IX.

Physical Assessment

Vital signs:
Temperature: 37.0ºC Pulse rate: 69 bpm
Blood Pressure: 130/800 mmHg Respiratory rate: 18 cpm
PROBLEM
SYSTEM PROCEDURE OBJECTIVE SUBJECTIVE
IDENTIFIED
 Patient is lying on bed, stupor
and, nasogastric tube is
 Assess for LOC signs of attached and elastic bandage Stupor
General
distress on her both legs. Glasgow  No subjective data. Hemiparesis
Appearance
Coma score is 8 (E₄V₁M₃) and
he presently has left side body
weakness.
“ ako man dyod ga trapo
 Observed patient’s over-all ka mama” as verbalized
 The client has good hygiene. none
hygiene and grooming. by the daughter of the
patient.
 Assessed body and mouth odor  Patient have oral plaque and Oral plaque
 No subjected data.
in relation to activity level. unpleasant odor is noted. Halitosis

 Brownish all over the body.

Integumentary  Inspected skin color.  None None
Uniform skin
 Assessed for edema.  No edema noted. None None
 Inspected, palpated and  No lesions.  None None
  Warm to touch
described skin lesions.

 Observed skin moisture.  The patient has dry skin.  None None
 The patient has a body
 Inspected body temperature.  None None
temperature of 37.0°C.
 Inspected skin turgor. None
 Good skin turgor.
 Inspected for any discharges in None
 None.
the skin.

 Inspected the skull for size,  51 cm in size and

Head None None
shape and symmetry.  Normocephalic
 Palpated skull for nodule,  Absence of nodules, masses
None None
masses and depression. and depression.
 Inspected facial features.  Symmetrical facial features. None hemiparesis
 Numbness on the left side of
the face

 Patient has already have white

hair and curly hair, coarse to
 Inspected the hair growth and touch and evenly distributed.
Hair  None None.
scalp. Scalp is clean and intact No
dandruff noted or lice.

Eyes  Inspected the eyebrows for hair  Hairs evenly distributed; skin None None
distribution, alignment and skin intact; eyebrows
quality movement. symmetrically aligned.
  Inspected the palpebral
conjunctiva for color, texture
and in the presence of lesions.
Retracted the eyelids with the
 Anicteric transparent,
thumb and index finger, exerting None None
capillaries evident.
pressure over the upper and
lower bony orbits and asked the
patient to look down, up and
from side to side.
 Inspected and palpated the
 No edema or tenderness noted
lacrimal gland by the tip of the None None
all over the lacrimal gland.
index finger.
 Inspected the cornea for clarity
and texture as the patient tries to
look straight ahead. Held the
 Transparent, shiny and smooth
penlight at an oblique angle of None None
details of the iris are visible.
the eye and moved the light
slowly across the corneal
surface.
 Performed the corneal  Client blinks when the cornea None None
sensitivity test to determine the is touched indicating that the
function of the fifth (trigeminal) trigeminal nerve is intact.
cranial nerve. Asked the patient
to keep both eyes open and to
 look straight ahead.
 Inspected the pupils for color,
shape and symmetry of size.
 Assessed each pupil’s direct and
consensual reaction to light to
determine the function of the
third (oculomotor) and the
fourth (trochlear) cranial nerves.
Darkened the room and let the
patient look straight ahead.
Using a penlight and
approaching from side to side,
shine a light on the pupil. Shine
the light on the pupil again and
observe the response of the other
pupil.
 Assessed each pupil’s reaction
to accommodation. Held a
penlight about 10 cm from the
bridge of the client’s nose.
Asked the patient to look first at
the top of the penlight and then
at a distant object behind the
 Brownish in color; 3-6 mm in
size, round, smooth border; iris None None
flat and round.
 Illuminated pupils constrict
 Non-illuminated pupil
constricts.
 The pupils constricted when
looking at the near object and
dilated when looking at the far None None
object.
 Pupils converge. PERRLA
 When looking straight ahead,
the patient can see the objects
in the periphery.
 Both eyes coordinated; moved None None
in unison with parallel
alignment.
 penlight. Alternate the penlight
from near to far. Observed the
pupil response. Next, moved the
penlight or pencil toward the
client’s nose.
 Inspected the auricles for color,
Ears
symmetry of size and position.
 Palpated the auricles for texture,
elasticity and areas of
tenderness. Gently pulled the
auricle upward, downward and
backward; folded the pinna
forward, pushed in on the tragus,
and applied pressure to the
mastoid process.
 Noted color, quantity and
consistency of any discharge
from the ears.
 Noted any structural changes in
the nose by observing the patient
Nose while breathing. Occluded one
nostril at a time, and asked the
patient to breathe through the
 Color is the same as facial
skin.
 None None
 Symmetrical.
 Auricles aligned with outer
cantus of the eye.
None None
 Mobile, firm and not tender;
pinna recoils after it is folded.
 No discharges or lesions noted
None None
on the external canal.
 Nasolabial fold is symmetrical
external nose have nasogastric
tube attached by tapes. There None None
are no lesions. Nasal septum is
intact and in midline.
 non-occluded nostril.
 Noted color, quantity and
 Presence of minimal
consistency of any discharge  None None
discharges.
from the nose.
 Noted size, color, and location  No external lesions noted.
Mouth and Lips
of any external lesions. Palpated  Cavities in the upper and  None. Presence of
Assessment
for mobility and firmness. lower jaw. cavities

 Noted any lesions or swelling on

the neck. Asked the patient to
 No lymphadenopathies noted;
relax and flex neck slightly.
Neck  Trachea at the midline;  None. None
Palpated the neck using the pads
 No jugular venous distention.
of the fingers to move the skin
and underlying tissues.

 Noted general appearance of the

 Relaxed breathing; equal chest
Chest chest. While patient is standing
expansion; rib cage moved  None. None
o Thorax or sitting, or in high Fowler’s
symmetrically with
position.
respirations
 Noted shape of ribs.  Downward shape of ribs. None

 Inspected size and symmetry and  Breast equal in size.

Breast  None. None
contour of breasts.  Symmetrical.
Lungs  Respiratory rate taken.  RR of 18 cpm None None
 Noted location and quality of
 Clear breath sounds. None None
lung sounds.

Heart  Evaluated atrioventricular heart  Lubb sounds heard.

None None
sounds.
 Evaluated semilunar heart  Dubb sounds heard.
None None
sounds.
 Evaluated presence of other  No other sounds noted.
None None
heart sounds.
 Assessed for heart murmurs.  No heart murmurs noted. None None
 Evaluated the apical pulse  HR of 69 bpm
assessing for general heart rate None None
and rhythm of contractions.
 Palpated peripheral pulses.  Palpable radial and dorsalis
None None
pedis pulses.
Abdomen  Assessed the general contour of
the abdomen with the patient
lying flat on bed.
 None.
 Client’s abdomen is uniform
in color,symmetrical and no
venous engorgement noted.
Umbilicus is sunken. Bowel
sounds are audible but None
slightly hypoactive.

 Auscultated abdomen to for any

presence and quality of bowel
sounds.

 Palpated abdomen to determine

condition of the abdominal
muscles and organs beneath
muscles. Instructed the patient to
relax, laid flat on bed, knee
flexed. Placed the fingers on the
patient’s abdomen, holding four
fingers together while exerting
 pressure with the flat part of the
fingers. Palpated from pubis
moving upward. Palpated all
quadrants of the abdomen to
assess organ contained in each
quadrant.
 Reviewed laboratory results for
any abnormalities.

 Assessed for pain in the

abdomen and appetite.

Urinary Tract
 Assessed the external urethra.  Not performed . None
Assessment
 Output of about 20 cc/hr
 Assessed the quantity, color,
 yellow amber in color
odor, specific gravity and pH or None
 Slight odor noted
urine output.

 Assessed for blood in urine and

Presence of RBC
any substances that is  Presence of RBC and protein
and protein
abnormally present in the urine the urine
 Palpated for any signs of bladder  Bladder not palpable. None
distention.

Mental – spiritual  Assessed physical appearance.  Stuporous with Glasgow Stupor

Assessment Coma score of 8 (E₄V₁M₃) None hemiparesis
 and presently has left side
body weakness where the
reflex scale is no response
while in the right side it is low
normal.
“tan-aw ra dyod na
si mama pag naa
 Noted speed, pressure, pace,
siya kailangan” as
quantity, volume and direction  Patient cannot talk. aphasia
verbalized by the
of speech.
daughter of the
patient
 Decrease strength and has the
 Assessed purposeful movements
limited ability to perform None weakness
and gestures.
active ROM.
 Slightly able to perceive, hear, Decrease
 Assessed the five senses. feel, touch to appropriate None sensory
stimulus. perception

NURSING CARE PLAN

INTERVENTION
CUES NURSING PLAN/ (Independent, Dependent, RATIONALE EVALUATION
DIAGNOSIS OBJECTIV Interdependent)
 ES
Subjective cues: 1. Provide side rails, For position changes and
Impaired After 8 hours overhead trapeze patient’s safety After 8 hours of
“dili ghapon siya physical of nursing nursing
2. Change position at least Reduce risk of tissue
kaayo makalihok mobility related intervention every 2 hours and ischemia. Affected side intervention the
sukad gi-admit to the patient possibly more often if has poorer circulation and patient was able to
siya” as neuromuscular will be able placed on affected side. reduced sensation and is maintain optimal
verbalized by the involvement: to maintain more predisposed to skin position of
daughter of left side optimal breakdown function .
patient paralysis as position of
3. Prop extremities in Flaccid paralysis may
evidenced by function functional position; interfere with ability to
Objective cues: inability to maintain neutral position support head.
purposefully of head
 Limited range move within the
of motion physical 4. Evaluate use for Prevent adduction of
positional aids: Place shoulder and flexion of
 Limited environment
pillow under axilla to elbow
ability to abduct hand
perform
gross/fine 5. Observed affected side Edematous tissue is more
motor skills for color, edema, or other easily traumatized and
 Difficulty signs of compromised heals more slowly.
circulation
turning to
sides 6. Inspect skin regularly, Pressure points over bony
 Hemiparesis particularly over bony prominences are most at
noted prominences. Gently risk for decreased
massage any reddened perfusion or
areas. ischemia.circulatory
stimulation help prevent
skin breakdown and
decubitus development.
7. Begin passive ROM to Minimizes muscle atrophy
all extremities. and promotes circulation.
Encourage exercises such
as squeezing rubber ball

8. Set goals with SO for Promotes sense of

participation in expectation of
activities/exercise and progress/improvement
position changes

9. Consult with physical Individualized program

therapist regarding can be developed to meet
active, resistive particular needs/deal with
exercises. deficits in balance,
coordination, strength

10. Administer muscle May be required to relieve

relaxants, antispasmodics spasticity in affected
as prescribed extremities.

Sources:
-Nursing Care Plans
by Marilynn E.
Doenges, Mary
Frances Moorhouse
and Alice C.
Geissler-Murr, pp.
232-233 6th Edition
 NURSING CARE PLAN
INTERVENTION
CUES NURSING PLAN/ (Independent, Dependent, RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES Interdependent)
1. Monitor vital signs Fluctuations in pressure
Subjective data: Ineffective After 8 hours of and changes in pulse After 8 hours of
cerebral tissue holistic nursing and respiratory rate can holistic nursing care
No subjective perfusion related care the patient occur because of brain the patient was able to
data to interruption of will be able to damage. demonstrate stable
blood flow: demonstrate stable vital signs and absence
Objective data: hemorrhage as vital signs and Useful in determining if of signs of increased
evidence by absence of signs of 2. Evaluate pupils, noting the brainstem is intact ICP
 Altered sensory, language increased ICP size, shape, equality, light anddetermined the
mental deficits reactivity balance between
status symphatetic and
 Changes in parasymphatetic
motor enervation.
response
 Difficulty in 3. Position with head slightly Reduce arterial pressure
swallowing elevated and in neutral by promoting venous
position. draineage and may
improve cerebral
circulation/ perfusion.

4. Maintain bedrest; provide Continual stimulation

quiet environment; restrict can increase ICP.
visitors as indicated Absolute rest and quiet
maybe needed to
prevent rebleeding in the
case of hemorrhage

5. Prevent straining at stool, Valsalva maneuver

holding breath increases ICP and

6. Assess for nuchal rigidity,
twitching, increased
restlessness, irritability,
onset of seizure activity
7. Administer supplemental
oxygen as indicated.
8. Administer anticoagulant
and antihypertensive as
prescribed.
potentiates risk of
rebleeding
Indicative for meningeal
irritation, especially in
hemorrhage disorders.
Reduces hypoxemia,
which can cause
cerebral vasodilation
and increase pressure.
Used to improve
cerebral blood flow and
prevent further clotting.
Sources:
-Nursing Care Plans
by Marilynn E.
 Doenges, Mary
Frances Moorhouse
and Alice C. Geissler-
Murr, pp. 230-231 6th
Edition
INTERVENTION
CUES NURSING PLAN/ (Independent, Dependent, RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES Interdependent)
Inspect skin on daily basis, To monitor skin
Subjective Risk for note any changes like redness integrity
impaired skin After 8 hours of After 8 hours of
cues:
integrity related holistic nursing holistic nursing care
dili ghapon to hemiparesis care the patient Keep the area clean/dry, To prevent infection, the patient was able to
siya kaayo and decreased will be able to stimulate circulation to demonstrate
makalihok mobility demonstrate surrounding area techniques to
sukad gi-admit techniques to maintained skin
siya” as maintained skin Employ pressure-relieving Pressure points over integrity
integrity devices and minimize shear bony prominences are
verbalized by
and friction when positioning most at risk for
the daughter of decreased perfusion or
patient ischemia.circulatory
stimulation help prevent
skin breakdown and
Objective decubitus development
cues:
gently massage healthy dry To promote circulation
skin and maintain adequate
 Limited nutrition
range of
motion change position at least 2 Reduce risk of tissue
 Limited hours ischemia. Affected side
has poorer circulation
ability to
and reduced sensation
perform and is more Nurse’s pocket guide
 gross/fine predisposed to skin by Marilynn E.
motor skills breakdown Doenges, Mary
Frances Moorhouse
 Difficulty
use appropriate padding To reduce pressure and and Alice C. Geissler-
turning to devices when indicated enhance circulation Murr, pp. 619-620 11th
sides Edition
Hemiparesis
noted

PREDISPOSING PRECIPITATING
FACTORS FACTORS

 Age  Uncontrolled hypertension

 Gender  Diet

 Family History  Diabetes

 Sedentary lifestyle

Uncontrolled BP
 Penetrator vessels (Small arteries branching off
as major cerebral arteries) primary affected
Initial hyperplasia with hyalinosis in Focal necrosis Disruption/ break in the vessel wall
the vessel wall

Blood leaks out of the ruptured

Obstruction of CSF pathway Seeps into the ventricles vessel wall

CSF accumulation in the ventricles Ventricles dilate behind point of

obstruction

Direct mechanical injury to the Imbalance between the contents of Herniation secondary to mass
brain parynchema the cranial vault effect

Imbalance between the contents of

the cranial vault
 Altered perfusion and function of the following arteries

Middle Anterior Posterior Internal Vertebrobasilar Antero- Posterior-

cerebral cerebral cerebral carotid system Inferior Inferior
cerebellar cerebellar

Lateral Frontal lobe Occipital Branches into Cerebellum

hemisphere, lobe, ophthalmic & Cerebellu Cerebellu
frontal, anterior & PCA, BrainS/SX:
stem S/SX:
m m
Ataxia,
parietal and medial anterior Alternating
S/SX:
temporal portion of choroidal motor paralysis of
S/SX: the larynx
Contra-
lobes, basal Contra- temporal ACA, MCA weakness,
lateral
ganglia ataxic gait, & softplate,
lateral S/SX: S/SX: S/SX: ipsilateral
hemiparesis hemiparesis, Contralatel dysmetria, Ipsilateral
or Mild diplopia, loss of
foot & leg contalateral hemiparesis ataxia, sensation in
hemiplegia, deficits with facial nystagmus, facial
altered hemiparesis, conjugate face,
greater than intention asymmetry, paralysis, contralatera
consciousne the arm, ipsilateral gaze, loss of
ss, inability tremor, loss paralysis, l on body,
footdrop, gait of conjugate priods of sensation in nystagmus,
to turn eyes disturbances, aphasia, memory loss, face,
toward side, gaze, disorientatio dysarthria,
vision nystagmus, carotid sensation hiccups,
aphasia, changes, bruits n, changes ion
agnosia, memory Drop attacks, coughing,
confussion, deficits, trunk and vertigo,
vomiting, amnesia, tinnitus, limbs,
memory hallucinatio vertigo, nausea and
shortened ns nystagmus, vomiting
deficit attention dysphagia, tinnitus,
 Loss of neural feedback mechanism Cerebral death Coma

Cessation of
physiologic
functions
Respirator GIT GUT Other systems
Cardiovascula
y
r
Restlessness,
abnormal
Loss of Relaxation Loss of Loss of thermorgulat
cardiac of venous Loss of bowel sphincter ion, mental
muscle valves lung movemen moveme confusion,inc
t nt rease
movemen secretion
t
Bradycardia Hypotension
Relaxatio
Failure of n of Neurologic
accessory intestines bladder
 CO muscles for and
breathing sphincter
Cardiopulmonary
Arrest Apnea
XI. COMPARATIVE STUDY

CLASSICAL CLINICAL RATIONALE

Hemiparesis manifested The resultant deficit is
believed to be due to the
large representation of the
affected muscles in the
homunculus.
hemiplegia Manifested Due to damage of the
lateral gaze center
Aphasia Manifested Blood clot from the CVA
can prevent oxygen and
nutrients from reaching
nerve cells thus, resulting
to the cell death and the
affected body cease to
function
Dysphagia Manifested Cranial nerve 9 and 10 are
located at the left
hemisphere of the brain,
which is the affected area,
and aids in the eating
process.
Dysarthria Manifested Blood clot from the CVA
Numbness or weakness Manifested can prevent oxygen and
of face, arm or leg nutrients from reaching
Dizziness Not manifested nerve cells thus, resulting
Severe headache Not manifested to the cell death and the
Impaired vision Not manifested
affected body cease to
function