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Submitted by: Listano, Abigail Joy Longasa, Christel Nina Jane Lopez, Anna Margarita Lorico, May Anne Losaria, Allen Rolan Maga, Betina Mercy Magano, Jamaica Maligalig, Iric John Manabat, Cherrie-lyn Mana-ay, Regine Dianne Manaig, Leah Submitted by: 3BSN3 – Group 9 July 18, 2009 Submitted to:
Professor Lady Anne Ortega de Jesus
Introduction Background of the Study What is a stroke? A stroke happens when the blood supply to the brain is disturbed in some way. As a result, brain cells are starved of oxygen. This causes some cells to die and leaves other cells damaged. Types of stroke Most strokes happen when a blood clot blocks one of the arteries (blood vessels) that carry blood to the brain. This type of stroke is called an ischaemic stroke.
Transient ischaemic attack (TIA) or 'mini-stroke' is a short-term stroke that lasts for less than 24 hours. The oxygen supply to the brain is quickly restored and symptoms disappear. A transient stroke needs prompt medical attention because it indicates a serious risk of a major stroke. Cerebral thrombosis is when a blood clot (thrombus) forms in an artery that supplies blood to the brain. Blood vessels that are furred up with fatty deposits (atheroma) make a blockage more likely. The clot prevents blood flowing to the brain and cells are starved of oxygen. Cerebral embolism is a blood clot that forms elsewhere in the body before travelling through the blood vessels and lodging in the brain. In the brain, it starve cells of oxygen. An irregular heartbeat or recent heart attack may make you prone to forming blood clots. Cerebral haemorrhage is when a blood vessel bursts inside the brain and bleeds (haemorrhages). With a haemorrhage, blood seeps into the brain tissue and causes extra damage.
The control centers of the brain The brain controls how our body functions, how we think, how we see, how we talk, and how we move. • •
• • •
The right side of the brain controls the left side of the body, and the left side of the brain controls the right side of the body. This includes movement and sensation. Speech centers usually located in the Broca's area on the left side of the brain. Vision is controlled by the back of the brain in the occipital lobes. The carotid arteries provide the majority of the blood supply to these parts of the brain (anterior circulation). Balance and coordination are controlled by the cerebellum, or the base of the brain, and its blood supply comes from the vertebral arteries located in the bony canals in the back of the vertebral column (posterior circulation).
When an area of the brain loses its blood supply it stops working, the part of the body it controls also stops working. This is what happens with a stroke or CVA (cerebrovascular accident). When the brain loses blood supply, it tries to restore blood flow. If blood supply is restored, function may return to the affected brain cells, permitting return of function to the affected body part. This is what happens with a TIA (transient ischemic attack). Some may consider this a mini-stroke, however, in reality, it is a stroke that resolved or improved functionality to the affected body part. By definition, a TIA resolves within 24 hours, but most TIA symptoms resolve within a few minutes. TIAs are often warning signs of a future stroke. The risk of a stroke increases dramatically in the days and weeks after a transient ischemic attack, and the TIA may offer an opportunity to find a cause and prevent the permanent neurologic damage that results because of a stroke. A transient ischemic attack has the same origins as that of an ischemic stroke, the most common type of stroke. In an ischemic stroke, a clot blocks the blood supply to part of your brain. In a transient ischemic attack, unlike a stroke, the blockage is brief and there is no permanent damage. The underlying cause of a TIA often is a buildup of cholesterol-containing fatty deposits called plaques (atherosclerosis) in an artery or one of its branches that supply oxygen and nutrients to your brain. Plaques can decrease the blood flow through an artery or lead to the development of a clot. Other causes include a blood clot moving to your brain from another part of your body, most commonly from your heart.
What are the risk factors?
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High blood pressure does not cause any symptoms, so everyone over the age of 40 should have an annual blood pressure check. Smokers have double the risk of stroke as non-smokers. Irregular heart beat (atrial fibrillation) is fairly common in old age. It increases the risk of stroke by causing blood clots to form in the heart. Blood clots can be prevented from forming by taking warfarin (e.g. Marevan), a medicine that makes the blood less likely to clot. Warfarin treatment requires careful monitoring with regular blood checks and is a very effective way to reduce the risk of stroke. Diabetes affects 1 in 20 older people and can increase the risk of having a stroke. Good control of diabetes is important and requires attention to diet, regular urine tests or blood tests and probably some medication. Too much alcohol increases the risk of a stroke. The recommended safe limits for alcohol consumption are 21 units each week for women and 28 units each week for men. One unit of alcohol is equivalent to a measure of spirits, a 125ml glass of wine or half a pint of beer. People who drink more than this run a higher risk of stroke, liver disease and dementia.
Rationale for choosing the case • The researchers want to deepen their knowledge about Transient Ischemic Attack. • The researchers want to extend their understanding and their findings in the said case for future studies that might come up. • The researchers want to create awareness for the readers to further understand what it can cause and generate. Significance of the Study • This study will enable the readers to widen their understanding about the Cerebrovascular Disorders. • This study will give guidance to whom that is experiencing and will experience Transient Ischemic Attack. • This study will create deeper knowledge on how to handle, the preventive measures and the interventions that could be done. • This study can build good health habits as one of the essential aspect of life, this can change ones attitude towards health thus prevention of probable disease that may be acquired. Scope and Limitation of the Study • This study is focusing primarily on the client’s condition and lifestyle that is said to be the most reliable information to outline his present condition.
The researcher limits its study on the Anatomy and Physiology of the Nervous and Circulatory System, pathophysiology of the disease, how it came to be and its cause, medication and diagnostic tests. Furthermore, this study is focused on the provision of proper nursing care and interventions that can and will alleviate condition when one experience the disease.
Clinical Summary General Data Name: Patient A Age: 60 years old Birth Date: May 4, 1949 Sex: M Civil Status: Married Occupation: Driver Religion: Roman Catholic Address: San Antonio Bay, Laguna Date Admitted: July 17, 2009 Chief Complaint L-side body weakness History of Present Illness Two hours PTA, patient suddenly lost balance and experienced left sided body weakness. Patient claims of inability to walk due to unsteadiness of gait and he feels failure to his left side.
Past Medical History He was first hospitalized last 2004. This is due to Acute Cholisistitis. Patient has no known allergies. Diseases like Hypertension and Diabetes Mellitus is not in the family.
Physical Assessment AREA I. SKULL 1. Size, shape and Inspection symmetry of the Palpation skull Rounded (normocephalicRounded and symmetrical, with(normocephalic); frontal, parietal, andsmooth skull contour occipital prominences); Smooth skull contour Normal TECHNIQUE NORMS FINDINGS ANALYSIS and INTERPRETATION
2. Presence of Palpation nodules, masses, Inspection and depressions
Smooth, uniformHas no tenderness; noNormal consistence; absence ofmasses nor nodules nodules or masses
3. Facial Features
Symmetric or slightlySymmetrical andNormal asymmetric facial features;palpebral fissure equal palpebral fissure equal toin size, nasolabial folds size; symmetric nasolabial are symmetrical.
4. Presence of Inspection edema and hollowness in the eye. II. HAIR 1. Evenness of Inspection growth, thickness, Palpation or thinness of hair
No edema and hollowness
Evenly distributed andAlopecia or hair loss covers the whole scalp; maybe thick or thin
Abnormal. In some cases, alopecia is an indication of an underlying medical concern, such as iron deficiency. In some cases, due to aging. (http://en.wikipedia.org/wiki/Alopecia)
2. Texture and Inspection oiliness over the Palpation scalp
Silky; resilient hair
Silky; smooth resilient hair.
3. Presence of Inspection infection and Palpation infestation
No infection and infestation No infection infestation
III. FACE Facial features, Inspection symmetry of facial movements Symmetric or slightlySymmetrical facialNormal asymmetrical facialfeatures while talking features; palpebral fissuresand elevating the equal in size; symmetriceyebrow. Equal nasolabial folds palpebral fissure, symmetrical nasolabial folds.
IV. EYES A. EYEBROWS Hair distribution, Inspection alignment, skin quality and movement Symmetrical and in lineSymmetrical andNormal with each other; maybealigned with each other; black, brown or blondblack; evenly depending on race; evenlydistributed, movements distributed are symmetrical.
B. EYELASHES Evenness of Inspection distribution and Palpation direction of curl C. EYELIDS Surface Inspection characteristics and position (in relation to the cornea, ability to blink, and frequency of blinking) Upper eyelids cover theAble to close the eyesNormal small portion of the iris,and has the ability to cornea, and sclera whenblink. eyes open; eyelids meet completely when the eyes are closed; symmetrical Evenly distributed; turnedTurned outwardNormal outward eyelashes: hair equally distributed.
D. CONJUNCTIVA 1. Color texture Inspection and the presence Palpation of lesions in the bulbar conjunctiva Pinkish or red in color;Pinkish in color; no foreignNormal. with presence of smallbodies, no ulcers. capillaries; moist; no foreign bodies; no ulcers
2. Color, texture, Inspection and the presence Palpation of lesions in the palpebral conjunctiva
Pinkish or red in color;Pinkish or red in color; withNormal. with presence of smallpresence of small capillaries capillaries; moist; no foreign bodies; no ulcers
E. SCLERA Color and clarity Inspection White in color; clear; noWhite sclera with some visibleNormal. yellowish discoloration;capillaries some capillaries maybe visible
F. CORNEA Clarity and texture Inspection No irregularities on theClear and smooth in texture. surface; looks smooth; clear or transparent Normal
G. IRIS Shape and color Inspection Anterior chamber isDark brown in color;Normal transparent: no noted visibletransparent anterior chamber. materials; color depends on the person’s race
1. Color, shape, Inspection and symmetry of size
Color depends on thePupil equally round. person’s race; size ranges from 3-7 mm, and are equal in size; equally round
2. Light reaction Inspection and accommodation
Constrict briskly/sluggishlyDilates when looking at farNormal when light is directed to theobjects and constrict when eye, both directly andlooking at near objects. consensual
I. VISUAL ACUITY
1. Near Vision
Able to read newsprint
Presbyopia (loss of elasticity ofAbnormal. Presbyopia is the decrease the lens and thus loss of abilityability of the eye to accommodate for to see close object). near vision. This occurs as a normal part of aging and the lens becomes less flexible. The average age of onset of presbyopia is the midforties. (Essentials of Anatomy and Physiology 6th edition by Seeley, et. Al page 256.
J. LACRIMAL GLAND Palpability and Palpation tenderness of lacrimal gland K. EXTRAOCULAR MUSCLE No edema or tendernessNo tenderness and edema. over lacrimal gland Normal.
Eye alignment and Inspection coordination
Both eyes coordinated’Eyed moves move in unison, withalignment. parallel alignment
L. VISUAL FIELDS Peripheral fields visual Inspection When looking straightCan see ahead, client can see objectsperiphery. in the periphery objects in theNormal
V. EARS A. AURICLES
1. Color, Inspection symmetry of size and position
Color same as facial skin;Same color as the facial skin;Normal symmetrical; auricle alignedtip of auricle aligned at the with outer canthus of eye,outer canthus of the eye. about 10 degrees from vertical
2. Texture, Palpation elasticity and areas of tenderness
Mobile, firm, and notSmooth in texture, flexible andNormal tender; pinna recoils after itelastic pinna; no tenderness. is folded
B. HEARING ACUITY TESTS Client’s response Inspection to normal voice tones Normal voice tones audible Can hear normal volume, tonesNormal. or words.
1. Any deviation in Inspection shape, size, or color and flaring or discharge from the nares
Symmetric and straight; noSymmetric and straight; uniformNormal discharge or flaring;color with no nasal flaring. uniform color
2. Nasal septum Inspection (between the nasal Palpation chambers) 3. Patency of both Inspection nasal cavities
Nasal septum intact and inNasal septum intact and inNormal middle midline.
Air moves freely as theBoth nasal cavities are patent. client breathes through the nares Not tender; no lesions No tenderness or lesions.
4. Tenderness, Palpation masses and displacements of bone and cartilage
Identification of Palpation the sinuses and for tenderness VIII. MOUTH A. LIPS Symmetry of Inspection contour, color and Palpation texture B. BUCCAL MUCOSA Color, moisture, Inspection texture, and the presence of lesions
No tenderness present.
Uniform pink color; soft,Uniform pink color; soft, moist,Normal. moist, smooth texture;smooth texture; ability to purse symmetry of contour;lips ability to purse lips
Uniform pink color; moist,Uniform pink smooth, soft, glistening, andsmooth, soft elastic texture
Color, number and Inspection condition and presence of dentures
32 adult teeth; smooth,Intact dentures white, shiny tooth enamel; smooth, intact dentures
D. GUMS Color condition and Inspection Pink gums; no retraction Pink gums. Normal.
E. TONGUE/ FLOOR OF THE MOUTH 1. Color and Inspection texture of the mouth floor and frenulum Pink color; moist;Pink color; moist; thin whitishNormal. slightly rough; thincoating; moves freely; no whitish coating; movestenderness. freely; no tenderness
2. Position, color Inspection and texture, movement and base of the tongue
Central position; pinkLocated and positioned in theNormal color; smooth tonguecenter. base with prominent veins
3. Any nodules, Palpation lumps or Inspection excoriated areas
Smooth with no palpableNo tenderness or masses. nodules, lumps, or excoriated areas
F. PALATES and UVULA 1. Color, shape, Inspection texture and the Palpation presence of bony prominences Light pink, smooth, softLighter hard palate; more irregularNormal palate, lighter pink hardtexture palate, more irregular texture
2. Position of the Inspection uvula and mobility (while examining the palates)
Positioned in midline ofPositioned at the center. soft palate
G. OROPHARYNX and TONSILS 1. Color texture and Inspection Pink and posterior wall smoothPink and smooth. Normal.
2. Size, color, and Inspection discharge of the tonsils
Pink and smooth; noPink and smooth; no discharge; ofNormal. discharge; of normal size normal size
3. Gag reflex
IX. THORAX A. ANTERIOR THORAX
Quiet, rhythmic, effortless respirations
andNormal breathing pattern.
2. Temperature, Palpation tenderness, masses
Skin intact; uniformHas intact skin; has equalNormal temperature; chest wall intact;warmth on both sides. No no tenderness; no masses masses.
3. Anterior thorax Auscultation auscultation B. POSTERIOR THORAX 1.Shape, symmetry, Inspection and comparison of Palpation anteroposterior thorax to transverse diameter
Bronchovesicular vesicular breath sounds
andAbsence of crackles.
Anteroposterior to transverseSymmetrical chest. diameter in ratio 1:2; chest symmetric
2. Spinal alignment Inspection
Spine vertically aligned
Spine vertically aligned
3. Temperature, Palpation tenderness, masses
Skin intact; uniformNo masses nor tenderness: hasNormal temperature; chest wall intact;equal warmth on each side no tenderness; no masses
4. Posterior thorax Auscultation auscultation
Vesicular bronchovesicular sounds
andAbsence of crackles. breath
XI. CARDIOVASCULAR A. AORTIC PULMONIC AREAS and Auscultation No pulsations No pulsations felt Normal
B. TRICUSPID Auscultation AREA C. APICAL AREA Auscultation
No pulsations; no lift or heaveNo pulsations felt
Pulsation visible in 50% ofHas full pulsation adults and palpable in most PMI in 5th LICS at or medial to MCL
D. EPIGASTRIC Auscultation AREA
E. Auscultation CARDIOVASCUL AR AREAS AUSCULTATION
S1: Usually heard at all sites Has full and rapid pulsation, 78Abnormal. Blood Usually louder at the apicalbpm. indicates hypertension. area Sounds on the aortic and S2: Usually heard at all sites pulmonic areas; has a lub Usually louder at the base ofsound on the apex and dub heart sounds on the tricuspid area. Systole: silent interval;Blood pressure is 140/80 slightly shorter duration thanmmHg diastole at normal heart rate (60 to 90 bpm) Diastole: silent interval; slightly longer duration than systole at normal heart rates. S3: in children and young adults S4: in many older adults
XII. CAROTID ARTERIES 1. Carotid artery Palpation palpation Symmetric pulse volumes;Has full pulsation. SymmetricalNormal. full pulsations, thrustingpulse volume. quality; quality remains same when the client breathes, turns head, and changes from sitting to supine position; elastic arterial wall
1. Axillary, Inspection subclavicular, and supraclavicular lymph nodes
No tenderness, masses, orNo tenderness, nodules nodules
XIII. ABDOMEN 1. Skin integrity Inspection Unblemished skin; uniformUniform color. color Flat, rounded (convex), orHas a flat scaphoid (concave) abdomen and Normal. concaveNormal
2. Abdominal Inspection contour
3. Enlargement of Inspection liver or spleen
No evidence of enlargementNo enlargement of the spleenNormal of liver or speen and liver seen.
4. Symmetry of Inspection contour
Has a symmetrical abdominalNormal contour.
5. Abdominal Inspection movements associated with respirations, peristalsis or aortic pulsations 6. Vascular pattern Inspection
Symmetric movementsAbdominal movements notedNormal caused by respiration; visiblewhen inhaling. peristalsis in very lean people; aortic pulsations in thin persons at epigastric area
No visible vascular pattern
Has no blood vessel visible.
XIV. MUSCULOSKELETAL SYSTEM A. MUSCLES 1. Muscle size and Inspection comparison on the other side Proportionate to the body:Proportionate to the body; inNormal. even in both sides both sides.
2. Fasciculation Inspection and tremors in the muscles 3. Muscle tonicity Palpation
No fasciculation and tremors No tremors.
Even and firm muscle tone
Firm muscle tone
Normal. Abnormal. Patient is experiencing weakness on the left side of his body.
4. Muscle strength Palpation
Has equal muscular strengthUnequal muscular strength on both sides
B. JOINTS 1. Joint swelling Inspection No swelling, no warmth, noAbsence of swelling, pain orNormal. redness, no pain, no crepitus redness.
No swelling, no warmth, noAbsence of swelling, rednessNormal. redness, no pain. or pain.
Neurological Assessment Category Normal Findings Mental Status Level Consciousness Orientation Language test Recall Alert of Oriented Coherent Able to remember
Actual Findings Alert
Analysis and Interpretation Patient was able to response in motor and verbal activities.
Oriented to person, time Patient was oriented. and place Coherent Able to state what happened to him in the past
Cranial Nerves Category CN1 Olfactory CNII Optic
Analysis and Interpretation
Able to smell and Able to identify the scent Able to recognize what food is served by merely smelling. recognize stimuli of food
20x20 vision, Presbyopia(loss of Abnormal. Presbyopia is the decrease ability of the eye to able to read elasticity of the lens and accommodate for near vision. This occurs as a normal part of newsprint thus loss of ability to see aging and the lens becomes less flexible. The average age of onset close object) of presbiopia is the midforties. (Essentials of Anatomy and Physiology 6th edition by Seeley, et. Al page 256.
CN III,IV, VI Occulomotor Trochlear Abducens
(+) Extraocular Movement (EOM); Lateral Upward and Downward; pupils reactive to light
Pupils react to light. There The patient has a normal eye movement; pupils react to light and is constriction and able to move his eyes in any direction. consensual accommodation. Able to move the eyes in any direction in unison.
CN V Trigeminal
Able to feel and Able to feel the tip of the Patient response in the test and has a normal sense of touch. clearly identify reflex hammer while stimulus, with covering his eyes bilateral facial sensation, with active corneal reflex
CN VII Facial
(+) Corneal (+) Facial symmetry reflex, facial symmetry
Able to do facial expression according to his feelings
CN VIII Vestibulocochlear
Able to hear Cannot maintain balance clearly, can maintain balance
Weakness present on left side thus, cannot maintain balance.
CN IX, X Glossopharyngeal Vagus
(+) gag reflex, uvula at the center, soft palate rises
Present gag reflex, able to Patient was able to identify the taste of the food. swallow and able to identify the taste of the food
CN XI Accessory (Spinal)
Able to shrug shoulders against resistance and able to turn the head side and against resistance.
Cannot able to shrug Patient was able to move or turn his head from right to left and but shoulders against unable to shrug his left shoulder against resistance. resistance and can turn the head from right to left
CN XII Hypoglossal
Able to move Able to protrude tongue Patient able to move tongue without difficulty. tongue from side and move it side to side to side
Category Muscle Strength Left Arm
Analysis and Interpretation
100% of normal strength; active motion against full resistance
25% of normal strength; Patient not able to move on his left leg with full muscle movement full muscle movement without difficulty. against gravity; with support.
100% of normal 100% of normal strength; Patient able to move on his right arm with full muscle movement strength; active full muscle movement without difficulty. motion against against gravity full resistance
100% of normal strength; active motion against full resistance
25% of normal strength; Patient not able to move on his left leg with full muscle movement full muscle movement without difficulty. against gravity; with support.
100% of normal 100% of normal strength; Patient able to move on his right leg with full muscle movement strength; active full muscle movement without difficulty. motion against against gravity full resistance
Patterns of Functioning Functional Health Pattern Prior to Hospitalization Health Perception – Health Management • • • • • • • • • • The patient does have complete immunization. He was first hospitalized last 2004. This is due to Acute Cholisistitis. No known allergies to any foods and drugs. He can eat sea foods and others. For him, being healthy is important. But in his case, it is not being prioritized due to financial constraints. He does not have any regular medical and dental check-ups. The patient takes a bath once a day and brushes his teeth three times a day. He washes his hand but does not use soap regularly. Whenever he is sick, the family borrows money from their relatives. The patient is a non-smoker but drinks alcoholic occasionally. The patient doesn’t have hereditary disease.
Norms and Standards Health Perception and Health Management. • Data collection is focused on the person's perceived level of health and well-being, and on practices for maintaining health. Habits that may be detrimental to health are also evaluated, including smoking and alcohol or drug use. Actual or potential problems related to safety and health management may be identified as well as needs for modifications in the home or needs for continued care in the home. • Hygiene, a practice for personal cleanliness and grooming, promote physical and psychological well-being. Some studies carry out that developed personal hygiene could decrease illness occurrence. (Larson, 2002; Larson and Aiello, 2001) • Personal hygiene practices include: seeing a doctor, seeing a dentist, regular washing (bathing or showering) of the body, regular hand washing, brushing and flossing of the teeth, basic manicure and pedicure, feminine hygiene and healthy eating. What is important is that personal be carried out conveniently and frequently enough to promote personal hygiene.
Illness, hospitalization and institutionalization generally require modifications in hygiene practices. In these situations, the nurse helps the patient to continue some hygiene practices, and can teach the patient and family members regarding hygiene. Nurses assist the patient with basic hygiene must respect individual patient preferences, providing only the care that patients cannot or should not provide for themselves. (Fundamentals of Nursing by Taylor) The purpose of hand washing is to remove possible harmful bacteria from the skin. Soap and water act on the surface of the skin to loosen and remove soil and grime, body secretions, dead skin cells, and germs. Studies have shown that washing with water alone removes no bacteria whatsoever. (http://www.health.uab.edu/17728/)
Nutritional Metabolic Pattern • • • • He loves to eat, especially “bagoong”. He is not choosy when it comes to any menu and kind of food. He eats three times a day. He is able to reach the maximum required glasses of water per day which is 12 glasses or more.
Nutrition and Metabolism Assessment is focused on the pattern of food and fluid consumption relative to metabolic need. The adequacy of local nutrient supplies is evaluated. Actual or potential problems related to fluid balance, tissue integrity, and host defenses may be identified as well as problems with the gastrointestinal system. Nutrition can be defined as the study of the relationship between diet and states of health and disease. Without appropriate nutrition, functioning will be compromised and diseases can take hold, potentially resulting in death. Good nutrition can help prevent disease and promote health. (http://www.nutrition-information.net/index.html)
• Elimination • He defecates every morning and but sometimes his bowel elimination is loose and sometimes his constipated, due to his Acute Cholecystectomy. •
Water helps to regulate body temperature, transports nutrients to cells, and rids the body of waste materials.The middle aged adult should continue to eat healthy diet, following the recommended portions of the five food groups, with special attention to protein, calcium and limiting consumption to cholesterol. Two to three liters of fluid should be included in the diet. Inadequate nutrition is associated with marked weight loss, generalized muscle weakness, altered functional activity, and increased susceptibility to infection, impaired pulmonary function and prolonged length of hospitalization. (Kozier et. al, Fundamentals of Nursing 8th edition) In order to remain healthy, adults must be aware of changes in their energy needs, based on their level of physical activity, and balance their energy intake accordingly. Data collection is focused on excretory patterns (bowel, bladder, skin). Excretory problems such as incontinence, constipation, diarrhea, and urinary retention may be identified. It is the act of discharging or excreting waste products from the body. Elimination can be affected by a person’s developmental stage, daily patterns, the amount and quantity of fluid or food intake, the level of activity, lifestyle, emotional states pathologic processes, medication, and the procedures such as diagnostic test and the surgery. The frequency of defecation is highly individualized, varying from several times per day to two to three times per week. Sufficient bulk in the diet is necessary to provide fecal volume. Bland diets and low-fiber diets are lacking in the bulk and therefore create insufficient residue of waste products to stimulate the reflex for defecation. (Kozier et al, Fundamentals of Nursing 8th Ed.)A person’s Urinary habits depend on social culture, personal habits and physical
Activity and Exercise
Before, he exercises regularly with her wife. But now, he doesn't get enough exercise because of his early work. He usually gets the morning shift of 8am-4pm.
abilities. Urine collected in the bladder contains between 250 to 450 mL of urine. The amount of fluid intake affects the urinary frequency of an individual. Foods high in sodium or fluids high in sodium can cause fluid retention because water is retained to maintain the normal concentration of the electrolyte. (Kozier et al, Fundamentals of Nursing 8th Ed.) Assessment is focused on the activities of daily living requiring energy expenditure, including self-care activities, exercise, and leisure activities. The status of major body systems involved with activity and exercise is evaluated, including the respiratory, cardiovascular, and musculoskeletal systems. The human body is designed for motion, and regular exercise is necessary for its healthy functioning. Individuals who choose inactive lifestyles or who are forced into inactivity by illness or injury placed themselves at high risks for serious health problems. Lack of exercise, inactivity, or immobility related to illness, or injury place a person at high risk for serious health problems. Immobility can affect the major body systems. Regular exercise can help you prevent — or manage — high blood pressure. Your cholesterol will benefit, too. Regular exercise boosts high-density lipoprotein (HDL), or "good," cholesterol while decreasing low-density lipoprotein (LDL), or "bad," cholesterol. This one-two punch keeps your blood flowing smoothly by lowering the buildup of plaques in your arteries. Exercise delivers oxygen and nutrients to your tissues. In fact, regular exercise helps your entire cardiovascular system — the circulation of blood through your heart and blood vessels — work more efficiently. When your heart and lungs work more efficiently, you'll have more energy to do the things you enjoy.
• • • •
The patient is a High School Graduate. He can write and read. He can talk clearly. He expresses his feelings appropriately.
Assessment is focused on the ability to comprehend and use information and on the sensory functions. Data pertaining to neurologic functions are collected to aid this process. Sensory experiences such as pain and altered sensory input may be identified and further evaluated. Cognition is affected by education. Those who study and develop their skills have better cognitive performances because they have been provided with different information and chances to develop their self. Perception is affected by the sensory diseases. Presence of any sensory abnormalities affects perception that would affect proper communication. Cognition involves a person’s intelligence, perceptual ability and ability to process information. It represents a progression of mental abilities from illogical to logical thinking, from simple to complex problem solving and from concrete to abstract ideas. (Kozier et al, Fundamentals of Nursing 8th Ed.)
Sleep and Rest
The patient regularly sleeps at 10:00 PM and wakes up at around 5:00 AM The patient appears to be not relaxed.
Assessment is focused on the person's sleep, rest, and relaxation practices. Dysfunctional sleep patterns, fatigue, and responses to sleep deprivation may be identified. We have also learned that sleep seems to enhance the functioning of the immune system. Perhaps that is why we feel like sleeping a lot during illness. In babies, sleep is believed to help maintain and organize newly learned skills within the brain, and it may even play a role in how the brain is wired. Children also seem to do the majority of their growing while asleep. Whatever sleep's purpose, it must be very important in children, since the younger they are, the more they sleep. Eight hours of sleep every night has been the accepted standard for adults. It is important that a person follows a pattern of rest that maintains well-being. Illness and various life situations that causes physiological stress trends to disturb sleep.
Self Perception and Self Concept
He is concerned with his family. He shows love and respect to them. Patient is eager to get out of the hospital and start another day in work.
Assessment is focused on the person's attitudes toward self, including identity, body image, and sense of self-worth. The person's level of self-esteem and response to threats to his or her self-concept may be identified. It refers to the global understanding a sentient being has of him or her. It presupposes but can be distinguished from selfconsciousness, which is simply an awareness of one's self. It is also more general than self-esteem, which is the purely evaluative element of the self-concept. The self-concept is composed of relatively permanent selfassessments, such as personality attributes, knowledge of one's skills and abilities, one's occupation and hobbies, and awareness of one's physical attributes.
He develops good relationship in his family, his grand children and son/daughter in law.
Assessment is focused on the person's roles in the world and relationships with others. Satisfaction with roles, role strain, or dysfunctional relationships may be further evaluated. An interpersonal relationship is a relatively long-term association between two or more people. This association may be based on emotions like love and liking, regular business interactions, or some other type of social commitment. Interpersonal relationships take place in a great variety of contexts, such as family, friends, marriage, acquaintances, work, clubs, neighborhoods, and churches. They may be regulated by law, custom, or mutual agreement, and are the basis of social groups and society as a whole. Interpersonal relationships include kinship and family relations in which people become associated by genetics or consanguinity. These include such roles as father, mother, son, or daughter. Relationships can also be established by marriage, such as husband, wife, father-in-law, mother-inlaw, uncle by marriage, or aunt by marriage.
According to attachment theory, relationships can be viewed in terms of attachment styles that develop during early childhood. These patterns are believed to influence interactions throughout adulthood by shaping the roles people adopt in relationships. For example, one partner may be securely attached while the other is anxious and avoidant. Thus, early childhood experience (primarily with parents) is believed to have long lasting effects on all future relationships.(http://en.wikipedia.org/wiki/Interpersonal_rela tionship)
Sexuality-Reproductive Pattern • • • The patient did not practice family planning. He has 3 children. He dresses according to his gender.
• • •
Assessment is focused on the person's satisfaction or dissatisfaction with sexuality patterns and reproductive functions. Concerns with sexuality may he identified. Sexuality can be defined as the quality or state of being sexual. Quite often it is an aspect of one's need for closeness, caring, and touch. Faced with a disease such as cancer most people initially lose interest in sex. Sexual desire is overshadowed by concern for one's health. Sexuality is a crucial part of a person’s identity. Sex is central to who we are, to our emotional well-being and to the quality of our lives. The world health organization defined sexual beings in ways that are positively enriching and enhances the personality, communication and love. (Kozier et al. Fundamentals of Nursing 7th ed.)
Pattern of Coping and Stress Tolerance
During the times of having a problem, he gets outside the house and takes his time to reflect.
Assessment is focused on the person's perception of stress and on his or her coping strategies Support systems are evaluated, and symptoms of stress are noted. The effectiveness of a person's coping strategies in terms of stress tolerance may be further evaluated. Coping mechanisms which are behaviors used to decrease stress and anxiety. Many coping behaviors are learned based on one’s family past experiences, and socio-cultural influences and expectations. (Kozier et al, Fundamentals of Nursing 8th Ed.) Stress is a natural part of life. Everyday there are responsibilities, obligations and pressures that change and challenge you. In response to these daily strains your body automatically increases blood pressure, heart rate, respiration, metabolism, and blood flow to muscles. However, when this natural response is prolonged or triggered too often without sufficient adjustments to counter its effects, it can threaten your health and well-being. Therefore, it is essential that you learn to cope with these natural responses in order to avoid physical and/or emotional problems.
Pattern of Values and Beliefs
Values and Belief. • Assessment is focused on the person's values and beliefs He is a Roman Catholic. (including spiritual beliefs), or on the goals that guide his or Before, he attends mass every Sunday, but due to his work her choices or decisions. during weekdays, he sometimes forgot to attend mass this Spiritual well-being past 2 months. • is defined as an "ability to experience and integrate meaning and purpose in life through a person's connectedness with self, others art, music, literature, nature, or a power greater than oneself.” It is a sense of peace and contentment stemming from an individual's relationship with the spiritual aspects of life. • Spiritual well-being is the condition that exist when the universal spiritual needs for meaning and purpose, love and belonging, and forgiveness are met. O’ Briens conceptual model of spiritual well-being: personal faith, religious practice and spiritual contentment. Spiritual beliefs are of special importance to nurses because of the many ways they can influence a patient’s level of health and self-care behaviors. (Kozier et. al, Fundamentals of Nursing 7th ed.)
Activities of Daily Living ASPECT
TO DURING HOPITALIZATION
He loves to eat, especially “bagoong”. He is not choosy when it comes to any menu and kind of food. He eats three times a day. He is able to reach the maximum required glasses of water per day which is 12 glasses or more. He defecates every morning and but sometimes his bowel elimination is loose and sometimes his constipated, due to his Acute Cholecystectomy. Before, he exercises regularly with her wife. But now, he doesn't get enough exercise because of his early work. He usually gets the morning shift of 8am-4pm. The patient takes a bath once a day and brushes his teeth three times a day. He washes his hand but does not use soap regularly.
Patient is on low fat and low Before, patient can eat any food he salt diet. wants unlike when he obtained the disease, is on low fat and low salt diet.
He defecates every morning and Patient has difficulty in elimination. but sometimes his bowel elimination is loose and sometimes his constipated, due to his Acute Cholecystectomy. He does not get to execise because of his weakness on the This further lessened his activity. left side of his body. Patient had the chance to rest and sleep without doing any work related activities. He is not able to take a bath. Due to his left side weakness, he’s not able to perform usual activities.
5. Substance Use
The patient is a non-smoker but The patient is a non-smoker but The patient has not tried any drinks alcoholic occasionally. drinks alcoholic occasionally. substance use that can affect his He does not use illicit drugs He does not use illicit drugs condition.
6. Sleep and Rest The patient regularly sleeps at Patient is relaxed and rested. 10:00 PM and wakes up at around 5:00 AM The patient appears to be not relaxed. 7. Sexual Activity He dresses appropriately, based Not applicable on his gender. He is engage in sexual activity to his wife only. Presently he is not active in his sex life. It is due to his work and duty that he seldom acquires enough sleep.
Laboratory and Diagnostic Examination TEST Hemoglobin Hematocrit WBC RBC DIFFERENTIAL COUNT Segmenters Lymphocytes Eosinophils Monocytes 65 30 0.5 55 – 65% 25 – 35% 1 – 3% 3 – 7% RESULT 14.4 47 5900 5.0 NORMAL VALUE M= 13 – 18 M= 40 – 54 vol% 5000 – 10000cumm 4.5 – 5.5 mill/cumm.
July 17, 2009 9:30AM Blood Chemistry Examination RBS BUN SI units 3.6-6.1mmol/l 1.7-8.3mmol/l Conventional units 65-110 mg/dl 10-50mg/dl Results 345 mg/dl 16mg/dl
Creatinine Sodium Potassium Triglycerides Cholesterol HDL Cholesterol LDL Cholesterol
45.104mmol/l 135-142mmol/l 3.8-5.0mmol/l Less 2.26mmol/l Less 5.1mmol/l >1.04mmol/l <0.47mmol/dl
0.51-1.17mg/dl 135-142mmol/l ----Less 165mg/dl Less 200mg/dl >40mg/l <130mg/l
0.7mg/dl 135mmol/l 4.3mmol/l 179mg/l 253mg/l 45mg/l 172mg/l
Computed tomography scan Pertinent history: Left sided weakness to consider T.I.A.
Findings: Method 5 and 10 mm axial tomographic sections from the skull base to the vertex where obtain without IV contrast. Questionable tiny low attenuating foci are noted in both crura of both internal capsules. No mass lesions nor intra/extraaxial hemorrhage noted.
Questionable lacunar infacts both internal capsules (crural portion) Follow through contrast CT exam of the brain after 48 hours recommended. No evident intra/extraaxial hemorrhage nor intracerebral mass. Chronic mastoiditis ® Impression/ Diagnosis According to the patient’s physician patient experienced Transient Ischemic Attack. By definition, TIA or “mini stroke”, from the word itself, is transitory and is not like the kind of stroke that creates permanent damage to parts or body systems; rather it serves as a mark that the patient can experience stroke. One should take precaution, members of the family and the patient himself must take action for the betterment of his situation.
Course in the ward DATE
NURSING ASSESSMENT and FUNCTION
July 17, 2009
Physician • Dr. Moran Medications: • Glibenclamide • Citicoline • Mannitol (through IV) • Norten • IV insertion of PNSS 1L
Checked vital signs T- 35.9 P- 84 R- 20 BP- 130/90 Developed good Nurse-Patient interaction
July 18, 2009
Physician • Dr. Moran Medications: • Glibenclamide • Citicoline • Mannitol (through IV) • Norten IV insertion of PNSS 1L
Checked Vital signs T-36.5 P-79 R-16 BP- 140/80 Performed Physical Assessment
Hypothesis Patient may have obtained this disease for the reason that he has hypertension and diabetes mellitus. Agent A decrease in cerebrovascular blood flow, which disrupts neuronal function temporarily to the extent that clinical deficits can be detected. Host 60 years old Male Roman Catholic Driver Environment Patient resides in San Antonio Bay, Laguna. Type of living is average. Analysis An episode of TIA is brief and recovery is complete. It may recur later that same day or at a later time. Some people have only a single episode, some have recurrent episodes, and some will have a stroke. A TIA needs to be treated as aggressively as a stroke would, as any given TIA could develop into a stroke. Conclusion and Recommendation
The researchers therefore conclude that Transient Ischemic Attack is an episode in which a person has stroke-like symptoms for less than 24 hours, usually less than 1-2 hours, a warning sign that a true stroke may happen in the future if something is not done to prevent it.
Anatomy and Physiology The systems involved in giving part to the development of TIA are the circulatory system and the nervous system. The circulatory system is a network that carries blood throughout the body. The human circulatory system supplies the cells of the body with the food and oxygen they need to survive. At the same time, it carries carbon dioxide and other wastes away from the cells. The circulatory system also helps regulate the temperature of the body and carries substances that protect the body from disease. In addition, the system transports chemical substances called hormones, which help regulate the activities of various parts of the body. One of the parts of the circulatory system is the heart. It is a hollow, muscular organ that pumps blood. It consists of two pumps that lie side by side. These pumps relax when taking in blood and contract as they send out blood. The left side of the heart is a stronger pump than the right side. The stronger pump receives blood from the lungs and sends it to cells throughout the body. The weaker pump receives blood from the cells throughout the body and sends the blood to the lungs. Another of the parts of the circulatory system is the blood vessels. They form a complicated system of connecting tubes throughout the body. There are three major types of these vessels. Arteries carry blood from the heart. Veins return blood to the heart. Capillaries are extremely tiny vessels that connect the arteries and the veins. The blood consists chiefly of liquid called plasma, and three kinds of solid particles known as formed elements. Plasma is made up mostly of water, but it also contains proteins, minerals, and other substances. The three types of formed elements are called red blood cells, white blood cells, and platelets. Red blood cells
carry oxygen and carbon dioxide throughout the body. White blood cells help protect the body from disease. Platelets release substances that enable blood to clot. Platelets thus aid in preventing the loss of blood from injured vessels.
The nervous system is a very complex system in the body. It has many, many parts. The nervous system is divided into two main systems, the central nervous system (CNS) and the peripheral nervous system. The spinal cord and the brain make up the CNS. Its main job is to get the information from the body and send out instructions. The peripheral nervous system is made up of all of the nerves and the wiring. This system sends the messages from the brain to the rest of the body. One of the parts of the CNS is the brain. It keeps the body in order. It helps to control all of the body systems and organs, keeping them working like they should. The brain also allows us to think, feel, remember and imagine. In general, the brain is what makes us behave as human beings. The brain communicates with the rest of the body through the spinal cord and the nerves. They tell the brain what is going on in the body at all times. This system also gives instructions to all parts of the body about what to do and when to do it. There are five main senses - touch, smell, taste, hearing and sight. These are the external sensory system, because they tell you about the world outside your body. Your senses tell you what is happening in the outside world. Your body's sense organs constantly send signals about what is happening outside and inside it to your control center - the brain. The cerebrum is part of the forebrain. The cerebral cortex is the outer layer of the cerebrum. Certain areas of the cerebral cortex are involved with certain functions.
Sensory areas such as touch, smell, taste, hearing and sight receive messages from the skin, nose, mouth, ears and eyes. We feel, taste, hear and see when these messages are received by the sensory parts of the brain. The second main part of the nervous system is the peripheral nervous system. The nervous system is made up of nerve cells or neurons that are "wired" together throughout the body, somewhat like communication system. Neurons carry messages in the form of electrical impulses. The messages move from one neuron to another to keep the body functioning. Neurons have a limited ability to repair themselves. Unlike other body tissues, nerve cells cannot also be repaired if damaged due to injury or disease.
Predisposing factors -age -sex -sedentary lifestyle -personal HTN
Precipitating factors - cigarette smoking - increased fatty food on diet - stress -Diabetes Mellitus
Infarct causing decrease blood supply in the brain
Decrease blood supply leads to O2 and glucose supply brain thus Hypoxia occurs
Hypoxia can cause Ischemia which may lead to temporary neurologic deficits or a TIA also known as Transient Ischemic Attack Ischemia quickly alters cerebral metabolism
decrease cerebral perfusion
affects blood flow in the body
Leading to Hypoxia on the brain will cause further damage if not be reversed and will further result to higher damaged to the brain
Leading to hypotension
leading to syncope and chest pain, and left sided weakness of the body
Leading to Transient Ischemic Attack Drug Study
Generic Name Metformin
Classification and Action Anti-diabetic, Increases insulin sensitivity by decreasing glucose production and absorption in liver and intestines and enhancing glucose uptake and utilization.
Adverse Reactions Adjunct to diet PO Type Anorexia, and exercise to 2 nausea, improve DMInitia vomiting, glycemic l: 500 mg diarrhoea, wt control in type 2 2-3 loss, (non-insulin times/day flatulence, dependent) , may occasional diabetes increase metallic taste; mellitus. slowly. weakness; Max:2.25 hypoglycaemi g/day. a; rash, Polycysti malabsorption c ovary of vit B12. syndrome Chest Initial: discomfort, 500 flushing, mg/day palpitation, in the chills, morning headache, for 1 wk, lightheadedne then 500 ss, mg twice indigestion, daily for abdominal 1 wk, discomfort. then 1.5- Potentially 1.7 g/day Fatal: Lactic in 2-3 acidosis in divided presence of doses. renal failure and alcoholism.
Side Effect Symptoms of hypoglyce mia may occur, although this is more frequent in elderly or weak patients, or those suffering from trauma. Although rare, lactic acidosis symptoms may appear in patients with a predisposi tion to renal insufficien cy or serious cardiocirc
Contraindications Acute or chronic metabolic acidosis with or without coma (including diabetic ketoacidosis). Renal failure, severe renal or hepatic impairment, acute conditions which may affect renal function e.g. dehydration, severe infection or shock. Cardiac failure, CHF, IDDM, severe impairment of thyroid function; acute or chronic alcoholism.
Nursing Intervention Monitor blood glucose level closely. if it isn’t controlled after 4 weeks at maximum dosage, oral sulfonylurea may be added. Monitor kidney and liver function tests, particularly in elderly patients.
Glibenclamide Anti-diabetic, works by inhibiting ATPsensitive potassium channels in
Treatment of type II diabetes
Initially, 2.5 to 5 mg (regular tablets) PO daily;
Dizziness, drowsiness, headache, weakness, visual accommodati
ulatory problems. Should this occur, see a physician. The patient may also suffer from gastroente ric disorders (nausea, loss of appetite, stomach pain, vomiting and diarrhea) and allergic reactions of varying intensity. Major cause of drug induced hypoglyce mia.
Acute or chronic diseases which may cause tissue hypoxia e.g. cardiac or respiratory failure, recent MI or shock. Pregnancy, lactation.
Diabetes mellitus complicated by fever, trauma, or gangrene, and
Monitor blood glucose level especially during periods of increased stress.
pancreatic beta cells. This inhibition causes cell membrane depolarization, which causes voltagedependent calcium channels to open, which causes an increase in intracellular calcium in the beta cell, which stimulates insulin release.
range is 1.25 to 20 mg/day as a single dose or in divided doses.
on changes, nausea, vomiting, diarrhea, constipation, cramps, heartburn,rash
Cholestati c jaundice is noted.
Nootropics & Neurotonics, activating the central cholinergic system, also increases plasma adrenocorticotrop ic hormone
Psychiatric, CNS disorders, arteriosclerotic states.
PO Parkinso n's disease; Cerebrov ascular disorders and head injury
Stomach pain, diarrhea; hypotension, tachycardia, bradycardia.
in patients with impaired renal or hepatic function or serious impairment of thyroid or adrenal function. Diabetes mellitus in patients with a history of metabolic decompensati on eg. acidosis, diabetic precoma and coma. Diabetes mellitus in young people. Contraindicati on in patients hypersensitive to the drug or any of its components and in those with insulindependent
Monitor CBC and renal function test results. If patient is ill or has abnormal laboratory findings, monitor electrolyte, ketone, glucose, pH, lactate hydrogenase, and pyruvate levels.
(ACTH) levels and potentiates serum thyrotrophin (TSH) levels. The stimulation of central nicotinic and muscarinic receptors also increases growth hormone (GH) and luteinizing hormone (LH) serum levels. This activity on the cholinergic system is of high therapeutic usefulness in those clinical conditions where alterations of acetylcholine metabolism are considered one of the primary causes of disease eg, Alzheimers Disease (AD).
200-600 mg/day in divided doses. IV/IM Parkinso n's disease; Cerebrov ascular disorders and head injury Up to 1 g/day.
diabetes mellitus or diabetic ketoacidosis with or without coma.
GENERI C NAME/ BRAND NAME Humili nR
CLASSIFICATIO N Pharmacologic class: pancreatic hormone Therapeutic class: antidiabetic
INDICATION CONTRAINDICATION Mild to Contraindicated moderate in hypoglycemia diabetic and in patients ketoacidosisor hypersensitive to hyperosmolar insulin or any of hyperglycemia its content. . Newly diagnosed diabetes mellitus
SIDE EFFECTS Dyspnea, respiratory tract infection, itching, rash
NURSING INTERVENTION Assess patient’s glucose level before starting therapy and regularly thereafter. Monitor urine ketone level when glucose level is elevated. Store drug in cool area. Make sure patint is following appropriate diet and exercise programs.
Increases glucose transport across muscle and fat cell membranes to reduce glucose level. Promotes conversion of glucose to its storage form, glycogen.
IV Fluid Treatment/ Infusion D5NM
Classification It is a sterile, nonpyrogenic,hypertoni c solution of balanced maintenance electrolytes and 5% dextrose injection in water for injection. The solution is administered by intravenous infusion for parenteral maintenance of routine daily fluid and electrolyte requirements with minimal carbohydrate calories.
Nursing Responsibilities > Do not administer unless solution is clear and container is undamaged. > Caution must be exercised in the administration of parenteral fluids, especially those containing sodium ions to patients receiving corticosteroids or corticotrophin. >Solution containing acetate should be used with caution as excess administration may result in metabolic alkalosis. >Solution containing dextrose should be used with caution in patients with known subclinical or overt diabetes mellitus. > Discard unused portion. > In very low birth weight infants, excessive or rapid administration of dextrose injection may result in increased serum osmolality and possible intracerebral hemorrhage.
It is indicated for Hypersensitivity parenteral to any of the maintenance of components. routine daily fluid and electrolyte requirements with minimal carbohydrate calories from dextrose. Magnesium in the formula may help to prevent iatrogenic magnesium deficiency in patients receiving prolonged parenteral therapy.
( Potter 2005: 1162)
Nursing Process Long Term Objective After a month of treatment, the patient’s condition will be better through proper compliance of the patient in taking medications, proper participation to the medical and nursing interventions. Problem List CUES Subjecive: “Di niya kaya mag isa kumilos kasi baldado na ang kalahati ng katawan nya” as verbalized by the client. Objective: - Pale in color - Impaired - irritable Subjective: ”kailangan pa ng tulong ko kapag igagalaw siya sa kama” as verbalized by the relative Objective: - weakness - numbness of the left side of the body Impaired bed mobility related 2 to insufficient muscle strength This condition needs to be considered for the client to be able to recover faster and go back to perform his usual activities and tasks.
JUSTIFICATION This condition needs to be addressed for the client to be able to know proper management and actions enough to gain strength in performing his usual activities.
Self care deficit related to 1 neuromuscular/ musculoskeletal impairment
Risk for Situational Low Self- 3 esteem related to functional impairment
“ Ilang araw na ako hindi nakakapagtrabaho” as verbalized by the client.
This condition is not lifethreatening, thus it is not the primary focus in this study. But it can affect the individual’s perception of one’s self.
Objective: Afebrile Conscious Weakness Ambulatory with assistance Confused
Nursing Care Plan Assessment Subjecive: “Di niya kaya mag isa kumilos kasi baldado na ang kalahati ng katawan nya” as verbalized by the relative. Objective: - Pale in color - Impaired Diagnosis Self care deficit related to neuromuscular/ musculoskeletal impairment Plan After implementing nursing interventions, the relative will demonstrate techniques in self care needs. Intervention Rationale - Determined - Provides current activity information to level/ physical develop plan condition of care for. - Anticipated - Acceptance of hygienic needs handling and calmly mundane assisted as needs. necessary. - Allotted sufficient time - Decreased to perform tasks. motor skills - Repositioned frequently because of the - Reduces immobilization pressure on condition of the susceptible patient. areas, prevent s skin - Encourage breakdown stretching and toning exercises - Helps decrease and use of spasticity and medications as its effect, also Evaluation Goal partially met, Patient was able to verbalize some factors affecting activity tolerance.
taught to the relative.
Assessment Subjective: ”kailangan pa ng tulong ko kapag igagalaw siya sa kama” as verbalized by the relative
Diagnosis Impaired bed mobility related to insufficient muscle strength; deconditioning.
Plan After implementing nursing interventions, the relative could verbalize understanding of situation/risk factors, individual therapeutic regimen.
Intervention Reviewed functional ability and reasons for impairment. Assessed degree of immobility. Positioned patient to avoid skin/tissue pressure damage. Provided meticulous skin care, massaging
Rationale Identifies probable functional impairments. To cope on the patient, risk for injury. Distributes body weight and promotes normal circulation.
Evaluation Goal partially met, the relative was able to verbalize some factor that could change his lifestyle.
Objective: - weak looking Facial grimace Coherent and conscious Limited range of motion
Promotes circulation, elasticity and reduces risk for skin excoriation.
DIAGNOSIS Risk for Situational Low Self-esteem related to functional impairment
PLANNING After implementing the nursing intervention, the client will verbalize view of self as a worthwhile and important person.
INTERVENTION Verify client’s concept of self in relation to cultural/religious ideals
“ Ilang araw na ako hindi nakakapagtrabaho” as verbalized by the client.
Note nonverbal body language
Objective: Afebrile Conscious Weakness Ambulatory with
Conflict between Goal met current situation and these ideals may contribute to risk of The client view low self-esteem himself as important to his family and understand that after Incongruence recovery, he could between still do the things he verbal/nonverbal do prior to communications hospitalization. requires clarification.
The client may be predictive of current
Identify previous adaptations to illness or disruptive events in life
Advised patient to follow and comply with the managements and medications prescribed by the physician and the whole health care team. Advised patient to have the zeal in performing and doing activities that may enhance his health condition.
References: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing Eleventh Edition Volume 1 and 2 Marilynn E. Doenges, Mary Frances Moorhouse and Alice C. Murr Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales Edition 11 http://www.aafp.org/afp/20040401/1665.html http://www.netdoctor.co.uk/diseases/facts/stroke.htm http://health.nytimes.com/health/guides/disease/transient-ischemic-attack/overview.html http://www.emedmag.com/html/pre/fea/features/031506.asp http://emedicine.medscape.com/article/794281-overview http://kidshealth.org/parent/general/body_basics/brain_nervous_system.html#
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