A CASE STUDY

ON
CEREBROVASCULAR
ACCIDENT WITH LEFT
HEMIPARESIS
INTRODUCTION
 Cerebrovascular accident: The sudden death of some brain cells
due to lack of oxygen when the blood flow to the brain is impaired by blockage
or rupture of an artery to the brain. A CVA is also referred to as a stroke.

Symptoms of a stroke depend on the area of the brain affected. The

most common symptom is weakness or paralysis of one side of the body with
partial or complete loss of voluntary movement or sensation in a leg or arm.
There can be speech problems and weak face muscles, causing drooling.
Numbness or tingling is very common. A stroke involving the base of the brain
can affect balance, vision, and swallowing, breathing and
even unconsciousness

The causes of stroke: An artery to the brain may be blocked by a clot

(thrombosis) which typicallyoccurs in a blood vessel that has previously been
narrowed due to atherosclerosis ("hardening of the artery"). When a blood clot
or a piece of an atherosclerotic plaque (a cholesterol and calcium deposit on
the wall of the artery) breaks loose, it can travel through the circulation and
lodge in an artery of the brain, plugging it up and stopping the flow of blood;
this is referred to as an embolic stroke. A blood clot can form in a chamber of
the heart when the heart beats irregularly, as in atria fibrillation; such clots
usually stay attached to the inner lining of the heart but they may break off,
travel through the blood stream, form a plug (embolus)in a brain artery and
cause a stroke. A cerebral hemorrhage (bleeding in the brain), as from an
aneurysm (a widening and weakening) of a blood vessel in the brain, also
causes stroke.
 The diagnosis of stroke involves a medical history and a physical examination.
Tests are done to search for treatable causes of a stroke and help prevent further
brain damage. A CAT scan (a special X-ray study) of the brain is often done to show
bleeding into the brain; this is treated differently than a stroke caused by lack of blood
supply. A CAT scan also can rule out some other conditions that may mimic a stroke.
A sound wave of the heart (echocardiogram) may be done to look for a source of
blood clots in the heart. Narrowing of the carotid artery (the main artery that supplies
blood to each side of the brain) in the neck can be seen with a sound wave test
called a carotid ultrasound. Blood tests are done to look for signs of inflammation
which can suggest inflamed arteries. Certain blood proteins are tested that can
increase the chance of stroke by thickening the blood.

Treatment of a stroke: Early use of anticoagulants to minimize blood clotting

has value in some patients. Treatment of blood pressure that is too high or too low
may be necessary. (Lowering elevated blood pressure into the normal range is no
longer recommended during the first few days following a stroke since this may
further reduce blood flow through narrowed arteries and make the stroke worse.) The
blood sugar glucose in diabetics is often quite high after a stroke; controlling the
glucose level may minimize the size of a stroke. Drugs that can dissolve blood clots
may be useful in stroke treatment. Oxygen is given as needed. New medications that
can help oxygen-starved brain cells survive while circulation is reestablished are
being developed.
 Rehabilitation: When a patient is no longer acutely ill after a stroke,
the aim turns to maximizing the patient's functional abilities. This can be
done in an inpatient rehabilitation hospital or in a special area of a general
hospital and in a nursing facility. The rehabilitation process can involve
speech therapy to relearn talking and swallowing, occupational therapy for
regaining dexterity of the arms and hands, physical therapy for improving
strength and walking, etc. The goal is for the patient to resume as many of
their pre-stroke activities as possible.

According to the World Health Organization, 15 million people

worldwide will suffer from stroke this year. Five million will die and another
five million will be permanently disabled. Stroke is the third leading cause of
death in the United States. Over 143,579 people die each year from stroke
in the United States. In the Philippines, stroke affects 486 out of 100,000
Filipinos or roughly half a million Filipinos, according to Dr. Navarro in his
study published in The Philippine Journal of Neurology. Nearly three-
quarters of all strokes occur in people over the age of 65. The risk of having
a stroke more than doubles each decade after the age of 55. Among adults
age 20 and older, the prevalence of stroke in 2005 was 6,500,000 (about
2,600,000 males and 3,900,000 females).Each year, about 55,000 more
women than men have a stroke. Men’s stroke incidence rates are greater
than women’s at younger ages but not at older ages. The male/female
incidence ratio is 1.25 at ages 55–64; 1.50 for ages 65–74; 1.07 at 75–84
and 0.76 at 85 and older. Of all strokes, 87 percent are ischemic, 10 percent
are intracerebral hemorrhage, and 3 percent are subarachnoid hemorrhage.
 The objective of our study is to acquire knowledge on how to deal or
manage patient with Cerebrovascular Accident.
This study will aid us, student nurses, in revealing and educating
individuals and family members about neurologic disorder, treatment and
recovery. This would permit the development of appropriate strategies to
target high risk group.
NURSING HEALTH HISTORY
 Nursing health history is the first part and one of the most significant
aspects aspects in case studies. It is a systematic collection of subjective and
objective data, ordering and a step-by-step process inculcating detailed
information in determining client's history, health status, functional status and
coping pattern. This vital information's provide a conceptual baseline data
utilized in developing nursing diagnosis, subsequent plans for individualized
care and for nursing process application as a whole.

As I follow the rules and regulation on any hospitals, the ethical

guidelines must be realize to withhold for the confidentiality of the patient and
privacy. That's why as I go along, you've notice that I hidden the real name of
my patient with pseudonym of patient A to protect his right accordingly, and
also by its legality.

Patient A is a male, 54 years of age, was born on January 17, 1956,

through normal spontaneous vaginal delivery at their home in Buenavista,
Agusan Del Norte, a Filipino citizen. He is also Roman Catholic by faith. He
finished his elementary education at Alubijid Elementary School and finished
his secondary education at Benavista Institute. When he was in collage, he
studied at Mindanao State University and transferred at Saint Joseph Institute
of Technology but he wasn't able to finish his studies due to financial problem.
At the age of 25 he got married to Mrs. B and they have 2 siblings which both
are girls. Patient A and his family is currently residing at Purok 2, Alubijid,
Buenavista, Agusan Del Norte.
 On his early childhood, he had mumps and measles. When he had a
fever, his mother wiped his whole body to relieve the heat. He sometimes had
diarrhea But he will just take a herbal medicine for it. He also received a
complete immunization. He was not able to undergone any operation and
doesn't have any allergies to foods.

Patient A owned a farm which also his business. It is the primary

source of their income. They have carabao, chickens and pigs. Patient A
usually sleep 7-8 hours per day, which helps him to maximize his energy
during day time. Everyday he wakes-up at 5 in the morning to feed the
chickens and other animals which also one way of his exercise. He usually
eat 3 times a day with variety of foods. He likes to eat fatty food such as pork
and prefer to eat fried foods rather than soup. Patient A most likely to
consume 4-5 glass of water per day. He drink coffee twice a day one in the
morning and another one for his snack. He also drink a lot of soft drinks
everyday which he can consume about 16 oz and also drink beer
occasionally. He started to smoke when he was 18 years old and most likely
to consume 8-10 cigarette stick per day. Patient A usually defecates once a
day , specifically in the morning.

Patient A, reports that he was already been hospitalized in the year

1993 when he was 33 years old because of mild stroke at Agusan Del Norte
Provincial Hospital. It was the first time that hospitalized and according to his
doctor ,atherosclerosis the reason of his illness and when his history was
taken. Both side of his parents has the history of hypertension, that why he
genetically acquired it.
 Years passed, Patient A continue his life living with his family, After
being hospitalized he doesn't have nay medication maintained for bring
hypertensive person. Still, he continue his sedentary life style before. He still
drink soft drinks, eat fatty foods and doesn't limit himself to smoke everyday.

Until on November 29 , 2010 at around 6:30 pm in the morning, after

taking his breakfast. Patient A felt something wrong on his body. He was
weak, dizzy and have tinnitus. He also felt that he can't moved his extremities
already. That's why his wife was alarmed and decided to brought him to the
hospital.

At 8:20 am , He was admitted in to MJ Santos Hospital with the admitting

vital signs of:
T- 37 degree Celsius BP- 180/110 mmhg
P- 87 bpm O2 Sat- 99%
R- 20 bpm

His under the care of Dr. H with the chief complain of left sided body
weakness with elevated blood pressure. His admission orders are:
diet: low salt and low fat diet
IVF : PNSS iL 20 gtts/min
Monitoring: Vital signs every 2 hours
Neuro vital signs every 2 hours
Laboratory test:
» CBC
» Urinalysis
» Stool exam
» Electrolyte panel c
» Alanine aminotransferase
» Lipid profile
» Uric acid
» Creatinine
» FSB
» Capillary blood glucose
Diagnostic Procedure:
» 12 lead electrocardiogram
» CT scan
» X-ray, AP
Medication:
» Citicholine (citilin) 2 gms IV then 1 gm every 6 hours
» Captopril 25 mg 1 tab sl every g hours PRN for BP 160/100
» Telmesarten (micardis) 40 mg 1 tab now and OD 7am
Special Measures:
» O2 inhilation by nasal cannula 3 L/min
» Moderate high back rest
» Complete bed rest with toilet privileges
 November 29, 2010 at 8:40 am the doctor's order where:
- Polynerv 500 mg 1 tab now then OD
– Apirin (bayprin EC) 100mg 1 tab now then 1 tab OD pc lunch
– Fondaparinux (Arixtha) 0.5 ml sc now then o.5 ml sc OD
– please follow-up CT scan of the brain-plain once financilly
capable
– Discontinue citicholine

November 30, 2010 at 7:30 pm the doctor's order where:

– Piracetam (Nurocer) 1-2 gms 1 tab QID p.o.

December 1, 2010 at 12:05 noon the doctor's order where:

– IVFTF PNSS at 20 gtts/min

December 2, 2010 at 7:00 pm the doctors order where:

- Possible discharge in am
– allow the significant others to photocopy the lab result

When I visited patient A I observed him still weak and need assistance
but his BP is already stable 130/90 mmHg. At that time Patient A is for
discharge and still waiting for the doctors round.
 According to Erick Erickson's psychological developmental of Middle
Adulthood from the age of 35-65 years old, patient A belong to Generality
vs Stagnation. In this stage,work is the most cucial. Erikson observed that
middle-age is when we tend to be occupied with creative and meaningful
work and with issues surrounding our family. Also, middle adulthood is when
we can expect to "be in charge," the role we've longer envied.

The significant task is to perpetuate culture and transmit values of the

culture through the family (taming the kids) and working to establish a stable
environment. Strength comes through care of others and production of
something that contributes to the betterment of society, which Erikson calls
generativity, so when we're in this stage we often fear inactivity and
meaninglessness.

As our children leave home, or our relationships or goals change, we

may be faced with major life changes—the mid-life crisis—and struggle with
finding new meanings and purposes. If we don't get through this stage
successfully, we can become self-absorbed and stagnate.

Significant relationships are within the workplace, the community and

the family.
PHYSICAL ASSESSMENT
 Physical Examination follows a methodical head to toe format in the
cephalocaudal assessment. This is done systematically using the techniques
of inspection, palpation, percussion and auscultation with the use of materials
and investments such as the penlight, thermometer, tape measure,
stethoscope and also sense. During the procedure, I made every effort to
comfort measures and to follow appropriate safety precautions.

The physical examination Patient A was done last December 2, 2010

at 4:00 pm at MJ Santos Hospital (ANEX Station). The following instrument
were used namely BP apparatus, stethoscope, thermometer, wrist watch with
second hand, tape measure, penlight notebook and ballpen.

A. General Physical Assessment

Received lying on bed, awake, appears weak,coherent upon
interaction, with IVF # 3 PNSS 1L at the level of 500 cc regulated at 20
gtts/min infusing well hooked at right cephalic vein, site is clean and intact
Patient's vital signs were as follows:
T-36.8 degree Celsius
P-71 bpm
R-18 bpm
BP-130/90 mmHg
C. Assessment of the skin
The patient's skin is brown in color and is generally uniform except in the
areas exposed to the sun. Is is warm and dry to touch upon palpation of the
forearm. Skin fold retuens to place within 2 seconds when pinched. There is no
edema and abrations or other lesions

D. Assessment of the eyes

Eyebrows are symmetrically aligned but dont have equal movement. The
eyelids blinks response is not equal, 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

E. Assessment of the ears

The ears are of the same color as facial skin. There are symmetrical and
are alined with the outer canthus of the eye. As the pinna is folded forward, it
recoils after afterwards. Normal voices tones are audible as he can hear clearly the
questions without leaning forward.
G. Assessment of the 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 not inflamed. Uvula is in
the midline. The teeth are incomplete.

H. Assessment of the neck

neck is symmetrical without masses, scars and carotid pulse is palpated.
The trachea is in the midline of the neck. As the patient was instructed to
move the head he can moved it slowly

I. Assessment of the 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.
J. Assessment of the lungs and thorax
Chest is symmetric and the spinal column is in the normal state.
Chest wall is intact without any tenderness and masses upon palpation. No
hair was noted. Thorax expands evenly bilaterally. There are quiet, rhythmic
respirations at 18 breaths/min. No abnormal breathing sound were
auscultated.

K. Assessment of the Heart

Patient has an audible heart sound. PMI is heard between 4th - 5th
intercostals space. Heart is pumping well with a pulse rate of 82 bpm from
the normal rate of 60-100 beats per minute.

L. Assessment of the Abdomen

Abdominal movement as with respiration, presence of peristalsis
during auscultation. There are no presence of rashes and lesions

N. Assessment of the Upper Extremities

Hands: Medium in size with 5 fingernails in each side. Nails are
short, small dusty particles are present.
Arms: the left arm is weak at cannot able to do passive range of motion
M. Assement of the lower extremities
The left leg is weak and cannot be control.

O. Assessment of the Genitourinary

not assesed

P. Assessment of the neurologic system

Patient A is weak and cannot control his left side of his body,
responsive upon interviewed . He speaks in a soft but not that clear voice.
Patient oriented to the parson, place and time.
ANATOMY AND PHYSIOLOGY
Parts of Brain
PATHOPHYSIOLOGY
DIAGNOSTIC TEST AND
LABORATORY EXAM
 TEST DEFINITION RESULT REFERENCE INTERPRETATION CLINICAL
RANGE SIGNIFICANCE
- A high count may
indicate leukocytosis
Leukocytes or which is an increase
in the number of the
white blood cells
are responsible for WBC due to invading
White Blood Cell 9.44 5.0-10.0 x 10 g/dL Normal microbes and stress
the defense of the
microorganism - A low count may
due to drug toxicity or
bone marrow failure
A substance - A high count may
contained within indicate
the RBC and hemoconcentration,
responsible for polycythemia vera
their color, it has a and heart failure
unique property of
combining
Hemoglobin reversibly with 118 137-167 g/L Decreased - A low count is
oxygen and is the
caused by anemia
medium by the
oxygen is
transported within
the body.
 -A high value may
be due to
dehydration,
This is the
volume of the cell burns, congenital
in blood, heart disease and
Hematocrit 0.37 0.40-0.50 Decreased polycythemia
expressed as
fraction of the vera.
total volume of
the blood -- A low count is
caused by
imbalance in fluid
and electrolytes

This granulocyte - If the count

has very tiny light exceeds this
straining amount the cause
granules. The is usually due to
nucleus is an acute infection
frequently multi-
Neutrophils lobed with 0.73 0.55-0.75 Normal
connected by - If the count is
strands of nuclear low, it may be
material. These due to addison's
cells are capable disease or
of phagocytizing aplastic anemia
foreign cell, toxin
and viruses
 The level of -A persistently high level
glucose present is referred to as
in a blood hyperglycemia
sample drawn a
minimum of eight 74-100 mg/dL
Fasting Blood hours after the 112.1 Increased
Sugar - A low levels are
last meal. Helps
referred to as
to diagnose hypoglycemia
diabetes and to
monitor glucose
levels in persons
with diabetes.

Is different from - A high blood

most tests in that cholesterol has been
it is not used to associated with
diagnose or hardening of the
Cholesterol monitor a arteries , heart disease,
disease but is 168.5 < 200 mg/dL Normal and a raised risk of death
used to estimate from heart attact,
risk of developing cholesterol testing is
a disease considered a routine part
specifically of preventive health care.
heart disease
 Is a lipoprotein
which helps to
flush bad
cholesterol (also
known as LDL) - A low levels of
out of the body by HDL may place
HDL absorbing 38.1 < 40 mg/dL- low Decreased you at risk of
cholesterol and getting coronary
> 60 mg/dL-high heart disease
carrying it through
the blood to the
liver, where it is
eventually
expelled.

It's also
sometimes called
"bad" cholesterol.
Lipoproteins are
made of fat and - A high levels of
LDL protein. They 115.36 < 130 mg/dL Normal LDL may place at
carry cholesterol, risk of getting
triglycerides, and coronary heart
other fats, called disease
lipids, in the blood
to various parts of
the body.
CRANIAL CT SCAN (PLAIN STUDY)

Impression:

• Focal subacute infarct in the right fronto-parietal paraventicu;ar with

matter region
• Multifocal lacunar infarcts and old capsulo-ganglionic and left fontal
periventicular white matter regions right lentiform nucleus an in both
centrum semi-ovale
• Small old infarct in the left side of the pons
• Minimal inflammatory disease in both sides of ethmoid air cells

ELECTROGRAPHIC REPORT

Interpretation:

• Sinus rhythym/non-specific ST-T wave changes in leads III and AVF,

otherwise, WNL's
DRUG STUDY
• Drug No. 1

Generic name: Polynerv

Brand name: Vitamins B complex
Classification: Vitamins and minerals

Action: Vitamins B1, B6 and B12 (Polynerv) oral drops is valuable in conditions
where the requirements for B vitamins are increased as in growth,
physiologic stress, decreased resistance to infection and chronic illnesses,
metabolic disorders and in certain diseases of the digestive tract and
nervous system. It can also be given before and after surgical procedures.
Vitamins B1, B6 and B12 (Polynerv) oral drops is indicated for the
prevention and treatment of deficiency disorders arising from poor dietary
intake, impaired B vitamin absorption as in prolonged diarrhea, excessive
vomiting and antibiotic therapy, intake of drugs which interfere with the
utilization of the B vitamins (i.e. isoniazid). As a nutritional supplement to
promote appetite, weight gain and height increase
Dose: 500 mg 1 tab
Route: oral
Frequency: OD
Indication:Treatment of vit B deficiencies. Nutritional support in painful
neurological manifestations of neuritis & neuropathy eg cervical & shoulder-
arm syndrome, lumbago, ischialgia & sciatica. Neuropathies caused by
disease states eg diabetes, RA, TB, leprosy & cardiac disorders. Alcoholic
neuropathy due to INH or phenothiazine intoxication. Pregnancy,
hyperemesis gravidarium

Contraindicated: Vitamin B complex should not be used in hypersensitivity to

any of the vitamins, containing in the preparation, as well as in patients with
2-nd or 3-rd degree arterial hypertension

Adverse effect: Anaphylaxis,Pain,GI discomfort

Nursing consideration:
• Determine reticulocyte count, hct, Vit. B12, iron, folate levels before
beginning therapy.
• Obtain a sensitivity test history before administration
• Avoid I.V. Administration bec. faster systemic elimination will reduce
effectiveness of vitamin.
• May be taken with or without food (May be taken w/ meals to reduce GI
discomfort.).
Drug No. 2

Generic name: Aspirin

Brand name: Bayprin
Classification: Anticoagulants,antiplatelets,fibrinolytics (throbolytics)

Action: inhibits platelet aggregation by blocking thromboxane A2 synthesis in

platelets

Dose: 100 mg 1 tab

Route: oral
Frequency: OD

Indication: For prophylaxis of thromboembolic disorders, MI, transient ischemic

attacks & stroke. For patients w/ stable & unstable angina pectoris.

Contraindication:
Active peptic ulcer, hemorrhagic diathesis, history of asthma & last trimester of
pregnancy. Lactation.
Adverse effect:
GI: dyspepsia, heartburn,anorexia, nausea, epigastric discomfort, potentiation
of peptic ulcer
Allergic:Broncho spasm, asthma-like symptoms, anaphylaxis, skin rashes
urticaria
Hematologic: prolongation of bleeding time, thrombocytopenia, leucopenia,
Other: Thirst, fever, dimness of vision

Nursing Consideration:
• Should be taken with food
• Assess for pain:type, location and pattern
• Determine history of peptic ulcers or bleeding tendencies
• Note for asthma
• Monitor renal,LFTs and CBC
• Do not use in children with chicken pox or flu symptoms
•
• Drug No.3

Generic name: Telmisartan

Brand name: Micardis
Classification: Antihypertensive drug

Action: Blocks vasoconstriction and aldosterone secreting effects of

angiotensin II by selectively blocking the binding of angiotensin II to
angiotensin I receptor to many tissue

Dose: 40mg 1 tab

Route: oral
Frequency: OD

Indication: hypertension and cardiovascular risk reduction

Contraindication: pregnancy and lactation, billary obstructive disorders,

severe hepatic impairment

Adverse Effect: headache, upper respiratory tract infection, dizziness and

fatigue, diarrhea, sinusitis, back pain
Nursing Consideration:
• Instruct the patient that drug may be taken with or without food
• Monitor patient for hypotention after starting drug
• Tell the patient if he feel dizzy or has low blood pressure on standing he
should lie down and rise slowly from a lying to standing position

Drug No. 4

Generic name: Captopril

Brand name: Capoten
Classification: Antihypertensive and ACE inhibitor

Action: Block ACE fron converting angiotensin I to angiotansin II

a powerful vasoconstrictor leading to decreased blood pressure, decrease
secretion of aldosterone , a small increase in serum potassium level and
sodium and fluid loss, increase prostaglandin synthesis also may be
involved in the antihypertensive action.

Dose: 25 mg 1 tab
Route : oral SL
Frequency: every 6 hours PRN for BP 160/100 mmHg
Contraindication: with allergy to captopril, history of angioedema,pregnancy
ang lactation,renal impairment

Adverse effect: Tachycardia, rash, pruritus, astric irritation, pepetic ulcers,

dysuria,protenuria and cough

Nursing consideration:
• Monitor the patients blood pressure and pulse rate frequently
• Instruct to take this medication 1 hour before meals food in the GI tract may
reduce absorption
• Be aware that elderly patients may be more sensitive to the drugs
hypotensive effects
• Tell the patient to use caution in hot weather during exercise
• Advice to report any sign of infection such as fever and sore throat
• Drug No.5

Generic name: Citicholine

Brand name: citilin
Classification: Nootropics and neurotonics

Action: Citicoline is a complex organic molecule that functions as an

intermediate in the biosynthesis of cell membrane phospholipids. It is also
known as CDP-choline or cytidine diphosphate choline (cytidine 5'-
diphosphocholine). CDP-choline belongs to the group of biomolecules in
living systems known as nucleotides that play important roles in cellular
metabolism.

Dose: 2 gms IV then 1 gm

Route:
Frequency: every 6 hours
Indication:Cerebrovascular disorders including ischemic stroke, parkinsonism
& head injury
Contraindication: Parasympathetic hypertonia.
Adverse effect:Stomach pain,diarrhea; hypotension,tachycardia,
bradycardia.
Nursing consideration:
• Somazine must not be administered along with medicaments containing
meclophenoxate
 PROBLEM LIST
The problem list serve as valuable tool in patient care management. The
problem list complies the all past and current patient problem including social,
psychological and medical problems onto the document. At a glance, providers can
determine which problems are active or resolved, and formulate treatment plans
accordingly. Additionally, the problem list serves as communication tool and aids in
the evaluation and treatment decision.

NCP NURSING DATE DATE

NO. DIAGNOSIS IDENTIFIED EVALUATED
1 Ineffective tissue November November
perfusion related to 30,2010 30,2010
interruption of blood
flow
2 Impaired physical November November
mobility related to left 30,2010 30,2010
sided body weakness
3 Self care November November
deficit:bathing, 30,2010 30,2010
dressing,feeding
related to loss of
muscle control
NURSING CARE PLAN # 1
Name: Patient A Date identified: 11/30/10
Chief complain: Left sided weakness with Date evaluated: 11/30/10
Elevated blood pressure

Assessment:
Subjective cues: “binhod ug dili nako malihuk akong wala nga lawas”

Objective Cues:

• restlessness
• weak extremities
• dizziness
• need assistance
• low pitch voice
• altered level of consciousness
• Blood pressure of 160/110 mmHg

Diagnosis: Ineffective tissue perfusion related to interruption of blood flow

Planning: Within 4 hours of nursing intervention the patient will be able to verbalize
understanding of condition, therapy regimen,and side effect of medications
Intervention:

Independent:
• Determine factors related to individual situation/ cause for decrease cerebral
perfusion
Rationale: for appropriate nursing intervention that are applicable to the
patients condition

• Monitor vital signs every 2 hours

Rationale: variations may occur because of cerebral pressure/injury in
vasomotor area of the brain. Hypertension may have been a precipitating
factors.

• Evaluate pupils,noting size, shape and equity

Rationale:To gather baseline data and monitor any further complications/
deviations from normal

• Document changes in vision (eg. Reports of blurred vision)

Rationale: Specific visual alterations reflect area of brain involved, indicate
safety concerns and influence choice of intervention
• Elevation head of bed (15 degrees) and maintain head or neck in
midline
Rationale:to promote circulation and venous drainage and to maintain a
patent airway.

• Provide quite and restful atmosphere

Rationale: for conservation of energy and lowers oxygen demand

• Reposition patient every 2 hours

Rationale: to promote circulation and oxygen distribution

• Provide support on affected body part such as pillow and assistance to do

activity of daily living's as needed
Rationale: to maintain position of function and reduce discomfort

• Encourage the patient and significant others to avoid sedentary lifestyle

such as smoking,drinking liquor,improper exercise and to much fatty foods
Rationale: these factors may affect them in developing various diseases as
what like the patient is suffering

Dependent:

• Administer oxygen inhalation by nasal cannula 3L/min

Rationale: reduce hypoxemia, which can cause cerebral vasodilation and
increase pressure/edema formation
• Administer medication: citicholine (citilin) 2 gms Iv theb 1 gm every 6
hours
Rationale:It restores the activity and functions of the brain. It improves
neuromuscular function.

• Administer antihypertensive medication: captopril 25 mg 1 tab sl every 6

hours PRN for BP 160/100 mmHg
Rationale:Blocks ACE from converting angiotensin I to angiotensin II, a
powerful vasoconstrictor, leading to decreased blood pressure,
decreased aldosterone secretion, a small increase in serum potassium
levels, and sodium and fluid loss; increased prostaglandin synthesis also
may be involved in the antihypertensive action.

• Evaluation:

After 4 hours of nursing intervention the patient was able to

verbalized understanding of condition, therapy regimen,and side effect of
medications
• NURSING CARE PLAN # 2

Name: Patient A Date identified: 11/30/10

Chief complain: Left sided weakness with Date evaluated: 11/30/10
Elevated blood pressure

Assessment:
Subjective cues: “walay kusog akong wala nga lawas”

Objective cues:

• slow movement
• need assistance
• drowsy eyes
• limited range of motion
• postural instability
• degree of mobility of 2

Diagnosis: Impaired physical mobility related to decrease muscle strength

Planning: Within 4 hours of nursing intervention the patient will be able to

verbalize understanding of the situation and individual treatment regimen and
safety measures
• Intervention:

• Independent:

• Determine diagnosis that contributes to immobility

Rationale:for appropriate nursing intervention that are applicable to the
patients condition

• Assess functional ability/extent of impairment initially and on a basis.

Classify according to 0-4 scale.
Rationale: identifies strengths/deficiencies and may provide information
regarding recovery.

• Note emotional/behavioral responses to imobility

Rationale: feelings of frustration,powerlessness may impade attainment
goal

• Change position at least every 2 hours (supine,sidelying)and possibly more

often if placed on affected side.
Rationale: Reduces risk of tissue ischemia/injury. Affected side has poorer
circulation and reduced sensation and is more predisposed to skin
breakdown/decubitus.
• Begin active/passive range of motion to all extremities
Rationale: Minimizes muscle atrophy, promotes circulation helps to prevent
contructures.

• Provide support on affected body parts such as pillow

Rationale: To maintain position of function and reduce risk of pressure ulcer

• Inspect skin, particularly over bony promimemces regularly. Gently massage

any reddened areas as necessary
Rationale: pressure points over bony prominences are most ta risk for
decreased perfusion/ischemia. Circulation stimulation helps prevent skin
breakdown and decubitus development

• Schedule activities with adequate rest periods during the day

Rationale: to reduce fatigue

• Encourage participation in self-care activities

Rationale: Enhances self-concept and sense of independence

• Identify energy-conserving techniques for ADLs

Rationale: limits fatigue, maximizing participation
• Provide safety precautions by raising up the side rails
Rationale: to prevent fall and injury

• Encourage client's/SO's involvement in decision making as much as possible

Rationale: Enhances committed to plan, optimizing outcomes

Evaluation:

After 4 hours of nursing intervention the patient was able to verbalized

understanding of the situation and individual treatment regimen and safety
measures
• NURSING CARE PLAN # 3

Name: Patient A Date identified: 11/30/10

• Chief complain: Left sided weakness with Date evaluated: 11/30/10
Elevated blood pressure

Assessment:

Subjective cues: “dili ko kabuhat sa akong mga bulahaton tungod kay

dili nako malihok akong wala nga lawas”

Objective cues:

• inability to wash body parts

• inability to bring food from receptacle to mouth
• impaired ability to put on/off clothing
• need assistance
• degree of mobility of 2

Diagnosis: Self care deficit:bathing, dressing,feeding related to loss of muscle

control

Planning: After 8 hours of nursing intervention the patient will be able to

demonstrate techniques/lifestyle changes to meet self-care needs
Intervention:

Independent:

• Assess abilities and level of deficit (0–4 scale) for performing adls.
Rationale: aids in anticipating/planning for meeting individual needs

• Avoid doing things for patient that patient can do for self, but provide
assistance as necessary.
Rationale:these patients may become fearful and dependent, and although
assistance is helpful in preventing frustration, it is important for patient to do
as much as possible for self to maintain self-esteem and promote recovery.

• Be aware of impulsive behavior/actions suggestive of impaired judgment.

Rationale: may indicate need for additional interventions and supervision to
promote patient safety.

• Maintain a supportive, firm attitude. allow patient sufficient time to accomplish

tasks.
Rationale:patients need empathy and to know caregivers will be consistent
in their assistance.
• Provide positive feedback for efforts and accomplishments.
Rationale: enhances sense of self-worth, promotes independence, and
encourages patient to continue endeavors.

• Promote client's/SO's participation in problem identification and desired goals

and decision making
Rationale: Enhances commitment to plan, optimizing outcomes and supporting
recovery and/or health promotion

• Position furniture against wall/out of travel path

Rationale:provides for safety when patient is able to move around the room,
reducing risk of tripping/falling over furniture.

• Plan time for listening to the client's/SO's feelings/concers

Rationale: to discover barriers to participation in regimen and to work on
problem solution

• Encourage so to allow patient to do as much as possible for self.

Rationale: reestablishes sense of independence and fosters self-worth and
enhances rehabilitation process
• Eliminate extraneous noise/stimuli as necessary
Rationale: it helps to reduce anxiety

Evaluation:
After 8 hours of nursing intervention the patient was able to
demonstrated techniques/lifestyle changes to meet self-care needs
DISCHARGE PLAN
• DISCHARGE PLAN

- Received patient lying in bed,awake responsive and coherent upon interaction

With initial vital signs taken and recorded as follows:
T- 36.7 degree Celsius BP- 140/90 mmHg
P- 81 bpm O2 sat- 98%
R- 19 bpm

M- Instructed to continue the medication according to physician's prescription at the right

dose, time, frequency and route
- Encouraged to comply with the medications to prevent further complication

E- Instructed to stay in a safe, cool and well ventilated area to promote comfort

T- Instructed to follow up check-up as instructed by the physician

H- Demonstrated how to do passive range of motion

- Instructed the significant others to reposition every 2 hours to promote circulation and
to prevent skin irritation
- Demonstrated to do deep breathing exercise to promote lung expansion

- Encouraged the patient and significant others to avoid sedentary lifestyle such as
smoking,drinking liquor,improper exercise and to much fatty foods because these
factors may affect them in developing various diseases as what like the patient is
suffering
 - Instructed to perform activities of daily living as tolerated

O- Instructed to go to the nearest hospital if any unusuality occur ,

increase vital signs or any abnormalities

D- Instructed to eat foods low in fat and salt such as fish

- Instructed to increase fluid intake 8-10 glasses/day
- Instructed to eat nutritious foods especially those rich in vitamin c to boost
immune system

- Endorsed to staff nurse on duty

LEARNING OUTCOME
 We are surrounded by great challenges and obstacles in our lives but all of
the hardship will lead to an outcome of success, To be effective and efficient
nurse someday, the key to success is to try our best care for our patients.it is
indeed a great previlage to handle any cases of a patient withou expecting
anything in return but the experiences and the knowledge that will be learned
every exposure.

I was expose in the medical ward of MJ Santos Hospital. The exposure

was quit good yet challenging for me since you will truly give the best
performance you can brought to your assigned patient. Though I can say it was
a little bit hard once your going to avaoid any mistakes but at the end of the
roitation its the learning that counts a lot.

I found myself taking the path of training in rendering proper care for the
patients in terms of physical, emothinal, psychological and spiritual aspects.
During the days of rendering services to my patients it ends up as one of my
accomplishment as being a student.

I came to realize that you must have the attitude, the presence of mind
while working, also by organizing things to be done, by prioritization in every
situation ans the flexibilities in every field you are working with. Above all it is
important that we should apply all our knowledge and skills we've learned
already since there are interventions that are applicable in specific instansis on
situation.
 Sometimes I can say students cannot avoid mistakes we
commit but the important is we learened from commiting mistake, since
I have gained lessons from it, simply it helped me to mold to become a
better and more effective student nurse in the nest exposure.

All those things happened during my exposure, I would like to

say thank you to our clinical instructor for being motherly guiding us
during the exposure and for imparting all her knowledge and the
supercision she has done to us.

Above all, much more important us the interest passion and

motivation in the choosen course because, it will not be difficult to
sacrifice if we really love what we are doing.
-END-