodyweaknesssecondary to/erebrovascular accident

Mithi, theshift: there

ill +edemo,stratio, of self-care: as

-6sta+lished rapport$R! To *ai, trust a,dcooperatio,$-#o,itored S$R! To ha e a +aseli,edata$

Within the shift,N'A*1A?T A**+> T, asevidenced by!

a. eing

$7


39/65

as er+aliOed+y the

atcher$

;+?ecti ecues!- S! BP-

1 0/100 PR- &0 RR- 27 Temp-3 $&-ha,d *rip a,dle* mo eme,tat the ri*htside of the+ody area+se,t- ,a+ility tofeed selfi,depe,de,tly- ,a+ility todress selfi,depe,de,tly- ,a+ility toperformtoileti,* tasi,depe,de,tly -total

.;=

C

(

66D

(utritio,:clothi,*

a,delimi,ati

o,

?ationale!

>otor deficitare the mostobvious effectof stroke.0ymptoms arecaused bydestruction ofmotor neuronsin thepyramidalpathways%nerve fibersin the brainand passingthrough thespinal cord tothe motor

tract.& Whenthis happens,activities ofdaily living canbe impairedand even self-care.

e ide,ced+y!

-'ssured that theco,siste,cy of thediet is appropriate forpatie,t s a+ility toche a,d s allo $R! #echa,icalpro+lem may prohi+it

the patie,t fromeati,*$-'ssisted duri,* +ed+ath$R! To *i e comfort$-#ai,tai,ed pri acyduri,* +athi,*$R! The ,eed forpri acy isfu,dame,tal for mostpatie,ts$-'ssisted i, cha,*i,*the clothes$R! To *i e comforta,d to assess for theparts hich ca,,ot+e mo e fre ue,tly$-Pro ided fre ue,te,coura*eme,t a,dassista,ce as ,eeded

ith dressi,*$R! To reduce e,er*y

unable toplace theunnecessar y things atbedside onhis own.

b. eing ableto changeclotheswithminimalassistance.

c. eingunableto take abathwithouttotalassistance.

$3


40/65

assista,ceduri,* 'D. li e+athi,* a,dclothi,*

-

?eference!

http!==nurseslabs.com=cerebr ovascular-accident-nursing-care-plans=.

)ate?etrieved!)ecember ##,85#;

e pe,diture a,dfrustratio,$- Pro ided pri acy

hile patie,t istoileti,*$R! .ac of pri acymay i,hi+it the

patie,t s a+ility toe aluate their +o el +ladder$

-Stretched a,dtuc ed properly theli,e,s$R! To pre e,t thefeeli,* of +ei,*u,comforta+le he,lyi,* i, +ed$

Depe,de,t!-'dmi,ister meds asprescri+ed$R! To co,ti,uouslytreat u,derlyi,*causes a,dsymptoms$

Colla+orati e!-6,coura*ed

atchers to assist

;5


41/65


42/65

- ha,d *ripa,d le*mo eme,tat the ri*htside of the+ody area+se,t

- tur,s tosides ithassista,ce-,eeds totalassista,ce i,am+ulatio,-u,a+le toperform 'D.alo,e

S6C9R

T E

The sudde,death of some+rai, cells dueto lac ofo y*e, he,the +lood Voto the +rai, is

impaired +y+loc a*e orrupture of a,artery to the+rai,: this ca,cause +ody

ea ,ess orparalysis ofthe o,e side of the +ody:depe,di,* o,the area of the+rai, that isa ected$ This

ill lead thepatie,t toha ei,tolera,ce tosomeacti ities$

Refere,ce!

intolerance. ,ecessary or useof e uipme,tR! To determi,edcurre,t status a,d,eeds associated

ith participatio,i, ,eeded/desired

acti ities$- 'ssessedemotio,al a,dpsycholo*icalfactors a ecti,*the curre,tsituatio,$R! Stress ordepressio, may+ei,creasi,* thee ects of a,ill,ess: ordepressio, mi*ht+e the result offorced i,acti ity$- ,creasede ercise or acti ityle els *radually$R! To co,ser ee,er*y- Pla,,ed care tocarefully +ala,ce

acti ities$+$ '+le touseide,tiKedtech,i uesto e,ha,ceacti ity

i,tolera,ce$

;8


43/65


44/65

a+ilities i, thisarea$- Pla,,ed forpro*ressi ei,crease of acti ityle el/participatio,i, e ercise

trai,i,*: astolerated +y theclie,t$R! Both acti ityi,tolera,ce a,dhealth status mayimpro e ithpro*ressi etrai,i,*$- 'ssisted clie,t i,lear,i,* a,ddemo,strati,*appropriate safetymeasures$R! To pre e,ti,?uries

Depe,de,t!-'dmi,isteredmeds asprescri+ed$R! 8or co,ti,uous

;;


45/65

treatme,t ofu,derlyi,* causea,d symptoms$

Colla+orati e!-6,coura*ed

atchers to

support thepatie,t +yassisti,* i,performi,* 'D.$R! To pro idesafety a,d a oidaccide,ts thatmay cause i,?ury$

;4


46/65

B DISC%ARGE 'LAN

A$ea" O%&ecti'e Acti'itie"

#edicatio, 100 complia,ce to home

medici,es

# ncourage the patient to comply

with the prescribed medication. This prevents further

development of the disease

process and other possible

complication.8 ncourage the client to take the

medicine into the right time,

right dose, right amount, and

right frequency and take note

the side effects of the medicine. This would enable them to

know what are the drugs and its

desired dosage. The exact

dosage and time are important

;9


47/65

to ensure the drugCs

effectiveness.$ nstruct patient to notify

physician if there is any

abnormalities after taking the

medicine.; nstruct patient to do not buy

any drugs that does not

prescribed by the physician. To avoid the ineffectiveness of

the drug prescribed, and to

ensure the safety of the client.

6 ercise To sta+iliOe the co,ditio, of the

patie,t$ 6,coura*e to do li*ht

e ercise a,d u,dersta,ds it s

importa,t$

# Avoid strenuous activities.8 ncourage patient to have

activities of daily living.$ ncourage client to have

adequate rest periods

between activities.

#. xplain the purpose of

;2


48/65

Treatme,t 9,dersta,di,* the recomme,ded

treatme,t or lesse, u,derlyi,*

ill,ess$

the medication that is

prescribed by the

physician.8. nform the significant of

the treatment others that

they should be involved

in the treatment of the

client.$. ncourage to take

medications religiously.

)ealth teachi,*s To pre e,t the ris of a,y

complicatio,s that may lead to

death$

# nstruct to take extra care in

doing daily A)* especially in

ambulation.8 nstruct the client to have a

proper diet and hygiene.$ ncourage client to wash hands

before and after doing things.; 1atient is advised to avoid

strenuous activities until full

recovery is achieved

;7


49/65

4 ncourage significant others to

give total supportive care.

;ut - patie,t To mai,tai, uality health a,d

i,depe,de,ce to ards self - care$

# /ontinue prescribed medicines

and its right dosage. To attain the therapeutic

effect of each medicinestowards the client.

8 Follow up with appointments

with physician. To evaluate the progress of

the treatment and condition.$ ncourage the patient to have

adequate rest and sleep

periods. These aid faster recovery

from the illness and to have

enough strength in performing

activities of daily living and

range of motion exercises.; ncourage him to comply with

;3


50/65

all the modifications and

instructions given to her n order to have a fast

recovery.

Diet Decrease i,ta e of fatty a,d salty

foods as ell as those foods that

ca, irritate the = tract i,cludi,*

spicy a,d acidic foods$ ,clude a

ariety of e*eta+les a,d fruits i,

the diet$

# mphasi e intake of

nutritious foods.8 ncourage foods that are

less fatty and salty.$ 'bserve proper handling of

foods.; nstruct to include variety of

fruits and vegetables in the

diet.

45


51/65

I1. '%ARMACOLOGICAL MANAGEMENT

4#


52/65

)ene$icNa e

B$an#Na e

Cla""i*cation

In#ication Action Si#eE+ect"/A#'e$"eReaction

Ti e ,Do"age

Nu$"ingRe"!on"i%ilitie"

Ceftria o,e

8or*ram

Cephalospori,s

,dicated i,patie,ts ith,eurolo*iccomplicatio,s:carditis a,darthritis$ t isalso e ecti e i,=ram ,e*ati ei,fectio,s5#e,i,*itis:=o,orrhea$ t isalso for Bo,e

a,d ?oi,ti,fectio,s:.o errespiratory tracti,fectio,s:middle eari,fectio,: P D:Septicemia a,d9ri,ary Tract

Mor s +yi,hi+iti,*themucopeptidesy,thesisi, the+acterialcell all$

The +eta-lactammoiety of

Ceftria o,e+i,ds tocar+o ypeptidases:e,dopeptidases: a,dtra,speptidases i, the+acterialcyt

Pai,,duratio,

Phle+itisRashDiarrhea

Throm+ocytosis.eucope,ia=lossitisRespiratorysuperi,fectio,s

1 *rame ery12 hours'(ST H-I

TT

-'ssesspatie,t sPre iousse,siti ityreactio, tope,icilli, orothercephalosphori,s$

-'ssesspatie,t for

si*,s a,dsymptomsof i,fectio,+efore a,dduri,* thetreatme,t-;+tai, C S+efore+e*i,,i,*

48

)ene$icNa e

B$an#Nae

Cla""i*cation

Mec-ani" o( action

In#ication Si#e E+ect"/A#'e$"eReaction

Ti ean#Do"age


8urosemide

.asi .oop diuretic 8urosemidei,hi+itsrea+sorptio, of(a a,d chloridemai,ly i, themedullaryportio, of theasce,di,* .oopof )e,le$6 cretio, ofpotassium a,dammo,ia isalso i,creased

hile uric acide cretio, isreduced$ ti,creasesplasma-re,i,le els a,dseco,dary

hyperaldostero,ism mayresult$8urosemidereduces BP i,hyperte,si esas ell as i,,ormote,si es$

t also reducespulmo,aryoedema +eforediuresis has set

i,$

-6demaassociated

ith C)8:cirrhosis:re,aldisease-'cutepulmo,aryedema

• 8luid a,delectrolyteim+ala,ce$

• Rashes:photose,siti ity:,ausea:diarrhoea:+lurred

isio,:diOOi,ess:headache:hypote,sio,$ Bo,emarrodepressio,HrareI:hepaticdysfu,ctio,$

• )yper*lycaemia:*lycosuria:ototo icity$

• Pote,tially8atal!Rarely:sudde,death a,dcardiacarrest$)ypo alae

mia a,dma*,esiu

40m*;D

TT

-Reducedosa*e if*i e, ithothera,tihyperte,si

es5 read?ustdosa*e*radually asBP respo,ds$

-'dmi,isterith food or

mil topre e,t =upset$-=i e early i,the day sothat i,creaseduri,atio, ill,ot distur+

sleep$

-' oid useif oral use isat all possi+le$

-M'R( (=! Do,ot mipare,teralsolutio, ithhi*hly acidicsolutio,s ith

p) +elo 3$"$-Do ,ot


53/65

i,fectio,s$ oplasmicmem+ra,e$

Thesee,Oymesarei, ol ed i,cell- all

sy,thesisa,d celldi isio,$ By+i,di,* tothesee,Oymes:Ceftria o,eresults i,theformatio,ofof defecti ecell allsa,d celldeath$

dru* therapyto ide,tifyif correcttreatme,t has+ee, i,itiated$

-Report si*,s

such aspetechiae:ecchymoticareas:epista is orother formsof u,e plai,ed +leedi,*$

4$


54/65

)ene$icNa e

B$an#Nae

Cla""i*cation

In#ication Action Si#eE+ect"/A#'e$"eReaction

Ti e ,Do"age


Citicoli,e

Choli,er

C(Sstimula,t:Peripheral

asolidlator

Cere+ro ascularDiseases:acceleratesthe reco eryof co,scious,ess a,do ercomi,*motor deKcit

Citicoli,eacti atesthe +iosy,thesisof structural phospholipids i, the,euro,almem+ra,e:i,creasescere+ralmeta+olism a,di,creases thele el of arious,eurotra,smitters: i,cludi,*

acetylcholi,ea,d dopami,e$Citicoli,e hassho ,,europrotecti ea ects i,situatio,sof hypo ia a,dischemia$

citicoli,emay e ertastimulati,*actio, ofthe parasympathetic:as ell as aVeeti,*a,discretehypote,sore ect$

"00m*1 cap

T D

-Match outfor hypote,si ee ects$

-#ust ,ot +eadmi,isteredalo,* ithmedicame,tsco,tai,i,*

4;


55/65


56/65

49

)ene$ic Na e

B$an#Na e

Cla""i*cation

Mec-ani"o( action

In#ication Si#eE+ect"/A#'e$"eReaction

Ti ean#Do"age


#a,,itol

;smitrol

;smoticDiuretic

,creasesosmoticpressure ofplasma i,*lomerularKltrate:i,hi+iti,*tu+ularrea+sorptio,of ater a,delectrolytesHi,cludi,*sodium a,dpotassiumI$

These actio,se,ha,ce

ater Vofrom arioustissues a,dultimately

decreasei,tracra,iala,di,traocularpressures

Test dosefor mar edoli*uria orsuspectedi,ade uatere,alfu,ctio,:pre e,tacute re,alfailureduri,*cardio ascular a,dothersur*eries:acute re,alfailure: toreducei,tracra,ialpressure

a,d +rai,mass:reducei,traocularpressure:to promotedieresis i,dru*to icity:irri*atio,duri,*tra,surethr

al resectio,of prostate$

/ 0!di iness,headache,sei ures/H! chestpain,hypotension,hypertension,

tachycardia,thrombophlebitis, heartfailure,vascularoverload

T! blurredvision, rhinitisN ! nausea,vomiting,diarrhea, drymouth

N6! polyuria,urinaryretention,osmoticnephrosis>etabolic!dehydration,waterintoxication,hypernatremia, hyponatremia,

hypovolemia,h okalemia h

"0mlTT

e ery hrs

->onitor vital signs.

->onitor intake andoutput.

->onitor centralvenous pressure.

->onitor pulmonaryartery pressure.

->onitor signs andsymptoms ofdehydration.

->onitor signs ofelectrolyteimbalance


57/65

42


58/65

1. S5NT%ESES O) CLIENT4S CONDITION/STATUS )ROM ADMISSION TO

'RESENT

A. Concl-&ion

Therefore, after we had studied the case, our client has suffered from

/erebrovascular Accident because of some possible factors that might have contributed

on the development of the condition. /erebrovascular Accident refers to is the medical

term for a stroke. A stroke is when blood flow to a part of your brain is stopped either by

a blockage or a rupture of a blood vessel. There are important signs of a stroke that you

should be aware of and watch out for. f you think that you or someone around you

might be having a stroke, it is important to seek medical attention immediately. The

more quickly you get treatment, the better the prognosis. When a stroke goes untreated

for too long, there can be permanent brain damage.

The certain condition that the patient is suffering is really considered dangerous.

t is a life-threatening condition especially if the patient will not follow the prescribed

meds and a healthy lifestyle as it would lead to many other complications that may

greatly affect his life as well as his family and eventually may lead to death. )espite of

all that facts, there are treatments and preventive measures that people should do in

order to stop or prevent this condition from getting worst. We conclude that the need for

medical consultations and abiding the medical orders regarding health condition and atleast preventing the worst to happen should be really observed and taken into

consideration by the patient himself and by the significant others as well. )oing right

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6, iro,me

,t

The patie,t

stayed i, a ard

room a,d as

co,duci e for

heali,* a,d

reco ery$Diet The patie,t s

diet as more

o, salty a,d

fatty foods$

/omputation!

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78/? @ 8.; =)air 'rogno&i&>

C. RECOMMENDATIONS

Niving importance to the health of ourselves and maintaining a healthy lifestyle

as individuals, is highly required to maintain a good and healthy life. t is because

ignoring the health condition could greatly affect life especially when certain conditions

or diseases would develop.

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topics of this case study, we are now presenting our evaluation related to our ob(ectives

that have been presented. We have certified that we were able to complete the chosen

case with factual data gathered including the necessary information related to this case.

Within the span of at least of rendering care to 1atient Dowowo, we have drawn

together the important and relevant information that serve as the baseline of our study

and were able to identify potential problems. y gaining the patientCs trust and

cooperation and with the help of the significant others, we were able to assess properly

every single data regarding the patientCs condition and thoroughly assessed every

system involved. We were able to obtain his past health history that contributed to the

occurrence of the condition. Additionally, we were able to get the complete diagnosis,

able to perform the cephalocaudal physical assessment of the patient, and discussed

firmly the anatomy and physiology of the systems involved. esides, we were able to

present the pathogenesis of certain conditions included in the admitting diagnosis.

>oreover, we were able to present the factors that affect the patientCs condition,

comprehensively interpreted the laboratory results, discussed and enumerated the

medications prescribed including the nursing responsibilities and given the interventions

we have planned and implemented for our patient.

We were able to appreciate more the essence of utili ing the nursing process in

the care, service and management of our patient. This case study improves not only our

knowledge but also with our skills concerning on providing care for our patient with such

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• runner and 0uddarthUs Textbook of >ed.-0urg. ursing #8th ed /opyright V

85#5 by *ippincott Williams S Wilkins, a Wolter Dluwer business.

•

>edical - 0urgical ursing 2th

ed. by lack Eoyce >. and Eane "okanson "awks

• 1orthCs ssentials of 1athophysiology $rd dition/opyright V 85## by *ippincott

Williams S Wilkins, a Wolter Dluwer business.

• Fundamentals of ursing, 2 th ed. by Do ier, arbara

• >edical P 0urgical ursing 2 th ed. /opyright V 8557 by *ewis, et.al. urseCs

pocket guide, #8 th ed. by )oenges, >arilynn, et.al.

• urseCs "andbook of "ealth Assessment 9 th ed. by Weber, Eanet• )avisCs )rug Nuide for urses. T T" ) T ' .• )avisCs urseCs 1ocket Nuide. #8 th edition

nternet

• http!==www.healthline.com=health=cerebrovascular-accident@'verview# )ate

of ?etrieval! )ecember #$, 85#;• http!==www.medicinenet.com=script=main=art.aspLarticlekeyM8929)ate of

?etrieval! )ecember #$, 85#;• http!==health.cvs.com=Net/ontent.aspxLtokenMf24323d$-3c2c-;b#9-af49-

$e#88a$f#3e$SchunkiidM9;4534)ate of ?etrieval! )ecember #$, 85#;• http!==www.world-heart-federation.org=cardiovascular-health=stroke=)ate of

?etrieval! )ecember #$, 85#;• http!==www.strokeforum.com=stroke-background=epidemiology.html)ate of

?etrieval! )ecember #$, 85#;

9;


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