introduction

Objectives

CHAPTER 1: ASSESSMENT

A. NURSING HEALTH HISTORY

PERSONAL DATA

Our patient initial is B.L. He is 73 years old. He was born on June 5, 1935. He currently
residing at 9th Ave., Caloocan City. He is Filipino, pure Roman Catholic and married with 5
children. Educational attainment was high school graduate. Before, he was a painter but now
his sons and daughters support him. Our source of reliability of information is his eldest child
and his 3rd child. And the date of interviewed was May 15, 2009.

CHIEF COMPLAINT

Nahihilo ako. As stated

HISTORY OF PRESENT ILLNESS
Few hours prior to admission, the patient experienced dizziness and the patient was
rushed to the hospital because his son saw him that he fell down in the ground. The patient
was conscious but not responsive. He was admitted May 8, 2009 at 3:30 P.M. with vital sign
of Temp: 36.8C, PR: 90 bpm, RR: 21 cpm, BP: 130/90 mmHg. The patient was diagnosed
with post C.V.A.

HISTORY OF PAST ILLNESS

According to the daughter of our patient, patient B. L. Experienced C.V.A. 3 years ago.
Two months ago B.L. experienced ulcer. The patient doesnt have any allergies in
medications, foods and environment. He didnt go in any surgery

FAMILY HEALH HISTORY

They have a history of Hypertension and 1 died with heart attack in their family.

SOCIAL HISTORY

According to the son, his father is a responsible father., he gives all the necessary needs
of his children. He said that if his father is mad he was still quiet and keep it to himself. B. L.
Is very close to their neighbors, he spends time playing billiards with them.
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REVIEW SYSTEM

I. PSYCHOLOGICAL

Our patient is a hard working person at the age of 19 he already work as a helper this
consider him as a responsible father. He is small frame. It is a big chance in his body and mind.
He already have memory gap and hi skin became dry and less elastic, his hair is white. He
already experienced C.V.A. 3 years ago but he recovered from that.

ROLE RELATIONSHIP PATTERN

Our patient is lives with his eldest child. He is 73 years old turning 74 next month. He
stopped working when their children started to have new own families. His family was extended
and very close with their neighbors.

SEXUALITY AND REPRODUCTIVE

Our patient is not sexually active anymore because of his age and status. Before, when he
was a teenager he always use contraceptive method like condom is 100% safe to use. He is
already circumcised when he was first year high school at the age of 11 years old.
COGNITIVE PERCEPTUAL PATTERN
Our patient B. L. is not using any devices like auditory and visual devices but when was
diagnosed with C. V. A. he forgot everyone in his family. He is a high school graduate.
VALUE BELIEF PATTERN

He is not a religious person. He is satisfied with his life. He has superstitious belief like
Bawal lumabas ang baby pag gabi because the baby will get sick.

ELIMINATION

When the patient not diagnosed in C.V.A. he eliminates 2-3 times a day and the
characteristics of his stool is hard, brown in color, smells bad and the bowel movement is
normoactive, he urinates regularly, the characteristics of his urine is clear and the yellow in color
but when he hospitalize with the diagnosed in C.V.A. he defecate irregular and the
characteristics of his tool is slight yellow in color, sticky, smells bad and the bowel movement is
hypoactive, he urinates regularly, the characteristics of his urine is yellow in color and clear.
4

REST AND ACTIVITY

Because he is too old, he did not exercise everyday. His daily activities includes playing
billiards with his friends. He has enough of sleep about 8 hours a day he feel complete when he
has sufficient rest a day.
SLEEP REST PATTERN
When the patient not diagnosed in C.V.A. he sleeps 8 hours a day. He sleep 10 P.M. in
the evening and woke up 6:00 A.M. he has a good quantity of sleep, but when he hospitalize
with the diagnosed in C.V.A. he sleeps irregularly because having stroke feels pain, not
comfortable, irritability and restlessness.
SAFE AND ENVIRONMENT

He doesnt have any allergies in the environment. There is one lesion oh his right elbow.
He has a fever and the temperature was 38.8C.

OXYGENATION

The patients is always takes good care of his grand children and spends time time playing
billiards. He smokes and drinks alcohol until the first attack of his C. V. A.

NUTRITION

The patient was advised to have low salt, low fat and low cholesterol diet

FOOD INTAKE
NGT (low salt, low fat, low
cholesterol)

FLUID INTAKE
1 glass of water

LUNCH

NGT (low salt, low fat, low

cholesterol

1 glass of water

DINNER

NGT (low salt, low fat, low

cholesterol

1 glass of water

BREAKFAST

a. Physical Assessment

Vital signs

The clients pulse rate is 90 beats per minute, his respiratory rate is 21 breaths per minute,
temperature is 36.8c.

General appearance

The client is in medium frame with stooped posture, the client is bedridden since he was
admitted to the hospital last may 8, 2009. Well groomed and has no body odor. He doesnt have
any deformity.

Mental status

The client is conscious and cooperative. The client cant talk because he was stroke.

Skin

The clients skin is of normal racial tone which is brown. It is dry and smooth. The skin
turgor is wrinkled and loss of elasticity. The body hair is evenly distributed. He doesnt have
any edema. But he has a skin lesion on his right elbow.

Nail
The clients nail shape is convex clubbing, the nail is rough and the nail bed is pink. The
capillary refill is within 3 seconds and thise is an absence of beaus line.

Head and Face

The clients skull is proportionate to the body size, Thise were no tenderness in the scalp.
Thise were no presence of nodules, and infestation. His hair is evenly distributed and the strands
are thin and brittle. The color of his hair is a mixture of white and black. His head is round and
symmetrical its consistency is hard. He cant control his head and the shape of his face is round
and asymmetrical and its consistency is soft.

Eyes

The condition of his eyes is straight normal; the eye brows are evenly distributed. Eyelids
have effectively closure. The blink response is bilateral, eye balls are symmetrical, bulbar
conjunctiva is clear, the palpebral conjunctiva is pink and the sclera is white. The palpebral slant
is aligning with the tip of the pinna. The corneal sensitivity reflex is present cornea is
transparent, the color of his eyes are brown, the shape are equal, it is uniform in color. Pupils are
equal in size. Pupils are equally round and reactive to light and accommodation. He can execute
the occular movements. He can recognize objects within 12-14 inches away. The lacrimal
apparatus are moist.

Ear

The color of the ear is of normal racial tone which is brown, it is symmetrical. The
alignment of the pinna is symmetrical. The pinnas are elastic and recoil when folded. The
mastoid process is tender. The auditory canal contains some cerumen, the color is brown and
there is an absent of discharges.

Nose

The color of the clients nose is of racial tone which is brown. His septum is in the
midline. The mucosa is pink, nostrils are both patent, nasal flaring is absent. Landmarks are
visible. Sinuses are non-tender. There is an NGT in his right nostrils.

Mouth and Oropharynx

The lips is symmetrical and pink, the consistency is smooth, buccal mucosa is pink, the
gum is pink, the tongue is in the midline, the color is pink and it is smooth. The tongue
movements are not that smooth. Its texture is rough. The color of the hard and soft palate is pink.
And it is intact. The tonsils are inflamed grade of + 2. Ther is presence of mucous. Uvula is in
the midline, gag reflex is absent. The teeth are incomplete.

Neck

The neck has involuntary movement and with resistance, the muscle strength 3/5. The
trachea is in the midline, thyroid is in the midline and it is smooth. Maxillary lymph nodes are
palpable.

Breast

The breasts are symmetrical with flat contour. Shape is flat, the skin surface is smooth.
Lympnodes are not palpable. The areola is color brown, shape is round and the nipple is everted,
there are no discharges and there are no Lympnodes and no tenderness.

Chest and Lungs

The color of the chest is of normal racial tone which is brown, the shape is AP to lateral
ratio 1:2. There are absence of intercoastal retraction, costal angle is 45 chest wall are
symmetrical, and the chest expansion is symmetrical. Rib slope is less than 90. Respiratory
rhythm is regular. The respiratory depth is shallow. Respiratory pattern is normal. When palpated
he doesnt feet any tenderness. The vocal fremitus is normal, tactile fremitus is symmetrical. The
lung expansion is normal. When percussed the sound is resonance. When auscultated brondual is
absent. No adrentition sound. Respiratory rate is 21 breaths per minute.

Heart

The rhythm is regular. PMI is located in the apical pulse. Heart rate is 90 beats per
minute.

Abdomen

Skin is of normal racial tone which is brown, the contour is flat. Peristalsis is non-visible.
The color of his stool is brown, it is solid and formed. The bowel sound is normo active and no
bruits. When percussed the sound is tympany. When palpated he doesnt have any tenderness
and when light palpation is done muscle guarding is absent. The liver is not palpable.

Upper extremities

The client cannot resist force when asked to resist. Muscle strength is 3/5. He have a skin
lesion in his right elbow, The peripheral pulses are equal. Lympnodes are not palpable. The IV
site is in his left arm.

Lower extremities

The client cannot resist force when asked to resist. Muscle strength is 2/5. He doesnt
have any deformity. The peripheral pulses are equal. Lympnodes are non-palpable.

Genital(according to the client)

The client is circumcised and his genitals are fully developed

C. Diagnostic Procedure

1. Name of Diagnostic Procedure

- Hematology

Description:
The branch of biology (physiology), pathology, clinical laboratory, internal medicine, and
pediatrics that is concerned with the study of blood, the blood forming organs, and blood
diseases.

Indication:
- this is used to evaluate anemia, leukemia, reaction to inflammation and infections,
peripheral blood cellular characters, state of hydration and dehydration, polycythemia, hemolytic
disease of the newborn, to manage chemotheraphy decisions.

Nursing Responsibilities:
Pre-test
Explain procedure
Gather all equipments
Fasting is not necessary
9

During Test
Record the result
Post Test
Monitor patient response
Document
Results:

Name of
Procedure

Hematology

Date Ordered

May 8, 2009

Normal Values

Values Obtained

Interpretation

Hct: mo. 40-0,56

0.45

Normal

Hgb: M 135-180 g/L

152

Normal

RBC: 5.0-6.5x10 g/L

4.86

Normal

WBC: 4.511.00x10g/L

15.2

Above normal:
values obtained
is higher than the
normal values

Platelet count:
adequate

Adequate

Normal

Neutrophils: 0.50-0.70

0.82

Above normal:
values obtained
is higher than the
normal values

Lymphocytes 0.200.40

0.18

Normal

2. Name of Diagnostic Procedure

- Radiology

Definition:
-is the branch of specialty of medicine that deals with the study and application of
imaging technology like x-ray and radiation to diagnosing and treating disease.
Nursing Diagnosis:
Pre-test
Explain procedure
Check Vital Signs before the procedure
During Test
10

 Remove all jewelries

Record the result
Post Test
Monitor patient response
Check Vital Signs after the procedure
Document
Result:
No acute parenchymal infiltrates seen
Atherosclerotic Aorta
Date of Examination: May 8, 2009

3. Name of Diagnostic Procedure

- CT Scan

Definition:
- is a medical imaging method employing tomography. Digital geometry processing is
used to generate a three-dimensional image of the inside of an object from a large series of two
dimensional x-ray images taken around a single axis of rotation.

Indication:
CT Scanning of the head is typically used to detect:
1.
2.
3.
4.

Bleeding, brain injury and skin fractures

Brain Tumors
A blood clot or Bleeding
Enlarged brain cavities ,etc..

Nursing Responsibilities:

Pre-test
Explain procedure
Check Vital Signs before the procedure
During Test
Remove all jewelries
Record the result
Post Test
Monitor patient response
Check Vital Signs after the procedure
Document

11

Results:

Technique: Plan axial CT Images of the head sad 20m slices was done.

Findings:

There is widening of the sulci and narrowing of the gyri in both cerebral hemisphere.
The Cerebral vessels are calcified
There are low alterat ions noted in the left temporo-parietal lobes.
Impression:

Age related to cerebral atrophy with ex-vasodilatation at the ventricles

Atheromatous cerebral vessels
Acute to subacute infarcts in the distribution area of the left middle cerebral artery
Date of examination: May 8, 2009

4. Name of Diagnostic Procedure

- Ultrasound

Definition:
- Ultrasound, also known as sonography, or ultrasonography, is a diagnostic procedure
that transmits high-frequencysound waves, inaudible to the human ear, through body tissues. The
echoes are recorded and transformed into video or photogrsphic images of the internal structures
of the body.

Nursing Responsibilities:

Pre-test
Explain procedure
Check Vital Signs every 2 hours and check for patients skin
During Test
Provide Privacy
Determine if the test is accurately performed according to the procedure
Record the result
Post Test
12

 Monitor patient response

Document
Results:

- An irregular calcification is noted within the central zone of the prostate. The dimension
measures 39x35x37 mm. The capsule is irregular and echoic. No masses noted.

Impression:

- Prostate hypertrophy with evidence of repeated episodes of prostatitis.

Date of Examination: May 14, 2009

D. anatomy and physiology

BRAIN
13

Cerebrum- The biggest part of the brain is the cerebrum. The cerebrum makes up 85% of the
brain's weight, and it's easy to see why. The cerebrum is the thinking part of the brain and it
controls your voluntary muscles
Cerebellum- The cerebellum is at the back of the brain, below the cerebrum. It's a lot smaller
than the cerebrum at only 1/8 of its size. But it's a very important part of the brain. It controls
balance, movement, and coordination (how your muscles work together).
Brain Stem- The brain stem sits beneath the cerebrum and in front of the cerebellum. It connects
the rest of the brain to the spinal cord, which runs down your neck and back. The brain stem is in
charge of all the functions your body needs to stay alive, like breathing air, digesting food, and
circulating blood.
Midbrain/ Mesencephalon- the rostral part of the brain stem, which includes the tectum and
tegmentum. It is involved in functions such as vision, hearing, eyemovement, and body
movement. The anterior part has the cerebral peduncle, which is a huge bundle of axons
traveling from the cerebral cortex through the brain stem and these fibers (along with other
structures) are important for voluntary motor function.

Pons- part of the metencephalon in the hindbrain. It is involved in motor control and sensory
analysis... for example, information from the ear first enters the brain in the pons. It has parts that
are important for the level of consciousness and for sleep. Some structures within the pons are
linked to the cerebellum, thus are involved in movement and posture.
medulla oblongata is the lower portion of the brainstem. It deals with autonomic functions, such
as breathing and blood pressure. The cardiac center is the part of the medulla oblongata
responsible for controlling the heart rate.

Hypothalamus- The hypothalamus is like your brain's inner thermostat (that little box on the wall
that controls the heat in your house). The hypothalamus knows what temperature your body
should be (about 98.6 Fahrenheit or 37 Celsius).
PATHOPHYSIOLOGY OF HEMMORHAGIC STROKE
Tissue injury

Causing compression of tissue

Expanding hematoma or hematomas

Distort and injure tissue

The pressure may lead to a loss of blood supply to affected tissue with resulting infarction

The blood released by brain hemorrhage appears to have direct toxic effects on brain tissue and
vasculature
14

CHAPTER II: PLANNING

Nursing Diagnoses

Rank

Justification

Impaired verbal communication

related to neuromuscular
impairment as evidence by
absence of responding

It is the 1st prioritized diagnoses

because the client cant express
his feelings and emotions, and it
needs to have an immediate
intervention

Impaired walking related to

neuromuscular impairment as
evidence by paralyzed
extremities

it is my 2nd prioritized diagnoses

because the client cant walk
because of the neuromuscular
impairment that needs immediate
intervention

Impaired physical mobility as

evidence by functional level of
0

Risk for skin integrity related to

physical immobility

It is my 3rd prioritized diagnoses

because the patient cant mo w/
or w/out assistance

It is the 4th because it may cause

of bedsore

It is the last prioritized diagnoses

because the patient wants to gain
his power

Readiness for enhanced power

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Ncp1

16

Ncp2

17

Ncp3

18

Drug study1

19

Drug study 2

20

Drug study 3

21

TREATMENT

INTRAVENOUS FLUID
PNSS 1000M/12 hours (27.28 gtts/min.)
IVF is an essential when patient are unable to take enough food and fluids orally. It is
effective and efficient method of supplying liquids directly into the IVF compartment and
replacing electrolyte losses.
NURSING RESPONSIBILITIES

1. Explain the purpose of the IVF to the patients family

2. Checks the doctor order before looking the IVF
3. Frequently check the IVF site for infiltration, dislodge and inflammation

DIET

The patient was advised to have low salt. Low fat diet and he was feed through NGT.

ACTIVITY

The patient was ordered to have complete bedrest because the patient is weak and he
needs to conserve energy changing of position is required and advisable for proper blood
circulation.

NURSING RESPONSIBILITIES

1. Monitors patients vital signs frequently specially blood pressure because patient is
unstable in her condition.
2. Monitor patients I and O
3. Encourage bed rest
4. Check the IVF volume, follow flow rate and adjust it to prescribe

NURSING MANAGEMENT
Obtain vital sign and pulse oximetry measurements every 2 -4 hours or as ordered for 24 hours on
all patients with diagnosis of stroke.
Asses level of consciousness, random movements, response to stimuli, eye contact and speech.
Document.
Patient should have at least one IV access site in the non-paralytic side.
22

Monitor blood pressure every 30 minutes.

Check for urinary retention.
Initiate physical therapy.
Activity needs to be advanced as tolerated.
Avoid immobility.
Apply high knee ted hose for patients with impaired mobility.
Initiate the pressure ulcer prevention, general skin care, immobility management and fall
prevention management.

CLIENTS DAILY PROGRESS CHART

Admission

Diagnostic
Procedure

Diet

Activity

Medication

Treatment

Surgery

Low Salt
Low Fat
Diet

NGT 2000
Kcal /
feeding.

IV
PNSS 1 L
27 gtts to
run for 16
hours
Day 1

Low Salt
Low Fat

NGT 2000
Kcal /
feeding.

Diet
IV
PNSS 1 L
27 gtts to
run for 16
hours
Day 2

Low Salt
Low Fat

NGT 2000
Kcal /
feeding.

Diet
IV
PNSS 1 L
27 gtts to
run for 16
hours
Discharge

Low Salt
Low Fat
Diet

NGT 2000
Kcal /
feeding.

IV
PNSS 1 L
27 gtts to run
for 16 hours

23

Chapter IV: Evaluation

Narrative Evaluation
During the two days of hospital duty in the President Diosdado Macapagal Memorial
Medical Center, patient shows sign of improvement compare to his condition during admission.
Tonsils were not that inflamed, from a grade of 2 to the grade of 1. Vital sign became normal,
blood pressure decreased.
M-edication
Patient has to continue his medication. Amlodipine 5mg/ tab once a day, Zantac 150 mg
twice a day, 8am and 6pm.
E-xercise
The patient was advised to have complete bed rest until strength is regained. Have turn
side to side every 2 hours to prevent bed soars. Have ROM exercise on to enhance client's body
function.

T-reatment

Insist physical therapy for improving strength and walking. Occupational therapy for
regaining dexterity of the arms and hands. Should undergo speech therapy to learn talking and
swallowing. Oxygen inhalation if necessary and if possible 3-4 liters per minute.

H-ealth teaching

Teach the client how to have a healthy lifestyle. Teach patient the foods to eat and the
foods to avoid. Teach the family members how to prepare low sodium and low fat diet.
Encourage environmental modification to enhance safety and prevent injury.

O-ut Patient
The client was advised to have a follow-up check-up, as indicated by the physician.
D-iet
Patient was instructed to maintain the low salt and low fat diet. The low salt diet is
designed to induce a loss of sodium and water from the body or avoid sodium retention. A 2000
mg low sodium diet is sufficient to control blood pressure. A low fat diet help lose weight to
decrease risk of having CVA again

24

Table of Contents
Introduction ....................................................................................................................................1
Objectives ................................................................................................................................................... 2
Chapter I: Nursing health history ...............................................................................................3
Review of system ............................................................................................................................4
Physical assessment ................................................................................................................................. 6
Diagnostic procedure ....................................................................................................................9
Anatomy and physiology.............................................................................................................13
Chapter II: Prioritize Nursing diagnoses..................................................................................15
Nursing Care Plan 1.....................................................................................................................16
Nursing Care Plan 2.....................................................................................................................17
Nursing Care Plan........................................................................................................................18
Chapter III: Medication 1...........................................................................................................19
Medication 2 ................................................................................................................................20
Medication 3.................................................................................................................................21
Treatment, Diet, and Activity.....................................................................................................22
Nursing Management.............................................................................................................22-23
Clients Daily Progress Chart.....................................................................................................23
Chapter IV: Narrative Evaluation.............................................................................................24
METHODS...................................................................................................................................24

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