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College of Nursing
A Case Study of Transient Ischemic Attack
In partial fulfillment for the requirement in Medical-Surgical Nursing I
Submitted By: ESTEVES, Christian C. BSN III-1
Submitted To: Professor Enrico P. de Jesus, RN, RM
August 25, 2011
and admitted at Ospital ng Maynila on March 6. with chief complaint of Syncope. blood flows again. 2010 diagnosed with Transient Ischemic Attack. or ischemic stroke. On examination. Below is a presentation of case on Transient Ischemic Attack. no rales present. It occurs when the blood supply to part of the brain is briefly interrupted. brain tries to restore blood flow. If blood supply is restored. The sequence of the appearance of signs and symptoms are as follows: During dinner. and experienced leftsided weakness followed by loss of consciousness. female. with clear breath sounds. CASE REPORT This is a case of a 33 year-old. abdomen is flabby with presence of striae. who is currently residing at Quiapo. As a compensatory mechanism. Shortly after her dyspneic episode. the patient vomited. It is also called as “mini-stroke”. the patient exhibited Anicteric sclera.Manila. affected brain cells’ function may return. making blood flow to a part of the brain be reduced or blocked. Transient Ischemic Attack happens when blood clot is present in the arteries. PIE suddenly experienced difficulty of breathing. CASE INTRODUCTION Transient Ischemic Attack is the temporary episode of neurologic dysfunction that may last a few seconds or minutes but not longer than 24 hours. hemorrhagic stroke. It occurs when an area in the brain loses blood supply. married. pink palbebral conjunctiva. patient had positive signs and symptoms of sudden onset of dyspnea followed by vomiting and syncope.I. no murmur present upon auscultation. Within 24 hours. Generally. Mrs. Filipino. permitting the return of function to the affected body part. . Upon admission.
SCHEMATIC DIAGRAM OF PATHOPHYSIOLOGY .II.
III. and was also discharged after four (4) days. her uncle (father’s brother) and auntie(mother’s sister) was diagnosed of Hypertension in the year 2002. 2 hours after the onsent of symptoms. and has a cognitive orientation of 3 (moderately compromised). and a failure to register light touch on the left side of the body when both sides are touched simultaneously. the patient’s skin is cold. Also. there were no known past illness related to TIA. vomiting and leftsided weakness followed by loss of consciousness. and clammy to touch. Other than that. PIE experienced difficulty of breathing. Her father and auntie also had Transient Ischemic Attack. with no headache. Her blood pressure is 140/80 mm Hg. • • . Present Health History The Chief Complaint of the patient is Syncope. and has pale skin color on elevation. there were no other reported illness-related case within her family and relatives. She is a current smoker with a history of 1 pack-year. left homonymous hemianopia. and is regular. Neurologic examination shows dysarthria. the patient confirmed that she was confined to Ospital ng Tondo three years ago (2007) with a medical diagnosis of Gastroenteritis. PHYSICAL ASSESSMENT On arrival at the emergency department. DIAGNOSTIC PROCEDURES AND LABORATORY ANALYSIS NURSING HEALTH HISTORY • Past Health History Upon interview. Other than these. Family Health .Illness History Patient PIE’s mother had a cerebrovascular accident in 2003 and bedridden for 3 years. one of her first degree relatives. Mrs. she reports vomiting. On 1999. Prior to Admission. sever left sided-weakness. The patient has a capillary refill of 5 seconds on blunch test. The patient has positive Homan’s sign. and her pulse is 97 beats per minute.
DIAGNOSTIC AND LABORATORY PROCEDURES Diagnostic/ Laboratory Procedure Potassium Indications or Purposes To determine the amount of Potassium present in the blood. -high blood sodium level means you have hypernatremia. which is usually due to too much sodium loss. Results 3.0 mmo/L Analysis and Interpretation of Results Decreased levels of potassium indicate hypokalemia. too much water intake or retention.8 formed by digestion of carbohydrates and the conversion of glycogen by the liver. or to fluid accumulation in the body (edema). is the primary source 76-111 mg/ dl Normal -low level of blood sodium means you have hyponatremia.5-1.3 Normal Values (Units used in the hospital) 3. Potassium is an important electrolyte that helps regulate the flow of fluids in and out of the cells The creatinine blood test is usually ordered along with a BUN (blood urea nitrogen) test to assess kidney function The amount of Sodium present in the blood. 83. almost always due to excessive loss of water (dehydration) without enough water intake.6-5. Sodium is an important electrolyte that helps regulate the flow of fluids in and out of the cells. Creatinine 0.69 mg/dl Normal Sodium 141 137-145 mEq/L Glucose: FBS Glucose.64 0. Normal .
. They may be seen in severe liver disease. these conditions are typically identified by other tests and symptoms and not by an isolated low uric acid result.Higher than normal uric acid levels mean that the body is not handling the breakdown of purines well. The BUN test is primarily used. Although low values can be associated with some kinds of liver or kidney diseases. Normal . or failure. This may be due to acute or chronic kidney disease. but the BUN test is not usually used to diagnose or monitor these conditions. Normal 5. and sometimes when a patient is overhydrated (too much fluid volume). The doctor will have to learn whether the cause is the over-production of uric acid. malnutrition. -Low BUN levels are not common and are not usually a cause for concern.BUN Uric Acid of energy for most cells.0 7-21 mg/dl Normal -Increased BUN levels suggest impaired kidney function.07 2. and rarely as the result of an inherited metabolic defect. along with the creatinine test. to evaluate kidney function under a wide range of circumstances and to monitor patients with acute or chronic kidney dysfunction or failure The uric acid test is used to learn whether the body might be breaking down cells too quickly or not getting rid of uric acid quickly enough.9 up to 200 mg/dl .5-7 mg/dl Cholesterol To determine your nutritional status or to screen for certain liver and kidney disorders as well as other 187. 7.Low levels of uric acid in the blood are seen much less commonly than high levels and are seldom considered cause for concern. damage. or if the body is unable to clear away the uric acid. The test also is used to monitor levels of uric acid when a patient has had chemotherapy or radiation treatments. exposure to toxic compounds.
It is unusual to have high triglycerides without also having high cholesterol. ALT levels usually stay high for about 1–2 months. often due to a virus infection.0 mEq/L Normal Very high levels of AST (more than 10 times the highest normal level) are usually due to acute hepatitis. In acute hepatitis. Decreased levels of potassium indicate hypokalemia -Decreased levels of potassium . Most treatments for heart disease risk will be aimed at lowering LDL cholesterol. it may be used to monitor those who have risk factors for heart disease. Potassium is 3. Normal Very high levels of ALT (more than 10 times the highest normal level) are usually due to acute hepatitis. Used to detect liver damage. 9 7-56 u/L Potassium To determine the amount of Potassium present in the blood. but can take as long as 3–6 months to come back to normal. the type of treatment used to lower LDL cholesterol may differ depending on whether triglycerides are high or normal.7 3.Triglycerides SGOT/AST diseases Blood tests for triglycerides are usually part of a lipid profile used to identify the risk of developing heart disease. those who have had a heart attack. often due to a virus infection. 13 5-35 u/L SGPT/ ALT To detects liver injury. As part of a lipid profile. or those who are being treated for high lipid and/or triglyceride levels. However.0 35-135 mg/dl A normal level for fasting triglycerides is less than 150 mg/dL . Normal -Increased potassium levels indicate hyperkalemia.6-5. 115.
WBC Determines the 7. is not getting rid of enough carbon dioxide. This can result from bacterial infections.9 37-47 Decreased hematocrit indicates anemia. It 4. Results Normal Values Analysis and interpretation 36.an important electrolyte that helps regulate the flow of fluids in and out of the cells indicate hypokalemia. these conditions create an imbalance that could eventually be life threatening.0 . or that there is a problem with kidney function. Blood gas measurements are used to evaluate your oxygenation and acid/base status. Diagnostic/ Laboratory Procedure HCT Indications or Purposes Hematocrit test measures the amount of space (volume) RBC take up in the blood. inflammation. such as that caused by iron deficiency or other deficiencies pH 343 140-440 Normal -Abnormal results of any of the blood gas components may mean that your body is not getting enough oxygen.3-10. Normal -An elevated number of white blood cells is called leukocytosis. If left untreated.6 number of circulating WBCs per cubic ml of whole blood.
0-8. Granulocytes Determines the 62 level of granulocytes in the blood.8 28-48 The result is within normal range Below-normal hemoglobin levels . or diseases of the immune system.2 The result is within normal range (x10/1) Lympho/ monocytes Small agranulocytic leukocytes originating from fetal stem cells.is an indicator of immune function and helps to determine infection or inflammation leukemia. It is especially helpful in the evaluation of the patient with infection. An elevated level means that there is hgh bacterial infection 44. such as chemotherapy. A decreased WBC count is called leukopenia. or stress. It can result from many different situations. 4. intense exercise.7 38 2. radiation therapy. trauma.2-80.
IV. to detect renal and metabolic disease.2 12-16 may lead to anemia that can be the result of iron deficiency Diagnostic/ Laboratory Procedure Urinalysis Indications or Purpose To obtain clinical information. MEDICAL-SURGICAL MANAGEMENT . hyper lucent focus on parietal lobe the sub cortical portion of the left parietal lobe. protein. diagnosis of disease or disorder on kidneys or urinary tract. Results Macroscopic: Color: yellow Specific Gravity:1. Diagnostic/ Laboratory Procedure Brain Scan Indications or Purpose To identify structural lesions whether vascular or tumors. posterior fossae and basal skull structures are intact. Analysis and Interpretation of Results Lacunar Infarct.0 Albumin: negative Microscopic: Pus cells: 1-2 Red Cells: 0-1 Epithelial cells: few Mucus threads: rare Results Analysis and Interpretation of Results The greater the concentration of the abnormal substance (such as greatly increased amounts of glucose. or red blood cells). 11. The midline structures are not displaced. the more likely it will be that there is a problem that needs to be addressed. sub Plain multiple axial views of the head cortical portion. left reveals a small. The ventricles and cistern are not dilated.015 Sugar: negative Appearance: slightly turbid Reaction: pH 6.HGB Measures the amount of hemoglobin in blood and is a good measure of the bloods ability to carry oxygen throughout the body. The sella turtica.
Indications/ purpose It is indicated for parenteral maintenance of routine daily fluid and electrolyte requirements with minimal carbohydrate calories from dextrose. To increase brain metabolism . acting then as dopominergic agonist through the inhibition of tyrosine hydroxilase. Magnesium in the formula may help to prevent iatrogenic magnesium deficiency in patients receiving prolonged parenteral therapy. hypertonic solution of balanced maintenance electrolytes and 5% dextrose injection in water for injection. nonpyrogenic.Intravenous Fluid Medical Management IVF D5NM General description It is a sterile. Drugs Drugs Generic Name: Potassium Chloride Brand Name: Kalium Durule Action -Replaces potassium and maintains potassium level Indication To prevent hypokalemia Generic Name: Citicoline Brand Name: Somazine -increases the neurotransmission levels because it favors the synthesis and production speed of dopamine in the striatum. The solution is administered by intravenous infusion for parenteral maintenance of routine daily fluid and electrolyte requirements with minimal carbohydrate calories.
acting then as dopominergic agonist through the inhibition of tyrosine hydroxilase. inhibits secretion of gastric acid by irreversibly blocking the enzyme system of hydrogen/potassium adenosine triphosphate (H+/K+ ATPase). To prevent oliguria or acute renal failure Generic Name: omeprazole Brand Name: Risek To prevent gastroesophageal reflux and peptic ulcer. MI. inhibiting tubular reabsorption of water and electrolytes. impeding ADPmediated activation and subsequent platelet aggregation.Inhibits the binding of adenosine diphosphate (ADP) to its platelet receptor. drug elevates plasma osmolality. Generic Name: Clopidogrel bisulfate Brand Name: Plavix . .to reduce thrombotic events in patients with atherosclerosis documented by recent stroke. or peripheral arterial disease Generic Name: Citicoline Na Brand Name: Cholinerv -increases the neurotransmission levels because it favors the synthesis and production speed of dopamine in the striatum. to increase brain metabolism Diet . increasing water flow into extracellular fluid. and irreversibly modifies the platelet ADP receptor. the proton pump of the gastric parietal cell.Generic Name: Mannitol Brand Name: Osmitrol -Increases osmotic pressure of glomerular filtrate.
low fat and low cholesterol diet. low fat diet to assure compliance with daily diet regimen and to provide a continuous recovery state. Turning exercise Turning the client side to side on bed every 2 hours Flexionextension exercise Flexion and extension the unaffected extremities. To increase muscle strength. • • • • . birth control alternatives. V. Change lying position every 2 hours to prevent the stasis of blood and to reduce the risk of pressure ulcers. pressure ulcer formation and respiratory complication. Reinforce low salt. exercise and stress out the importance of need to lifestyle modification to decrease the prevalence of cerebrovascular disease and to prevent stroke Encourage energy-conserving techniques to prevent fatigue and overexertion. Low salt and low fat Acrivity Type of Exercise General description Indications /purpose To prevent venous stasis. thrombophlebitis. Increase fluid intake and reinforce nutrition-rich foods to aid in supplementing normal body functions. NURSING MANAGEMENT • • • Encourage early ambulation when possible to enhance venous return Elevate the Head of Bed at night to increase gravitational blood flow Provide information on smoking cessation.Type of Diet General description Indications /purpose To prevent the problems that result from the need to withhold food.
NURSING CARE PLAN PATIENT: MRS.Capillary Refill of less than or equal to 3 seconds > Warm skin (-) Homan’s Sign (-) Claudication (-) Altered Sensation NURSING DIAGNOSIS Ineffective Peripheral Tissue Perfusion related to impaired transport of oxygen. Smoking) Formation of Lacunar Infarction Decreased Blood Supply in the Brain Decreased Oxygen to the brain Hypoxia Ischemia Temporary Neurologic GENDER: Female PLANNING Within 2 days of nursing intervention. if possible >Elevate Head of Bed at night >Apply antithromboembolic hose bandages to lower extremities before arising from bed . Clammy skin > Pale skin color on elevation (+) Altered Sensation (+) Homan’s Sign (+) Claudication AGE: 33 years old INFERENCE History of Hypertension and Stroke in the family (Predisposing Factor) and Precipitating Factors (Stress. as manifested by: > Capillary Refill of 5 seconds > Cold. clammy Skin > Pale skin color on elevation (+) Altered Sensation (+) Homan’s Sign (+) Claudication INTERVENTION >Monitor vital signs q°4’ >Encourage quiet and restful environment >Caution patient to avoid activities that increases cardiac workload >Encourage early ambulation.Capillary Refill of less than or equal to 3 seconds > Warm skin (-) Homan’s Sign (-) Claudication (-) Altered Sensation Diagnosis: Transient Ischemic Attack RATIONALE >To obtain baseline data >To decrese Oxygen demand >To maximize tissue perfusion >To enhance venous return >To increase gravitational blood flow > To prevent venous stasis EVALUATION GOAL MET. the patient will demonstrate increased perfusion. as manifested by: . PIE ASSESSMENT Subjective Cues: “Sumasakit yung paa ko pag naglalakad. as manifested by: . Within 2 days of nursing intervention. pero nawawala yung sakit pag napapahinga.”as verbalized by the patient. the patient will demonstrate increased perfusion. Objective Cues: HR: 97 bpm BP: 140/80 mmHg > Capillary Refill of 5 seconds > Cold.
exercises or techniques .Deficit Altered cerebral metabolism Decreased Cerebral Perfusion S/Sx Capillary Refill of 5 seconds (+) Homan’s Sign >Encourage smoking cessation >Because smoking causes vasoconstrictio n and may further compromise perfusion >To decrease tension level >Demonstrate use of relaxation activities.
O. the patient will demonstrate restoration of cognitive status to baseline. and necessary activities. > Maintain calm environment and eliminate extraneous noise/ stimuli > To prevent overstimulation > To diagnose presence/seve rity of lungs disease.C. the patient will demonstrate restoration of cognitive status to baseline. >To meet identified needs > Discuss situation with family and involve in planning . staff. as verbalized by the patient Objective Cues: BP: 140/80 mm Hg HR: 97 bpm (+) restlessness (+) fluctuation in sleep-wake cycle (+) fluctuation in level of consciousness > Cognitive Orientation of 3 [moderately compromised] AGE: 33 years old INFERENCE History of Hypertension and Stroke in the family (Predisposing Factor) and Precipitating Factors (Stress. as manifested by: (+) restlessness (+) fluctuation in sleep-wake cycle (+) fluctuation in L. Smoking) Formation of Lacunar Infarction Decreased Blood Supply in the Brain Decreased Oxygen to the brain Hypoxia Ischemia Temporary Neurologic Deficit GENDER: Female OBJECTIVES Within 2 days of nursing intervention. lagi akong nagigisinggising.PATIENT: MRS. as needed. > Cognitive Orientation of 3 INTERVENTION > Monitor vital signs q°4’ > Assess diet or nutritional status > Orient client to surroundings. as manifested by: (-) restlessness > Normal sleep-wake cycle > Cognitive Orientation of 5 [not compromised] Diagnosis: Transient Ischemic Attack RATIONALE > To obtain baseline data >To identify possible deficiencies of essential nutrients that could affect mental status > For client not to feel endanger with his safety EVALUATION GOAL MET. PIE ASSESSMENT Subjective Cues: Hindi mahimbing yung tulog ko. Within 2 days of nursing intervention. as manifested by: (-) restlessness > Normal sleepwake cycle > Cognitive Orientation of 5 [not compromised NURSING DIAGNOSIS Acute Confusion related to decreased blood supply in the brain.
Altered cerebral metabolism Confusion >Discuss need for ongoing medical review of patient’s medications >To limit possibility of misuse or potential dangerous side effects .
> Provide positive atmosphere. PIE ASSESSMENT Subjective data: Nahihirapan akong igalaw tong left arm ko. >To reduce fatigue >To protect client from injury >To reduce fatigue . (+) fatigue Smoking) Formation of Lacunar Infarction Decreased Blood Supply in the Brain Decreased Oxygen to the brain Hypoxia Ischemia Temporary Neurologic Deficit Hypoxia at the OBJECTIVES Within 8 hours of nursing intervention. Objective data: BP: 140/80 mm Hg HR: 97 bpm (+)left extremity weakness (+) fatigue AGE: 33 years old GENDER: Female Diagnosis: Transient Ischemic Attack RATIONALE >To enhance sense of wellbeing > To develop individually appropriate therapeutic regimens.PATIENT: MRS. Within 8 hours of nursing intervention. the patient will participate willingly in necessary/ desired activities. EVALUATION GOAL MET. as verbalized by the patient. as manifested by: (-) left extremity weakness (-) fatigue NURSING INFERENCE DIAGNOSIS Activity History of Intolerance Hypertension related to and Stroke in neuromuscular the family impairment as (Predisposing manifested by: Factor) and (+) left Precipitating extremity Factors weakness (Stress. such as exercise physiologist. psychological counseling/therapy. etc. the patient will participate willingly in necessary/ desired activities. while acknowledging difficulty of the situation of the patient >Plan care to carefully balance rest periods >Assist with activities and monitor patient’s use of assistive devices >Plan care with rest periods between activities > To help minimize frustration and rechannel energy. parang nanghihina. as manifested by: (-) left extremity weakness (-) fatigue INTERVENTION >Encourage client to maintain positive attitude >Provide referral to other disciplines.
brain Left-sided weakness >Promote comfort measures and provide relief of pain >To enhance ability to participate in the activities .
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