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GROUP 3 Vernalin Terrado Lerma Auman Elenita Molina Richelle Manlangit Andres Jose Bernard Bartolome Marlen Tigno
INTRODUCTION: A Stroke, cerebrovascular Accident, or what is now being termed as “brain attack” is a sudden loss of brain functions resulting from disruption of blood supply to a part of the brain resulting from pathologic blood vessels. It denotes an abnormality of the brain. Stroke can be classified into ischemic and hemorrhagic strokes. Ischemic stroke can be divided into thrombotic and embolic stroke. Thrombotic stroke results from the narrowing or occlusion of blood vessels due to fat deposits while embolic strokes result from the occlusion of a blood vessel from a blood clot originating from the other parts of the body, most commonly from the heart.
Hemorrhagic stroke is further classified into intracerebral hemorrhage and subarachnoid hemorrhage. It results from the rupture of blood vessels in the brain. Rupture of arterioles result in bleeding into the parenchyma of the brain, while rupture of larger arteries or its tributaries result in bleeding in the subarachnoid space. Normal brain metabolism is impaired by interruption of blood supply, compression and increased ICP. Usually due to rupture of intracranial aneurysm, AV malformation, Subarachnoid hemorrhage.
Risk factors for hemorrhagic stroke includes age, gender, race, hypertension, smoking and use of illicit drugs. A stroke causes a wide variety of neurologic deficit, depending on thelocation of the lesion,the size of the area of inadequate perfusion and the amount of severity of blood flow. It may include vomiting, headache, seizures, hemiplegia and loss of consciousness. Pressure on the brain tissue from increase intracranial pressure may cause coma and death.
The primary concern of this study is to further enhance the understanding of Cerebrovascular Accident in congruence with the learned concepts of the Nursing students.
Objectives of the Study:
This case presentation seeks to provide different information about the disease to be presented about the client being considered with the ff. specific objectives: 1. Give a brief introduction about Cerebrovascular Accident together with it clinical manifestations. 2. Present a theoretical framework for the study in relation to a nursing approach applied to a patient with hemorrhagic stroke. 3. Present the clients demographic and health history with its Gordons eleven functional health pattern.
4. Present the abnormal results of the physical assessment and compare it to the normal values or findings. 5. Present the different laboratory test and results done to the client with its interpretation. 6. Discuss the normal Anatomy and Physiology of Circulatory and Central Nervous System. 7. Explain the Pathophysiology of Hemorrhagic stroke
8. Identify Nursing Problems related to the situation and case of the client 9. Discuss the drugs that has been used and prescribed to the client by a drug analysis. 10. Present a Nursing Care Plan for the prioritized problems of the client. 11. Show a Discharge Planning that the client may use upon discharge to the hospital.
Theoretical Framework: Virginia Henderson
Difficulty of Breathing Impaired skin Integrity
Loss of consciousness
Eat and drink adequately
Sleep and rest
Eliminate body wastes
Maintain body temp
Sleep and rest and Communicate with others
Move and maintain Desirable postures
Keep body clean and well groomed
Biographic History: Name City Address Provincial Address Age Gender Religious Affiliation Marital Status Occupation Source of Information Room & Bed No. Date of Birth Diagnosis Physician Chief complaint: Date of admission : D.A.C :Blk 14, lot 52 PVR-1, Norzagaray, Bulacan :Romblon (Visayas) : 53 years old : Male : Roman Catholic : Married : Unemployed (formerly a construction worker) : Daughter : Male Ward Bed #9 : November 18, 1955 : Cerebrovascular Accident (subarachnoid hemorrhagic) : Dr. Steve Conneroid : Loss of consciousness : January 05, 2009
Two days prior to admission, the patient experienced high blood pressure accompanied by low grade fever. At that time, the client is having an argument with his daughter that day before the time he was admitted which serves as a triggering factor of his present illness. Upon admission her daughter claim that her father experienced severe headache followed by loss of consciousness. After series of tests he was diagnosed to have experienced or suffered a hemorrhagic stroke.
Past Medical History:
Three months prior to admission, the patient Experienced intermittent flu and Arthritis in both knees. While on this condition, the patient’s blood pressure keeps elevating at a range of 150/90 mmHg To 190/100 mmHg. The patient also experienced a vehicular accident on his bicycle two months ago, but no abnormal manifestation has been observed aside from multiple superficial wounds.
The paternal side of the patient has a history of pulmonary tuberculosis. The maternal side of the patient has a history of hypertension and heart disease.
Activities of daily living
A. Health perception and health management pattern According to her, her father doesn’t go to the doctor for consultation on his health status. He seldom takes any medicine for his common illnesses though he sometimes takes paracetamol to relieve fever. She also states that her father is a heavy alcohol drinker and cigarette smoker.the patient self perception of health prior and upon hospitalization is undermined because the patient is in the state of coma.
B. Nutritional and Metabolic Pattern Before the patient was hospitalized, he normally eats fried chicken, especially the skin, chicharon and processed meats such as tocino and longganisa. He seldom eat vegetables and fruits. He prefers meat over fish.
C. Elimination Pattern Prior to admission the patient has a regular bowel pattern but after he was hospitalized he was not able to defecate for 3 days. He urinates 5 to 7 times a day with a light yellow color before he is admitted, now he has an indwelling urinary catheter draining dark yellow urine.
D. Activity-Exercise Pattern According to the patient’s daughter, her father spends most of his time gambling or having a drinking session with neighbors and friends. He doesn’t have a job and he didn’t mind looking for one. He doesn’t help in household chores instead he preferred spending his time watching television.
E. Sleep – Rest Pattern The patient has a habit of taking short nap in the afternoon for 2 hours. In the evening he usually retires at around 2:00am and usually sleeps for 3 hours. This is primarily due to his fathers’ failing ability to promote sleep.
F. Cognitive – Perceptual Pattern The patient can read and write, he doesn’t have hearing difficulty before he was hospitalized. He doesn’t wear eyeglasses. His daughter said that her father still possess a sharp memory and still recalls past experiences with spontaneity. Her daughter also reported that her father doesn’t have any speech problem and has a normal sense of taste and smell before he was hospitalized.
G. Self – perception and Self – Concept Pattern According to the daughter her father verbalizes that his contentment of a well balanced health condition. Now his self- perception is undermined, since the client is in the state of coma.
H. Role – Relationship Pattern Significant people to the client are his family. He is the head of the family. His daughter stated that the only problem they have is the hospitalization of her father because of financial problems that arises from it. They resolve and manage their problems through constant communication themselves.
I. Sexually – Reproductive Pattern
His daughter said that her father shows his affection to his family by constantly kissing and hugging them. The client has three children: two girls and a boy.
J. Coping – Stress Tolerance Pattern Before being hospitalized the client experiences many stressors are brought about by financial factor and health problems. They are able to cope up by constantly cooperating with one another.
K. Value – Belief Pattern Her father does not hear mass on a regular basis because he believes that God is always in our hearts and that we don’t need to go to church just to pray. Yet he believes that being a Catholic is the best way to be close to God.
BP: 160/90 Temp: 39˚C BODY PARTS TECHNIQUE USED
1. SKULL Inspection, palpation
PR: 102 Bpm RR: 38 Bpm ACTUAL FINDING
Proportional to the size of the body, round with prominences in the frontal and occipital area, symmetrical in all place White, clean, free from masses, lumps, scars, and lesions no areas of tenderness
The skull is Normal normocephalic and symmetrical to the body with prominences in the frontal and occipital area, symmetrical in all place White, no masses, lumps, scars, and lesions no area of tenderness is observed. Normal
Oblong or round or square, or heart shaped,, facial expression that is dependent on the mood or true feelings, no involuntary muscle, Symmetric facial movements.
Oblong. No facial Not normalmovement is Indicates observed. There wereimpairment of presence of acne facial nerves around his forehead. which cause paralysis.
Parallel and evenly Dilated pupils which spaced symmetrical, is black in color and non- protruding, non reacting to light. pink palpebral He have some conjunctiva, and discharges around pupils black in color, the lacrimal area. equal in size, round and constricts in response to light.
-Not NormalIndicates altered level of consciousness.
Midline symmetrical and patent, no discharge.
Midline symmetrical and patent, no discharge. With presence of nasogastric tube insertion on the right nares.
Parallel Parallel symmetrical, symmetrical, proportional to the proportional to the size of the head, size of the head, bean-shaped, skin bean-shaped, skin is same color as is same color as the surrounding the surrounding color, clean firm color, with dust cartilage. accumulation on firm cartilage.
Not normalIndicates poor personal hygieneinadequate selfcare primarily caused by self care deficit.
Symmetrical, gums Symmetrical, gums Normal pinkish in color, lips slightly dark in color margin is with yellowish teeth, symmetrical, no lips margin is lesion and symmetrical, no tenderness, without lesion and involuntary tenderness, without movement involuntary movement
Varies from light to deep brown, from ruddy pink to light pink, from yellow overtones to olive, generally uniform skin temperature
With uniform deep Not normal-The brown skin color client has with slightly elevatedimpaired skin temperature. Poor integrity with skin integrity and hyperthermia redness on bony and disruptions prominences. on skin integrity.
Thick, silky, Thick, oily with Normal resilient, free from traces of white infestation, evenly hairs evenly distributed and distributed which covers whole covers the whole scalp. scalp and free from infestation.
Convex curvature smooth texture, highly vascular and pink, prompt return of pink less than 4 seconds
Long with convex Normal curvature smooth texture, highly vascular with bluish to pinkish discoloration, capillary refill is prompt.
Symmetrical and straight, no palpable lumps, and supple, trachea is on midline of neck, and spaces are equal on both sides.
Symmetrical and Normal straight, no palpable lumps, and supple, trachea is on midline of neck, and spaces are equal on both sides.
Symmetrical chest Difficulty of expansion, clear breathing with breath sounds. breath sounds (ronchi) audible even without the use of stethoscope having the respiration rate of 38 Bpm.
Not normalIndicates tachypnea primarily due to hypertension.
A dynamic Palpitations with pericardium, elevated heart rate normal rate, of 115 bpm. regular rhythm, no murmur.
Not Normalindicates increase cardiac overload due to increase blood pressure
Symmetrical pulse Symmetrical pulse Normal volume, full volume, full pulsation pulsation
No tenderness, masses, nodules and discharge.
No tenderness, masses, nodules and discharge.
Inspection, Auscultation, Percussion, Palpation.
Uniform color, rounded symmetrical contour, audible bowel sounds, no tenderness, liver and bladder are not palpable
Uniform color, Normal rounded symmetrical contour, audible bowel sounds, no tenderness, liver and bladder are not palpable
Normal pubic hair distribution is noted and free from infestation. Penile lesions, masses, or discharges are not present.Testes is symmetric without masses or undue tenderness. The left testis may be slightly larger and hang lower than the right testis.Inguinal or femoral hernias are not present.
The genitalia was not assessed because the relatives refused to do so. The patient also has an indwelling catheter.
Not NormalIndicates Urinary dysfunction (refer to laboratory result).
K. UPPER AND Inspection LOWER EXTREMITIES
Equal size on both Immobilization of Not normal the sides of the body, all the extremities. patient is no contractures, comatose. deformities and tenderness, normally firm, joints move smoothly.
Test Glucose HGT Creatinine Sodium Potassium Uric acid Total Cholesterol Triglycerides HDL Results 105 1.7 142 3.5 4.5 250 133 40.8 Normal Values 75-115mg/dl 0.6-1.1mg/dl 135-140mmol/L 3.5-5.3mmol/L 3.4-7.0mg/dl <200mg/dl <200mg/dl 40-58.7mg/dl
Results RBC WBC Hgb Hct Platelet count Segmenters Lymphocytes Monocytes 8.0 15,900 21 0.62 300000 0.66 0.30 0.04 Normal Values 4.5-5.8 x 12/L 5000-10000/cumm 14-18 x 12/L 0.42-0.52 x 12/L 150000-450000/cumm 0.50-0.66 0.20-0.40 0.02-0.08
Anatomy and Physiology
Unoxygenated Blood Superior & Inferior Vena cava
Right Atrium Tricuspid Valve
Right Ventricle Pulmonary trunk & pulmonary Arteries
LUNGS (process f oxygenation)
Left Atrium Bicuspid valve
Left ventricle Aortic Valve Aorta
1. 2. 3. 4. 5. 6. 7.
Olfactory: Optic: Oculomotor: Trochlear: Trigeminal: Abducens: Facial: taste sensation 8. Auditory/vestibular: 9. Glossopharyngeal: 10. Vagus: 11. Accessory: 12. Hypoglossal:
BRAIN: Cranial Nerves Smell Visual fields and ability to see Eye movements; eyelid opening Eye movements Facial sensation Eye movements Eyelid closing; facial expression; Hearing; sense of balance Taste sensation; swallowing Swallowing; taste sensation Control of neck and shoulder muscles Tongue movement
• Cranial Nerves – There are 12 pairs of nerves that originate from the brain itself. These nerves are responsible for very specific activities and are named and numbered as follows: • Olfactory: Smell • Optic: Visual fields and ability to see • Oculomotor: Eye movements; eyelid opening • Trochlear: Eye movements • Trigeminal: Facial sensation • Abducens: Eye movements • Facial: Eyelid closing; facial expression; taste sensation • Auditory/vestibular: Hearing; sense of balance • Glossopharyngeal: Taste sensation; swallowing • Vagus: Swallowing; taste sensation • Accessory: Control of neck and shoulder muscles • Hypoglossal: Tongue movement
Non-modifiable Risk Factors >Advanced Age >Gender >Heredity
Modifiable Risk Factors >HPN >Smoking >excessive intake of foods high in fats and cholesterol
Triggering Factors >Sudden extreme emotion
Cerebral aneurysm rupture
Bleeding into the brain tissue and subarachnoid space
Blood Clots in the Subarachnoid Space
Blood supply interruption S/S: >Severe Headache >Drowsiness >Loss of consciousness
Tissue Necrosis Neuronal Death Regional Paralysis Total Paralysis
Increase Intracranial Pressure
Epileptic Seizure: increase intraocular pressure= blindness
Drug study 1
Medication Generic name: nifedipine Brand name: Calcibloc Route: oral Dosage: 180mg Frequency: once a day Classification/ Action Indication Contraindication Side effects Adverse effects Nursing consideration
Inhibits calcium Treatment of ion influx across vasospatic, all membrane angina, chronic during cardiac stable angina, depolarization, hypertension produces (sustainedrelaxation of released tablets coronary vascular only. smooth muscle and peripheral vascular smooth muscle, dilates coronary arteries, increase myocardial oxygen delivery in patients with vasospastic
Hypersensitivity, Patients Dizziness, flushing, Use caution in cardiovascular withdrawn headache, severe aortic stenosis shock, combination from blockers hypotension or severe hepatic with rifampicine while taking peripheral edema, impairment contraindicated in nifedifine may tachycardia and Assess potential for unstable angina and experience palpitation interactions with after resent MI increase angina other severe hypotension, pharmacological with systolic agents or herbal pressure less than 90 products patients is mmHg taking that may decompensate heart increase risk of failure pregnancy hypotension and and lactation toxicity Monitor blood pressure and pulse before therapy, during dose
filtration and periodically during therapy monitor ECG periodically during prolonged therapy Assess therapeutic effectiveness and adverse reaction Assess location, duration intensity, precipitating factor of patients angina pain
Drug study 2
Medication Classification/ Action Indication Contraindication Side effects Adverse effects CNS: headache, confusion. EENT: blurred vision, rhinitis CV: transient volume expansion, tachycardia, chest pain, congestive heart failure, pulmonary edema. GI: thirst, nausea, vomiting GU: renal failure, urinary retention. Nursing consideration Monitor vital signs, urine output, CVP, and pulmonary artery pressure prior to and hourly throughout administration. Assess patient for signs and symptoms of dehydration or signs of fluid over load. Assess patient for anorexia, muscle weakness, numbness, tingling, confusion and excessive thirst.
Generic name: Increases the Adjunct in the Hypersensitivity , Mannitol osmotic pressure treatment of acuteanuria, dehydration, of the glomerular oliguric renal intracranial bleeding. Brand name: filtrate, thereby failure, adjunct in Osmitrol inhibiting the treatment of Route: IV reabsorption of edema, Dosage: water and redunction of Adult 0.25-2 g/kg as electrolytes. intraocular 15 to 25% solution pressure, to over 30 to 60 min. promote the excreation of Children 1-2 g/kg certain toxic (30 – 60 g/m2)as a substances. 15 to 20 solution 0ver 30 – 60% Frequency: 4x daily
Monitor neurologic status and intracranial pressure readings in patient receiving this medication to decrease cerebral edema.
Drug study 3
Medication Generic name: Amlodipine Brand name: Amvasc, norvasc Route: Dosage: 5 mg Frequency: Once daily Classification/ Action Indication Contraindication Side effects Adverse effects Nursing consideration
Inhibits influx of Hypertension, Sick sinus calcium ion chronic stable syndrome; secondacross cell angina, or-third- degree membranes to vasospatic angina artrioventicular produce block exept with a relaxation of functioning coronary vascular pacemaker smooth muscle (dilatation of coronary arteries) decrease peripheral vascular resistance of smooth muscle (decrease blood pressure)
CHF, hepatic Palpitations, Assess cardio impairment, peripheral edema, respiratory status. caustious use is syncope, Angina pain, B/P required tachycardia, pulse, respiration, bradycardia, ECG arrythmias, ventricular Assess hydration and asystoles, headache,fluid volume status, dizziness, input and output ratio, lightheadedness, presence of edema, fatigue, lethargy, distended neck veins, somnolence, luck crackles, dermatitis,rash adequate pulses and pruritus, skin turgor. uticaria,nausea, abdominal discomfort, cramps, dyspepsia, shortness of breath,
and increases myocardial oxygen delivery in patients with vasospatioc angina.
dyspnea, wheezing, flushing, sexual difficulties, muscle cramps, pain or inflammation
Monitor liver function ALT, AST, bilirubin Monitor if platelet count is less than 150,000/mm, drug is usually discontinued and another drug started.
Drug study 4
Medication Classification/ Action Indication Contraindication Side effects Adverse effects Nursing consideration •Advise patient to take medication exactly as directed and not to take more than the recommended amount. Severe and permanent liver damage may result from prolonged use or high doses of acetomenophe. Adult should not take acetomenophen longer than 10 days and children longer than 5 days unless directed by physician.
Generic name: Inhibits the •Mild to synthesis of moderate pain Acetomenophen prostaglandin that •Fever Brand name: may serve as Aminofen mediators of pain Route: and fever. IV Dosage: Therapeutic effects. 325-1000mg every 4 •Analgesic (due to to 6 hrs needed peripheral prostaglandin inhibitors) •Antipyresis (lowers fever); due to inhibitors of prostaglandin in the CNS No significant anti inflammatory properties
Previous hypertensive Product containing alcohol, aspartame, saccharin, sugar or tartrazine.
GI: hepatic necrosis DERM: rash, urticaria.
•Advise the patient to consult the physician if discomfort or fever is not relieved by routine dosages of this drug or if fever is greater than 39.5 (103 F) or lasts longer than 3 days
ASSESSMENT DIAGNOSIS OBJECTIVE Objective cues: Ineffective After four airway hours of clearance nursing •Clavicular related to intervention •Breaking retained mucus the client •Rhonchi secretion due to airway breathing sound absence of clearance will cough reflex. be cleared. •Increase respiratory rate of 36 to 38 bpm Scientific Explanation: Inability to clear secretions or obstruction from the respiratory tract to maintain a clear air way.
Nursing Care Plan One PLANNING INTERVENTION Plan ways on how to reduce congestion on airway.
Position head midline To open or After four hours of with flexion maintain airway nursing appropriate for to the client. intervention the condition. client air way To clear airway clearance is Oropharyngial when secretions cleared. suctioning (as needed) are blocking on airway. To decrease the pressure on the diaphragm.
Elevate head of the bed and change position every 2 hrs.
To help liquefy Increased fluid intake secretion at least 3000 ml/day
Auscultate breath To maitain status souds and assess air and note progress movement
Nursing Care Plan Two
>To assess causative factors to the clients fever thus formulation of appropriate nursing intervention. >Heat loss by evaporation and conduction
>after 2 hours of nursing intervention the client’s temperature is decreased to a normal range
Subjective Cues: Hyperthermia related >”tatlong araw na to inflammation of siyang nilalagnat” cerebral tissue as as verbalized by the evidence by elevated body temp. relatives. Objective Cues: Scientific EXP: >elevated body temp of 39˚C Body temperature elevated above >flushing skin normal range, >warm to touch because of body’s >increase RR with a response to rate of 38 Bpm inflammation from >diaphoresis hemorrhage that result from ruptured cerebral artery.
>after 2 hours of >Plan techniques >Identify under lying nursing in which the cause interventions the temperature of client’s the client will temperature will decrease to a decrease to a normal rage. normal range.
>Promote surface cooling by means of >Heat loss by tepid sponge bath convection. >Establish cool environment by opening air vents and window panes >to avoid further >Advise relatives not increase of clients to cover the client with temperature. a blanket, and use less restrictive clothing’s
> Administer > For immediate antipyretics through IV alteration of body as prescribed. temperature
Nursing Care Plan Three
ASSESSMENT DIAGNOSIS OBJECTIVE PLANNING INTERVENTION RATIONALE EVALUATION
Objective Cues: >Risk for >After 3 hour s >Plan strategies>Note for general > To assess After two hours of nursing on how to debilitation, reduced aggravating of nursing >reddened skin impaired skin intervention the >poor skin turgor Integrity related to intervention the eliminate the mobility, changes in factor to skin physical client relatives risk for skin and muscle breakdown and possibilities for >immobility immobilization. will identify risk impaired skin mass, poor make appropriate impaired skin >friction factors for nutritional status intervention to it. integrity of the integrity. impaired skin and problems of self client is Scientific integrity , care eliminated. Explanation: verbalize > Maintain strict At risk for skin understanding skin hygiene, using being potentially of therapy mild non-detergent > To prevent skin vulnerable to regimens and soap, drying gently irritation breakdown demonstrate and thoroughly. and because of behaviors and lubricating with immobilization techniques to lotion prevent skin breakdown.
>Instruct the relative to turn the patient every two hours
>To reduce tissue pressure and prevent pressure sore.
> Avoid friction when changing position
> To prevent a shearing force on the skin.
>Provide protection >To increase by use of circulation and pads,pillows, foam eliminate excessive mattress. tissue pressure. >Observe for reddened or blanched areas and give proper management if there is any. >Reduces likelihood of progression to skin breakdown.
>Nifedipine must be given 10mg once a day by sublingual as prescribed. >Instruct the relative to follow medication regimen.
>Encourage the relative to do some exercises like a passive range of motion in affected and unaffected parts of the body of the client.
> Educate & instruct the family to monitor the blood pressure and pulse rate before administering medication.
>Inform the relative the importance of proper hygiene of the patient from head to toe. >regular inspection of the diaper of the patient and change if there a presence of fecal material, urine or even redness that would lead to skin rashes. >Educate and instruct the relatives on how to feed the client through nasogastric tube. >Instruct them to turn the client every 2 hrs to avoid pressure sores.
>Inform the family of the patient to have a regular check-up for the continuity of treatment. >Instruct the family of the patient to monitor if there is any sudden change to the patient and report immediately. >Instruct the relative to feed the client on time with nutrition food that is low in sodium, low in cholesterol, low in fat and give citrus fruits, moderate in fluid intake and increase fiber diet to improve health. >Follow the diet prescribed by the doctor.
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