Liceo de Cagayan University College of Nursing NCM501204 A Case Presentation of

Cerebrovascular

accident
Submitted to: Mr. Rey Solde; RN MAN Submitted by: Mellitante, Jandale Mendoza, Lucky Dawn Miranda Neil Namocatcat, Meriam Dominice Oliveros, Melvin Pearson, Almathea February 4, 2010
TABLE OF CONTENTS

P age I. Introduction .. a. Overview of the Case b. Objective of the Study.. c. Scope and Limitation

II.

Health History a. Profile of the Patient b. Family and Health History. c. History of Present Illness.....

III.

Developmental Data. Medical Management a. Medical Orders.. b. Significant Laboratory Exam c. Drugs Study. Anatomy, Physiology and Pathophysiology Nursing Assessment . (System Review Chart and Nursing Assessment II)

IV.

V. VI.

VII. Nursing Management.. a. Ideal Nursing Management (NCP) .

b. Actual Nursing Management (SOAPIE) . VIII. Evaluation . IX. X. XI. Referrals and Follow-up ... . Bibliography .. Documentation. ....

I. Introduction: a. Overview of the Case

A stroke (sometimes called an acute Cerebrovascular attack) is the rapidly developing loss of brain function(s) due to disturbance in the blood supply to the brain. This can be due to ischemia (lack of glucose and oxygen supply caused by thrombosis or embolism or due to a hemorrhage. As a result, the affected area of the brain is unable to function, leading to inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or inability to see one side of the visual field. A stroke is a medical emergency and can cause permanent neurological damage, complications, and death. It is the leading cause of adult

disability in the United States and Europe. It is the number two cause of death worldwide and may soon become the leading cause of death worldwide. Risk factors for stroke include advanced age, hypertension (high blood pressure), previous stroke or transient ischemic attack (TIA), diabetes, high cholesterol, cigarette smoking and atrial fibrillation.[4] High blood pressure is the most important modifiable risk factor of stroke. The traditional definition of stroke, devised by the World Health Organization in the 1970s,] is a "neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours". This definition was supposed to reflect the reversibility of tissue damage and was devised for the purpose, with the time frame of 24 hours being chosen arbitrarily. The 24-hour limit divides stroke from transient ischemic attack, which is a related syndrome of stroke symptoms that resolve completely within 24 hours. With the availability of treatments that, when given early, can reduce stroke severity, many now prefer alternative concepts, such as brain attack and acute ischemic Cerebrovascular syndrome (modeled after heart attack and acute coronary syndrome respectively), that reflect the urgency of stroke symptoms and the need to act swiftly.[6] A stroke is occasionally treated with thrombolysis ("clot buster"), but usually with supportive care (speech and language therapy, physiotherapy and occupational therapy) in a "stroke unit" and secondary prevention with antiplatelet drugs (aspirin and often dipyridamole), blood pressure control, statins, and in selected patients with carotid endarterectomy and anticoagulation. Ischemic stroke

In an ischemic stroke, blood supply to part of the brain is decreased, leading to dysfunction of the brain tissue in that area. There are four reasons why this might happen: 1. Thrombosis (obstruction of a blood vessel by a blood clot forming locally) 2. Embolism (obstruction due to an embolus from elsewhere in the body, see below), 3. Systemic hypoperfusion (general decrease in blood supply, e.g. in shock) 4. Venous thrombosis.

Stroke without an obvious explanation is termed "cryptogenic" (of unknown origin); this constitutes 30-40% of all ischemic strokes. There are various classification systems for acute ischemic stroke. The Oxford Community Stroke Project classification (OCSP, also known as the Bamford or Oxford classification) relies primarily on the initial symptoms; based on the extent of the symptoms, the stroke episode is classified as total anterior circulation infarct (TACI), partial anterior circulation infarct (PACI), lacunar infarct (LACI) or posterior circulation infarct (POCI). These four entities predict the extent of the stroke, the area of the brain affected, the underlying cause, and the prognosis.[11][12]

The TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification is based on clinical symptoms as well as results of further investigations; on this basis, a stroke is classified as being due to (1) thrombosis or embolism due to atherosclerosis of a large artery, (2) embolism of cardiac origin, (3) occlusion of a small blood vessel, (4) other determined cause, (5) undetermined cause (two possible causes, no cause identified, or incomplete investigation). b. Objective of the Study

After 1 hour of Presentation of the case (Cerebrovascular Accident), we, students and audience, will be able to: 1. Acquire knowledge about the disease process. 2. Discuss thoroughly the disease process. 3. Formulate realistic and appropriate nursing care plans. 4. Identify and learn more about the treatment and modalities of the said disease 5. Apply the nursing process and appreciate its significance in nursing practice.

c. Scope and Limitation This study covers about facts related to patients condition. It includes the nature, causes, signs and symptoms, Pathophysiology, prognosis, treatment and the nursing interventions appropriate for his condition. A nursing care plan is also provided which serves as a guide for the interventions to be applied to the patient to aid in recovery and it will also serve as basis for the evaluation of client care outcomes. Health

teachings including referrals were also imparted to the patient and the watcher to ensure his recovery during hospital stay and after discharge. It is limited only to the case of our client. For the completion of this study, some information was taken from significant others. The assessment and so with the interventions rendered to the patient were also limited due to time constraint, with a total of 2 days, dated December 9 and 10 of 2009. Thus, weve supplemented our study with facts from various references.

II. Health History a. Patients Profile Name: Address: Sex: Age: Birth date: Place of Birth: Educational Attainment: Occupation: Height: Weight: Civil status: Married Male 59 years old April 20, 1951 Cebu City College Graduate Pensioner 54 inches tall 84 kg S.R. Elzalvador, Misamis Oriental

Name of Spouse: Income: received from pension (5,000

N.S. Base only on every month pesos

Citizenship: Religion: Date of Admission: Time of Admission: Chief Complaints: hitting his

Filipino Roman Catholic December 07, 2009 7:54 pm Dizziness and Headache, later fall down forehead and loss of

consciousness Admitting Diagnosis: Attending Physician: Cerebrovascular Accident Dr. Surdilla

III. Health History A. History of Present Illness This is the case of R.S; who was admitted in Cagayan de Oro Medical Center at their Intensive Care Unit area last December. She was already known for being hypertensive for almost 20 years from this present day. She was maintaining anti hypertensive drugs like vascor and Metropolol. One day prior to admission he was apparently well and went to the city at late in the afternoon to buy some herbal medicines from certain company called DXN where his friends advise him to buy which

they believe that it can treat hypertension and other diseases. When he was bout to leave the building suddenly he felt dizzy and headache, inspite of what he felt he still try to wall in the hall way until he reached the outside the building. Until he suddenly felt more dizzy and fell down on the ground. He was brought to the hospital by the people who had seen the accident and they call one of his friends when they try to look some information from his wallet. His friend was the one whos with him when he was at the emergency area. Upon her arrival at the hospital at the emergency department he was cater under the care of Dr. Surdilla. They just found out after checking his vital signs and signs and symptoms that he just had a stroke (Cerebrovascular accident).

B. Family History and Health History Upon assessment, client and the significant others h he was 20 years old and used to consume about 1pack of cigarette stick in a day. He was also heavy drinker of alcohol in which he can consume about 1 case of jumbo red horse in every week. He was admitted last June, 2008 at one hospital in the city and diagnose with hypertension. Since then he was already maintaining anti hypertension drugs as mentioned earlier. On the first month he was cooperative and used to take the medication seriously but on the later months when he felt that he dont have the symptoms of hypertension he had an on and off taking compliance of medication. And occasionally continue smoking and still drinks alcohol until the present day.

III. Developmental Data Developmental theories of learning have to do with the additional learning tasks individuals can accomplish as they mature mentally, emotionally, and physically. Although this maturation actually progresses in slow, continuous fashion, it is often described as proceeding in stages. Many names are associated with developmental research. The following people and their stages of development are important in the field of development theory FREUDS PSYCHOSEXUAL THEORY Genital Stage: 13 yrs and above Freuds advanced a theory of personality development that centered on the effects of the sexual pleasure drive on the individual psyche. At particular points in the developmental process, he claimed, a single body part is particularly sensitive to sexual, erotic stimulation. Based on Sigmund Freuds Psychosexual Stages of development our client belongs to the genital Stage. Characteristics of this stage are that energy of a person is directed toward full sexual maturity and function and development of skills needed to cope with environment as well as its demands. The patient is able to achieve independence and able to practice decision-making. But this condition the patient needs support from family in activities of daily living as well as decision making to his present condition.

ERIKSONS THEORY OF PSYCHOSOCIAL DEVELOPMENT THEORY ROBERT J. HAVIGHURSTS DEVELOPMENTAL THEORY

PIAGETS COGNITIVE DEVELOPMENT THEORY Formal Operations Phase: 11- 15 and above In this developmental theory, our patient belongs to FORMALOPERATIONAL wherein logical reasoning processes are applied to abstract ideas as well as concrete objects. This is the time when people are most capable of forming new concepts and shifting their thinking in order to solve problems and general concepts are related to specific situations and alternatives are considered.

IV. Medical Management: A.Doctors Order: B.Significant Laboratory exam :

CT scans (without contrast enhancements) Sensitivity= 16% Specificity= 96%

MRI scan Sensitivity= 83% Specificity= 98%

C. Drug Study:
Name of Drug: Date Ordered: Citicoline 100mg TID Dec.07, 2009

Classification: stimulants /Neurotonics)

Mechanism of Action:

Central

Nervous

System

Drugs

(CNS

increase dopamine receptor densities, and suggest that CDP-choline supplementation can ameliorate memory impairment caused by environmental conditions.

Specific Indication: symptoms and signs of

CVA in acute and recovery phase.w/

cerebral insuffiency; dizziness, headache and recent crania trauma. Contraindication: hypertonia of the Hypersensitivity; Contraindicated in

parasympathetic meclofenoxate (clophexonate). Side Effects/Toxic Effects: It stimulates parasympathetic action and

fleeting and discreet hypotensor effect. Nursing Precaution: dosage, take vital signs Before Giving the medication can cause sudden drop of vital signs. Use cautiously in patients& observe proper

Name of Drug: Date Ordered: Classification: Mechanism of Action:

Metropolol 25mg q8h Dec. 07, 2009 antihypertensive, anti- anginas Bocks stimulation of beta adrenergic receptor; doest not usually affect beta2- adrenergic receptor sites.

Specific Indication: decreased mortality in

Hypertension,

prevention

of

M.I.

and

patients with recent M.I. management of stable angina, Symptomatic heart failure due to ischemic hypertensive or cardiomyopathic origin Contraindication: Side Effects/Toxic Effects: nervousness, erectile Dysfunction, hyperglycemia, back pain, dry mouth Hypersensitivity Dizziness, fatigue, anxiety, drowsiness,

Nursing Precaution:

. Monitor for possible drug induced adverse reactions

Name of Drug: Date Ordered:

Captopril 80mg q8h Dec 07, 2009

Classification: inhibitors
Mechanism of Action:

Angiotensin-

converting

enzyme

ace

It blocks the conversion of angiotensin1 to the vasoconstrictor prostaglandins. angiotensin2. It also prevents degradation of bradykinin and other vasodilatory

Specific Indication: management of hypertension. Contraindication: previous use of ace

alone

or

with

other

agents

in

the

hypersensitivity; history of angioedema with

Inhibitors Side Effects/Toxic Effects: dizziness, drowsiness, fatigue, headache,

weakness, cough, dyspnea Nursing Precaution: Monitor for possible drug induced adverse reactions

Name of Drug:

Valsartan 20mg BID

Date Ordered:

Dec. 07, 2009

Classification: Antihypertensives
Mechanism of Action:

Angiotensin

receptor

antagonist;

blocks vasoconstrictor and aldosterone producing effects of angiotensin 2 at receptor sites including vascular smooth muscles and adrenal glands.

Specific Indication: of hypertension Contraindication:

alone or with other agent in the management

Hypersensitivity Headache, dizziness, anxiety, depression,

Side Effects/Toxic Effects: fatigue, weakness Nursing Precaution: oliguria, acute renal

use cautiously in CHF patients may result

Failure.

Name of Drug: Date Ordered:

tranexamic acid / Hemostan 800 mg q6h Dec.07, 2009

Classification:
Mechanism of Action:

cardiovascular drugs/ hemostatics

Tranexamic acid plasminogen plasmin. concentrations, a is a competitive and at inhibitor inhibitor of of activation, much higher

noncompetitive

Specific Indication:

control of hemorrhage in surgical and clinical cases, hemostatics for traumatic injuries.

Contraindication:

severe renal insufficiency, patients with microscopic hematuria

Side Effects/Toxic Effects:

GI disturbances, giddiness, hypotension, color

vision disturbances. Nursing Precaution: thromboembolic disease. Use with caution in patients with

Name of Drug: Date Ordered:

Mannitol 100cc q4h Dec.09, 2009

Classification:
Mechanism of Action: glumerular filtrate, thereby

Diuretics
increase the osmotic pressure of the

inhibiting Reabsorption of water and electrolytes cause of excretion of water, sodium, potassium, sodium chloride calcium, Uric acid, urea, magnesium Specific Indication: failure, edema, increase Intracranial or intraocular pressure, toxic overdose Contraindication: Hypersensitivity; anuria dehydration transient volume expansion, confusion, adjunct treatment of acute oliguric renal

Side Effects/Toxic Effects:

pulmonary edema, urinary retention, nausea and vomiting, thirst

Nursing Precaution:

Used

cautiously

to

patient

with

drug

drug

interactions increase the risk of digoxin toxicity.

VII. Anatomy and Physiology, Pathophysiology The nervous system is an organ system containing a network of specialized cells called neurons that coordinate the actions of an animal and transmit signals between different parts of its body. In most animals the nervous system consists of two parts, central and peripheral. The

central nervous system contains the brain and spinal cord. The peripheral nervous system consists of sensory neurons, clusters of neurons called ganglia, and nerves connecting them to each other and to the central nervous system. These regions are all interconnected by means of complex neural pathways. The enteric nervous system, a subsystem of the peripheral nervous system, has the capacity, even when severed from the rest of the nervous system through its primary connection by the vagus nerve, to function independently in controlling the gastrointestinal system. Neurons send signals to other cells as electrochemical waves travelling along thin fibres called axons, which cause chemicals called neurotransmitters to be released at junctions called synapses. A cell that receives a synaptic signal may be excited, inhibited, or otherwise modulated. Sensory neurons are activated by physical stimuli impinging on them, and send signals that inform the central nervous system of the state of the body and the external environment. Motor neurons, situated either in the central nervous system or in peripheral ganglia, connect the nervous system to muscles or other effector organs. Central neurons, which in vertebrates greatly outnumber the other types, make all of their input and output connections with other neurons. The interactions of all these types of neurons form neural circuits that generate an organism's perception of the world and determine its behavior. Along with neurons, the nervous system contains other specialized cells called glial cells (or simply glia), which provide structural and metabolic support. Nervous systems are found in most multicellular animals, but vary greatly in complexity.[1] Sponges have no nervous system, although they have homologs of many genes that play crucial roles in nervous system function, and are capable of several whole-body responses, including a

primitive form of locomotion. Placozoans and mesozoansother simple animals that are not classified as part of the subkingdom Eumetazoa also have no nervous system. In Radiata (radially symmetric animals such as jellyfish) the nervous system consists of a simple nerve net. Bilateria, which include the great majority of vertebrates and invertebrates, all have a nervous system containing a brain, spinal cord, and peripheral nerves.

Structure The nervous system derives its name from nerves, which are cylindrical bundles of tissue that emanate from the brain and spinal cord and branch repeatedly to innervate every part of the body. Nerves are large

enough to have been recognized by the ancient Egyptians, Greeks, and Romans, but their internal structure was not understood until it became possible to examine them using a microscope. A microscopic examination shows that nerves consist primarily of the axons of neurons, along with a variety of membranes that wrap around them and segregate them into fascicles. The neurons that give rise to nerves do not lie within themtheir cell bodies reside within the brain, spinal cord, or peripheral ganglia. All animals more advanced than sponges have a nervous system. However, even sponges, unicellular animals, and non-animals such as slime molds have cell-to-cell signalling mechanisms that are precursors to those of neurons. In radially symmetric animals such as the jellyfish and hydra, the nervous system consists of a diffuse network of isolated cells. In bilaterian animals, which make up the great majority of existing species, the nervous system has a common structure that originated early in the Cambrian period, over 500 million years ago. Cells The nervous system is primarily made up of two categories of cells: neurons and glial cells

Neurons
The nervous system is defined by the presence of a special type of cell, the neuron (sometimes called "neurone" or "nerve cell"). Neurons can be distinguished from other cells in a number of ways, but their most fundamental property is that they communicate with other cells via synapses, which are membrane-to-membrane junctions containing molecular machinery that allows rapid transmission of signals, either electrical or chemical. Many types of neuron possess an axon, a

protoplasmic protrusion that can extend to distant parts of the body and make thousands of synaptic contacts. Axons frequently travel through the body in bundles called nerves. Even in the nervous system of a single species such as humans, hundreds of different types of neurons exist, with a wide variety of morphologies and functions.These include sensory neurons that transmute physical stimuli such as light and sound into neural signals, and motor neurons that transmute neural signals into activation of mucles or glands; however in many species the great majority of neurons receive all of their input from other neurons and send their output to other neurons. Glial cells Glial cells are non-neuronal cells that provide support and nutrition, maintain homeostasis, form myelin, and participate in signal transmission in the nervous system.In the human brain, it is estimated that the total number of glia roughly equals the number of neurons, although the proportions vary in different brain areas.Among the most important functions of glial cells are to support neurons and hold them in place; to supply nutrients to neurons; to insulate neurons electrically; to destroy pathogens and remove dead neurons; and to provide guidance cues directing the axons of neurons to their targets.One very important type of glial cell generates layers of a fatty substance called myelin that wraps around axons and provides electrical insulation which allows them to transmit action potentials much more rapidly and efficiently. The central nervous system (CNS) is the largest part, and includes the brain and spinal cord. The spinal cavity contains the spinal cord, while the head contains the brain. The CNS is enclosed and protected by

meninges, a three-layered system of membranes, including a tough, leathery outer layer called the dura mater. The brain is also protected by the skull, and the spinal cord by the vertebrae. The peripheral nervous system (PNS) is a collective term for the nervous system structures that do not lie within the CNS.The large majority of the axon bundles called nerves are considered to belong to the PNS, even when the cell bodies of the neurons to which they belong reside within the brain or spinal cord. The PNS is divided into somatic and visceral parts. The somatic part consists of the nerves that innervate the skin, joints, and muscles. The cell bodies of somatic sensory neurons lie in dorsal root ganglia of the spinal cord. The visceral part, also known as the autonomic nervous system, contains neurons that innervate the internal organs, blood vessels, and glands. The autonomic nervous system itself consists of two parts: the sympathetic nervous system and the parasympathetic nervous system. Some authors also include sensory neurons whose cell bodies lie in the periphery (for senses such as hearing) as part of the PNS; others, however, omit them.

Horizontal bisection of the head of an adult man, showing skin, skull, and brain with grey matter (brown in this image) and underlying white matter

The vertebrate nervous system can also be divided into areas called grey matter ("gray matter" in American spelling) and white matter.[14] Grey matter (which is only grey in preserved tissue, and is better described as pink or light brown in living tissue) contains a high proportion of cell bodies of neurons. White matter is composed mainly of myelinated axons, and takes its color from the myelin. White matter includes all of the peripheral nerves, and much of the interior of the brain and spinal cord. Grey matter is found in clusters of neurons in the brain and spinal cord, and in cortical layers that line their surfaces. There is an anatomical convention that a cluster of neurons in the brain or spinal cord is called a nucleus, whereas a cluster of neurons in the periphery is called a ganglion There are, however, a few exceptions to this rule, notably including the part of the forebrain called the basal ganglia.

Pathophysiology

NURSING ASSESSMENT
Nursing System Review Chart: Name: S.R. Age: 59 Sex: MaleBP: 130 /80 mmHg Status: Married Temp: 36.5C Height: 54 Pulse Rate: 80 bpm Resp. Rate: 16 cpm Weight: 72 kg
[x] Impaired vision [ ] blind With [ ] pain redden [ ] drainage nasogastric [ ] gums [ ] hard of hearing [ ] deaf tubing at the [ ] burning [ ] edema [ ] lesion teeth Assess eyes ears nose [ ] throat for abnormality [ ] no problem RESP: [ ] asymmetric [ ] tachypnea [ ] barrel chest paralysis at the lower [ ] apnea [ ] rales [ ] cough right [x] Bradypnea [ ] shallow [ ] rhonchi [ ] sputum [ ] diminished [ ] dyspnea extremeties [ ] orthopnea [ ] labored [ ] wheezing [ ] pain [ ] cyanotic Assess Resp. rate, rhythm, pulse blood [ ] breath sounds, comfort [ ] no problem CARDIOVASCULAR: [ ] arrhythmia [ ] tachycardia [ ] numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] mur mur [ ] tingling [ ] absent pulses [x] pain Assess heart sounds, rate rhythm, pulse, blood Pressure, circ., fluid retention, comfort [ ] No problem GASTROINTESTINAL TRACT: [ ] obese [ ] distention [ ] mass [x] Dysphagia [ ] rigidity [ ] pain Assess abdomen, bowel habits, swallowing Bowel sounds, comfort [ ] no problem GENITO URINARY AND GYNE [ ] pain [ ] urine [ ] color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia [ ] gyne bleeding [ ] discharge [x] no problem Assess urine frequency, control, color, odor, comfort NEURO:

head injury due to fall

Oxygen supply Via nasal cannula altered swallowin g Dry mouth

Catherizati on site (uro bag attached at the bed

IV. Nursing Assessment SUBJECTIVE COMMUNICATION: [ ] hearing loss [ ] visual changes [ x] denied

[x] Paralysis [x] stuporus [ ] unsteady [ ] seizure [ ] lethargic [ ] assess motor, function, sensation, LOC, strength [ ] grip, gait, coordination, (x) speech [ ] no problem MUSCULOSKELETAL and SKIN: Untrimm [ ] appliance [ ] stiffness [ ] itching [ ] petechie ed finger [ ] hot [ ] drainage [ ] prosthesis [ ] swelling nails [ ] lesion [ ] poor turgor [ ] cool [ ] flushed [ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic Assess(x) mobility, motion gait, alignment, joint function Skin color, texture, turgor, integrity [ ] no problem

Generalize d body weakness IV inserti on site

OBJECTIVE [ ] languages

Pulse oxymet er

Comments: the [ ] glasses patient speech to the was [ ] contact lenses was of pupil L:3mm R:4mm

[ ] hearing aide

stuporous and his Pupil size: anisocoria /Unequal size affected also due disease condition. but the patient was able to alternative communication in communicating us like nodding and language. sign Resp. [] regular ( respiration [ ] irregular are both used

present [x ] speech difficulties Reaction: sluggish reaction

OXYGENATION: [ ] dyspnea [x] history [ ] cough [ ]sputum smoking patients daughter that his

Comments: the Describe:

symmetrical in left and right area states R: 16 cpm symmetrical father L: 16 cpm symmetrical

was a smoker.

[ ] denied CIRCULATION: [ x] chest pain [ ] leg pain [ ] numbness of extremities [ ] denied

Heart Rhythm Comments: The irregular patient shows a Ankle Edema nod when he was Pulse ask pain. if he And was R _ he L +_ + experiencing pointed his chest. Car +

[ ] regular none seen Rad. 80bpm 80bpm DP

[/ ]

Fem* +___ + +___

Comments: The pulse are palpable and is irregularly fast NUTRITION: Low salt diet []N[]V Character [ ]recent change in weight and appetite [ x] swallowing Difficulty [ ] denied Note: presence of Lower nasogastric tube Note: impaired function of swallowing of the cranial nerve affected. the [] patient [] have no Comments: None >the patient was unresponsive Upper [] [] Full Partial [ ]dentures [x]none

for feeding due to presence of dentures

ELIMINATION: Usual bowel pattern Once a day [ ] constipation remedy NONE Date of last BM Dec. 7, 2008 [ ] diarrhea character [ ] urgency [ ] dysuria [ ] hematuria [ ] incontinence [ ] Polyuria [ x] foley in place [ ] denied

None Note: the

Bowel sound: normoactive patient bowel sound. Abdominal Distention Present [] yes [ ] no Urine* (color, consistency, odor) Urine color is dark yellow with aromatic odor. the patients

was unresponsive

MGT. OF HEALTH & ILLNESS: [] alcohol [ ] denied (amount & frequency) known limits [ ] SBE Last Pap Smear: LMP: N/A Skin Integrity [x ] dry [ ] itching [ ] denied [ ]moist Comments: patients the

Briefly

describe

ability to follow treatments (diet, meds, etc.) for chronic health The patient was very cooperative N/A during the treatment.

The patient is a heavy drinker with no problems (if present):

[x] dry [ ] moist

[ ] cold [ ] warm [ ] cyanotic

[ ] pale

skin [ ] flushed

shows dryness.

Rashes,ulcers,decubitus size, location,drainage)

(describe

>the patients skin is dry and it has no rashes, and ulcers that can be Activity Safety [ ] convulsion Comments: found [ ]LOC and orientation:

The patient was The patient was having an altered

[ ]dizziness of joints Limitation in ability to [x ] ambulate [ x]bathe self [ ] denied

experiencing

speech due to the accident and he [ ] walker [ ] cane [ ]

[x ] limited motion paralysis at lower has altered level of consciousness right extremities Gait: and have limited other range of motion >the patient has limited range of due to the motion and in Complete Bed Rest. [x] steady [ ]unsteady___________ the patient was lower extremities [x] sensory and motor losses in face or extremities: experiencing paralysis accident

] ROM limitations: the patient has limited range of motion Comfort/Sleep/Aw ake [ ] pain (location frequency remedies) [ ] nocturia [ ] sleep difficulties [x ] denied [ ] side rail release formed signed Side rails: the patient was placed in bed with side rails to prevent from falling from the bed specially that his lower right extremities are paralyze. Comments: none Note: >The patient was unresponsive [ x] facial grimaces [ ] guarding [ ] other signs of pain: patient is weak in appearance and shows no other signs of pain except for facial grimace

VII. NURSING MANAGEMENT

A. IDEAL NURSING MANAGEMENT Nursing Diagnosis Altered Cerebral Tissue Perfusion related to interruption of blood flow as evidenced by altered level of consciousness and changes of motor responses Desired Outcome The patient will be able to demonstrate behaviors, and verbalizes knowledge condition, therapy regimen. Interventions INDEPENDENT: > Monitor patients vital signs and changes in mentation. >Observe a close monitoring for any signs of sudden chest pain, respiratory distress and restlessness. >Assess visual personality, sensory / motor changes such as headaches, dizziness, and altered mental status. >Elevate the bed about 30 degrees and maintain head /neck in midline or neutral position. DEPENDENT: >Administer medications as prescribed by the attending -This is for the treatment of the present disease condition. Rationale -This is to check the patients condition and mental status for further treatment to be rendered. -This is to ensure that he patient is safe from getting worse of the condition and to be given management in early time -This is to ensure that the patients condition is monitor and to check for any progress in the status. - This is to promote circulation and venous drainage.

physician.

Nursing Diagnosis Impaired Physical Mobility related to neuromuscular involvement , weakness, limited range of motion and impaired coordination

Desired Outcome The patient will be able to verbalize and demonstrate willingness to participate activities.

Interventions INDEPENDENT: >Assess degree of immobility in relation behavioral responses. > Position the patient for optimum comfort or side turnings in every 2hours

Rationale -This is to check the patients behavioral responses and its degree of mobility for further treatment.

- This is to promote ventilation and >Monitor to prevent any circulation / nerve bed sores of the function in the patients back. affected body parts noting the -This is to know temperatures the present color, sensation condition at the and movement. affected body parts for >Place a side treatment. rails each side of the bed of the - This is to patient and protect the encourages the patient from patient to do falling from the

range of motion exercises. DEPENDENT: > Give medications as prescribed by the attending physician

bed to the floor and ROM exercise promotes blood circulation of the body. - for the treatment of the present illness

Nursing Diagnosis Impaired Verbal Communicatio n related to motor deficits and generalized weakness as evidenced by inability to speak words.

Desired Outcome The patient will be able to established method of communication in which needs can be expressed

Interventions INDEPENDENT: > Observe the degree of Impairment and Assess the style of speech that the patient shows > Establish relationship with the patient listening carefully to patients verbal / nonverbal expressions. >Anticipate needs until effective communication is reestablished

Rationale -Helps evaluate degree of the impairment of the patient and to identify its type of speech for further treatment to be given. > To have the best way in communicating the patient and have his/her cooperation and also to know the patients needs. > this is to make sure that if earlier methods

>Provide environmental stimuli as needed to maintain contact with reality or reduce stimuli to lessen anxiety DEPENDENT: >Administer medication as order by the attending physician

are not very effective make more of the best of it until it will be met. > this to reduce or lessen the patients anxiety. > This is for therapeutic treatment of the patient for the present illness that she/ he have.

B. ACTUAL NURSING MANAGEMENT

S O A P

. No subject cues the patient cant able to speak due to the head injury where speech is affected. Restless, facial grimace, chest pain Acute Pain related to Head Injury as evidence by facial grimace when head is touch specifically the forehead area Short term: At the end of 30 minutes the patient will be relieve from pain. Long term: At the end of 8 hours the patient will be shows less stressful and relieved from pain that he was experiencing. 1. Monitored the patient closely by taking vital signs

- This is to check the patients status to prevent any complication and to know if there progress of the status of the patient. 2. Provided comfort measures such as back rub - Massage and backrubs helps to relieved pain that he was experiencing 3. provided a quite and comfortable place to relieved the patient from getting irritated 4. Provide diversional activities, like encouraging expressing the feeling in other form of communication through actions to lessen the feeling of having the pain. 5. Administered medication as ordered by the attending physician - This is for the treatment of the present illness of the patient At the end of 30 minutes the patient shows gestures and facial expressions that indicates no pain.

S O A P

. No subject cues the patient cant able to speak due to the head injury where speech is affected. Respiratory difficulties, dry mouth , weakness Anxiety related to the situational crisis, change in physical and emotional condition. Short term: At the end of 30 minutes the patient will be have lesser feeling of anxiety. Long term: At the end of 8 hours the patient will be shows less stress and anxiety. 1. Monitored the patient closely by taking vital signs - This is to check the patients status to prevent any complication and to know if there progress of the status of the patient. 2. Provided comfort measures such as back rub - Massage and backrubs decreases anxiety and tension 3. provided a quite and comfortable place to prevent the patient from getting irritation 4.Given oral care/ mouth care to the patient especially that its dry - This is to prevent halitosis and make sure to prevent cracks of the lips which are very painful. 5. Administered medication as ordered by the attending physician - This is for the treatment of the present illness of the patient At the end of 30 minutes the patient shows gestures and facial expressions that reflects decrease distress. . No subject cues the patient cant able to speak due to the head injury where speech is affected. Nasogastric tubing attached in the left nostrils for feeding and

S O

A P

per orem medications Altered facial muscle function Impaired swallowing related to neuromuscular dysfunction as evidenced by traumatic head injury Short term: At the end of 72 hours the patient will be able to pass food from the mouth to the stomach instead of using feedings through Nasogastric tubing. Long term: At the end of 5 days the patient will be able to demonstrate feeding methods appropriate to the individual situation. 1. Checked the oral mucosa for any abnormalities. - this is to identify the abnormalities that can be found and basis for the care to be given 2.Positioned the bed about 30 degrees in the head part especially when giving feedings - this is to prevent aspiration 3.Turned the patient in every 2 hours in the sides and monitored neurovital signs hourly - This is to prevent bed sores and pressure ulcers and to check the neurological status of the patient 4.Applied baby powder to patients back and give back tapping - This is to maintain the patients back dry and prevent aspiration in the lungs 5. Administer medication as ordered by the attending physician To treat the present illness At the end of 5 days the patient was able to maintain adequate hydration and achieve the desired body weight and good skin turgor. . . No subject cues the patient cant able to speak due to the head injury where speech is affected. Difficulty in forming words/ verbalizes with difficulty Impaired Verbal communication patterns and motor coordination related to central nervous system alteration as evidenced by traumatic head injury Short term: at the end of 30 minutes the patient will be able to use alternative methods of communication effectively Long term: at the end of 8 hours the patient will be able to use effective communication techniques. 1. Assessed the patients condition that involves the communication status - This is to check the patients communication status to be given 2.Used simple communication ; speak in a well modulated voice that shows concern - This will encourage the client to have active participation and to

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prevent confusion 3. Encouraged to have a ROM exercises - This will promote blood circulation to the body 4. Established rapport with the patient by listening carefully through nonverbal cues - This will help you identify what the patient needs and feels 5. Administer medication as ordered - This is for the treatment of the present illness At the end of 30 minutes the patient was able to establish effective methods of communication needs can be expressed.

XI. Health Teachings MEDICATIONS Instructed complete procurement of stocks of medicine and take it on right time, dosage, route as prescribed. Emphasized the importance of following proper protocol and consideration upon taking the medicine. EXERCISE Encouraged to have range of motion exercises to promote blood circulation throughout the body. Encouraged also to have adequate balance between sleep and daily exercise to prevent

further stress that can more complicate the TREATMENT situation. Instructed to follow what has been ordered by the

doctor and stressed the importance of strict compliance of all the medications and treatment OUT-PATIENT (Check-up) prescribed by the physician. With patients critical case. He should see the

doctor regularly for check-up. Doing so will help foresee probable readmission and management. Proper compliance to every instruction given before discharge will help prevent untoward complications, and help patient live a normal life again. Eat well-balanced nutritious foods

DIET

diet

for

proper and

nutrition; leafy

like

fruits

green

vegetables (eg. pechay, Malunggay, and oranges, apple, banana, etc.) Instructed to avoid foods that are high in cholesterol, fats, and sodium. Evaluation: At the end of 3 days of hospital duty at Cagayan de Oro Medical center at their Intensive care unit area. The completion of this care study enabled the proponent to do the following: a. assessed clients profile, historical data and chief complaints; b. carried out medical orders and relate this interventions to the alleviation of the clients health; c. described the anatomy, physiology and Pathophysiology of the disease; d. identified clinical manifestations as basis for nursing care plans (NCP); e. established rapport and harmonious dealings during the whole course of the study;

f. used the nursing process as framework for client care through NCPs; g. intervened with each identified problem through action- based nursing care; h. Promoted patient self-care through health education.

Prognosis: CRITERIA A.) Onset of Illness B.) Duration of Illness C.)Precipitating Factor D.)Attitude and Willingness toward taking medication and treatment E.) Family Support / GOOD PROGNOSIS / / / POOR PROGNOSIS /

On the criteria listed above it shows only 2 out of 5 criteria falls under poor prognosis therefore the clients prognosis is good..

Referrals and Follow- up: Mr. R.S. will be referred to a doctor (internist) after discharge persistence of chief complaints reoccurs and complicates. Schedules for follow-up visits should not be over look to evaluate progress of the patients health condition after termed medical and nursing management he should have check up at the nearest hospital a week after discharge as scheduled by her physician. The physician also ordered to continue on using all the medications prescribed.

XIII. Bibliography Brunner and Suddarth Textbook of Medical-Surgical Nursing, 11th Edition by Johnson pages, 1000; 1500; 2013; 2089 Pocket Guide Nursing Diagnosis with Interventions, 3rd Edition by M. Doenges, pages,123; 423; 543; 589; 1002; 1570 Nursing 2010 Drug Handbook, 20th Anniversary Edition by Davis drug guide, pages, 23; 58; 348; 479; 996; 998 Medical Surgical Nursing, 7th Edition by Black and Hawks ,pages,1589; 5090 Manual of Nursing Practice, 7th edition, Volume 1, Lippincott, pages 899; 900

Documentation: we werent able to have any pictures with the patient due to their request that they dont want any pictures taken from them for confidentiality purposes.