Professional Documents
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A Case Presentation of Cva
A Case Presentation of Cva
CEREBROVASCULAR ACCIDENT
In Partial Fulfillment
of the Requirements for the Degree
BACHELOR OF SCIENCE IN NURSING
March 2020
TABLE OF CONTENTS
PAGES
I. TITLE PAGE i
V. OBJECTIVES 1
X. GENOGRAM 9
XIX. REFERENCES 42
ii
LIST OF TABLES
PAGE
V. DIAGNOSTIC TESTS 19
iii
LIST OF FIGURES
PAGE
I. GENOGRAMS 9
iv
OBJECTIVES
General Objective:
At the end of one hour of case presentation, the participants will be able to demonstrate
knowledge regarding the general health and disease process of the patient with Cerebrovascular
Specific Objective:
At the end of an hour of case presentation, the participants will be able to:
1. The nature of the disease, its signs and symptoms, diagnosis and treatment;
4. Efficiently provide appropriate and proper nursing diagnosis in line with the client’s
condition;
5. Skillfully formulate nursing care plan for the problems identified ; and
1
DEFINITION OF TERMS
leads to tangle of arteries and veins in the brain that lacks a capillary bed
the arteries
Brain Aneurism – Is a dilation of the walls of a cerebral artery that develops as a result
2
INTRODUCTION
conditions involving the death of brain tissue due to disruption of its vascular supply. According
to Hinkle, Cheever (2018), a stroke is a sudden loss of function resulting from disruption of the
blood supply to a part of the brain. Strokes can be divided into two major categories: ischemic
(approximately 87%) and hemorrhagic (13%). Ischemic stroke, being the most common type of
the two results when arteries supplying brain tissue are blocked. It is often caused by cerebral
thrombosis and cerebral embolism. Usually the plaque consists of cholesterol, calcium, fat, and
cellular waste products. For hemorrhagic strokes, it results from bleeding of arteries supplying
brain tissue.
Hemorrhage strokes accounts for 13% of strokes. As stated by Hinkle and Cheever
hemorrhage, or bleeding into the brain tissue, is most common in patient with hypertension and
leaking in the area of the circle of Willis and a congenital AVM of the brain.
According to Who (2016), cerebrovascular accidents are the second leading cause of
death and the third leading cause of disability. Globally, 70% of strokes and 87% of stroke-
related deaths and disability-adjusted life years occur in low- and middle-income countries. In
the Philippines, stroke second leading cause of death. It has a prevalence of 0·9%; ischemic
stroke comprises 70% while hemorrhagic stroke comprises 30%. Age-adjusted hypertension
prevalence is 20·6%, diabetes 6·0%, dyslipidemia 72·0%, smoking 31%, and obesity 4·9%. The
3
Health care is largely private, and the cost is borne out-of-pocket by patients and their families.
Challenges include delivering adequate support to the rural communities and to the
underprivileged sectors.
The risk factors predisposing of stroke are heart diseases, age and gender, race and
ethnicity, personal or family history of stroke or transient ischemic attack, and brain aneurysm or
mellitus, smoking, falls and alcoholic. Signs and symptoms of CVA is Face drooping, Arm
The purpose of this study is to instill knowledge to the listeners about cerebrovascular
accident or stroke particularly about hemorrhagic strokes. With this information, the listeners
will be able to recognize different types of cerebrovascular accidents along with its sign and
4
VITAL INFORMATION
Gender: Female
5
NURSING HEALTH HISTORY
According to the daughter of Mama, 6 hours prior to the admission, after their last prayer
session the client went to the bathroom to cleaned her body but she was found by her family
unconscious in the ground and was brought to the hospital after the incident.
Based on the information of the family, the Mama experienced mumps, chicken pox and
strep throat in her childhood days. She had not completed her immunization when she was
young. Way back to 2005, the Mama undergone cholecystectomy and it was performed by Dr.
Eustique Jr. T. Oliverio, General Surgeon at Iligan Medical Center. The client did not experience
any injuries or accidents in the past. It was stated by the daughter that the client was admitted
many times that it cannot be counted by fingers. She was admitted at Medical Community Center
either due to cough or hypertension was confined for 2-3 days. Last 2019 in September 4, 2019
at 7:45 PM, she was admitted due to mild stroke at Adventist Medical Center-Iligan (AMCI).
Based on the previous chart it was recorded that 4 hours prior to the admission, Mama started
having involuntary movement at the left side of her body associated with headache and the
symptoms persisted thus the family decided to send the patient to the hospital at AMCI. The
admitting diagnosis at the time is Transient Ischemic Stroke and the final diagnosis results are
attending physician at the time is Dr. Diamla a Neurologist. Dr. Diamla ordered to performed CT
scan to Mama on September 5, 2019 and the result is old infarctive changes in the right parietal
lobe white matter with malacic changes – as a sequela from previous history of cerebral bleed.
6
The medications that was given to Mama for parenteral are Pantoprazole (pantopraz) 40 mg IV
which is a proton pump inhibitor that decreases the amount of acid produced in the stomach,
Kepra 500 mg + 90 mL PNSS to run for 1 hour then every 12 hours x 2 more doses is used to
treat partial-onset, myoclonic, or generalized tonic-clonic seizure in patients with epilepsy and
diazepam 5 mg IV. For oral medications are Depakote 1 tablet is to prevent migraine headaches,
Pantoprazole 40 mg 1 tablet once a day after meals, this is used to treat certain stomach and
esophagus problems (such as acid reflux) and Levocetirizine 5 mg 1 tablet, an antihistamine used
to relieve allergy symptoms. She was discharge in September 6, 2019 at 11:30 AM. The last
check-up of her vision was last 2019 she was prescribed with eyeglasses by Dr. Salma
Gandamra, Ophthalmologist. In 2013 she had her pap smear by Dr. Saavedra, Gynecologist at
Amai Pakpak Medical Center and Mama is practicing Breast Self-Examination stated by the
daughter. She is allergic to seafoods. The current medications she took are B complex vitamins
and amlodipine. She delivered 6 babies and all of them are full term babies without any
7
GENOGRAM
PATERNAL MATERNAL
unrecalled unrecalled
86 Y.O ? ? ? ? ? ? ?
HPN HPN HPN HPN HPN HPN HPN HPN
CVA
LEGENDS:
- MALE HPN - HYPERTENSION
8
Physical Examination and Review of Systems
Table 2
9
2. Integumentary Warm to touch Impaired Skin
System Senile turgor Integrity
IV line attached at metacarpal vein at Altered body
the right and left hand temperature:
Has thickened nails hyperthermia
10
NGT attached
Breather mask attached with 15
L/min.
ORAL CAVITY
Lips were dry and pale
Removed dentures
Front teeth are missing
Saliva accumulated in the mouth
4. Neck Symmetrical and proportional to head No problem
and shoulder identified
No lumps, mass, and tenderness
noted upon palpation
11
The radial and apical pulse rates are
identical
Normally no murmurs are heard
BP – 70/40 mmHg
PR – 62 bpm
Chest X-ray results:
Minimal cardiomegaly
Atherosclerotic Aorta
7. Breast and axilla No masses should be palpated. No problem
No palpable nodes identified
12
HEMOGLOBIN 100.0 Decrease
LYMPHOCYTE
S 0.05 Decrease
STABS 0 Decrease
EOSINOPHILS 0 Decrease
BASOPHILS 0 Decrease
20. Endocrine system FBS(FASTING BLOOD SUGAR)
result:
Result Interpretation
10.03 Increase
13
described.
Linear fracture in the bilateral
parietal bones traversing the
sagittal suture.
Atherosclerotic bilateral internal
carotid and vertebral arteries.
14
admitted for many times that he unresponsive.
cannot remember the numbers.
Mama’s appetite decreases. She Because Mama is still
would ate ½ cup of rice that the unconscious, they attached
food is being served. She is NGT to feed her food and
allergic to seafood and does not PNSS is attached according
eat pork based of their religion to doctor’s order.
2. Nutrition and being a Muslim. She drinks 5
Metabolism Pattern glasses of water/day and drinks
coffee 3x a day. Eat 3x a day.
She likes to eat vegetables,
fruits and fish. They would eat
at the restaurant every twice a
week.
Defecating once a day and She was wearing diaper and
3. Elimination Pattern every time she drinks water she would defecate once a day.
would urinate.
Every day she had a routine that She was currently lying on
4. Activity and Exercise every morning upon woke up to bed because of her current
Pattern swipe the floor and attending condition.
prayer session.
She always woke up at 6 in the She is still unresponsive and
morning and sleeps at 9 in the unconscious.
5. Sleep and Rest Pattern evening. She sometimes had
some naps in the afternoon.
She is not drinking alcohol but No particular habit in
6. Personal Habits she had smoke in her teens and drinking alcohol and
stop after 2 years. smoking.
She had not taken some illegal Not taking illegal drugs.
7. Street Drugs drugs in her life.
15
Patter her family relationship with her family.
14. Coping and Stress She would cry when she is in Not applicable.
tolerance Pattern stress situations.
She believed that Allah gave According to the daughter
her years to live and be with her that her mother believes that
15. Values and Beliefs family. She happy that all her their Allah is always with
Pattern children is successful in their them.
careers.
16
1. Heart Blood pressure in the arteries is generated by
contraction and relaxation of muscles of the
heart’s ventricle walls. Systolic pressure
(systolic) measures the pressure in the arteries
when the heart beats (when the left ventricle
contracts). Diastolic pressure (diastole)
measures the pressure in the arteries between
heart beats (when the left ventricle release and
refills with blood).
2. Elastic Arteries The largest arteries closest to the heart. These
are the aorta and its largest branches and the
pulmonary trunk with their large pulmonary
arteries.
3. Tunica Media Made mostly of elastic fibers, the tunica media
stretches under systolic pressure and recoils
during diastolic. The recoil helps push blood
away from the heart and into smaller arteries.
4. Arteries/ Capillaries Arterioles are the smallest of all arteries,
eventually terminating into capillaries. The
middle layer of arterioles consists of tiny rings
of smooth muscle which act as sphincters. If
these rings stay constricted, pressure backs up
into the other arteries and the heart.
18
medulla oblongata.
a) Midbrain a) It connects to the pons and cerebellum
with cerebral hemispheres. It contains
sensory and motors pathways and serve as
the center of auditory and visual reflexes.
b) Pons
b) Portion of the pons help regulate
respiration.
c) Medulla c) Reflex centers for respiration, blood
pressure, heart rate, coughing, vomiting,
swallowing and sneezing. Reticular
information, responsible for arousal and
the sleep-wake cycle.
d) Cerebellum Located at the posterior to the midbrain and
pons and below the occipital lobe. It controls
fine movement, balance and position (postural)
sense or proprioception (awareness of position
of extremities without looking at them).
e) Structures protecting the brain
19
g) Cerebral Circulation The brain receives approximately 15% of the
cardiac output or 750 mL per minute of blood
flow.
h) Spinal Cord Spinal cord is continuous with the medulla,
extending from the cerebral hemispheres and
serving as the connection between the brain
and periphery. Approximately 45 cm (18
inches) long and about the thickness of a
finger.
20
DIAGNOSTIC TEST
Table 5
22
formation.
Instruct to resume
normal activities
and diet.
CBC & PLATELET Explain test
procedure. Explain
COUNT
that slight
RBC 4-6 x 10 12/L 3.25 DECREASE anemia, fluid discomfort may be
overload, or felt when the skin is
hemorrhage beyond punctured.
24 hours. Encourage to avoid
stress if possible
because altered
HEMATOCRIT 0.40-0.54 0.32 DECREASE anemia, physiologic status
hemodilution or influences and
changes normal
massive blood loss. hematologic values.
130-160 g/L 100.0 DECREASE anemia, recent Apply manual
HEMOGLOBIN pressure and
hemorrhage or fluid dressings over
retention causing puncture site.
Monitor the
hemodilution. puncture site for
5-10 x 10 9/L 21.76 INCREASE Infection such as an oozing or hematoma
WBC formation.
0.50-0.65 0.96 INCREASE abscess, meningitis, Instruct to resume
SEGMENTERS
appendicitis, normal activities
and diet.
leukemia.
(BILE)
25
CHEST X-RAY There is MINIMAL Remove all metallic
crowding of the CARDIOMEGALY objects.
lower lung No preparation is
parenchyma ATHEROSCLEROT required.
IC AORTA
The trachea is at
the midline. The SENILE Provide appropriate
heart is OSTEOPOROSIS clothing.
minimally
enlarged,
magnified and
transversely
oriented.
Tortuous aorta
with wall
calcifications.
The hilar vessels
are not dilated.
The diaphragm
is intact, situated
high. The
costophrenic
sulci are sharp
and distinct.
Generalized
bone rarefaction
Intraventricular
hemorrhagic
extension is
again seen in
both lateral
ventricles, third
ventricle and
fourth ventricle.
There is no
significant
change in the
subdural
hematomas in
the left
frontotemporal
convexity
(thickness of 0.9
cm) and
posterior
interhemispheric
region
(thickness of 0.5
28
cm)
Subarachnoid
hemorrhage is
again noted in
the bilateral
cerebral
hemispheres,
more extensive
in the left.
Linear fracture
in the bilateral
parietal bones is
again noted
traversing the
sagittal suture.
The bilateral
internal carotid
and vertebral
arteries remain
calcified.
Densities are
seen in the right
posterior
ethmoid air
cells. The rest of
the visualized
paranasal
sinuses are clear.
The orbits and
petromastoids
are
unremarkable
29
30
PHARMACOLOGIC MEDICATIONS
Table 7
Route/Frequency/Dos Nursing
Drug name Mechanism of Action Indication Contraindication
e responsibilities
Generic name: Route: IV push Increase osmotic To reduce intraocular Hypersensitivity to
Monitor v/s esp. BP
pressure, thus or intracranial pressure drug.
Mannitol Frequency: Q 6
inhibiting tubular on cerebral edema. I &o hourly.
Dose: 150 mL reabsorption of Patients with anuria,
water and severe pulmonary
Brand:
electrolytes. congestion, active
intracranial bleeding,
metabolic edema.
Generic name: Route: Oral Inhibits influx of Hypertension, chronic Sick sinus syndrome; Assess cardio
calcium ion across stable angina, second or third respiratory status.
Amlodipine Dosage:5mg cell membranes to vasospatic angina degree BP, pulse,
produce relaxation of antrioventricular respiration and
Frequnecy: OD coronary ECG.
vascular smooth
Assess hydration
muscle. Decrease
and fluid volume
peripheral vascular
status, I & O ratio
resistance of smooth
presence of
muscle (decrease
edema, distended
BP)
neck veins,
adequate pulses
and skin turgor.
Generic Name: Route: IVTT Inhibits cell wall Used to treat moderate Contraindicated to
Piperacillin + Monitor patient for
synthesis during to severe infections. hypersensitivity to
Tazobactam Dose: 4.5 mg diarrhea.
bacterial drug, other
multiplication. Moderate to severe penicillins, Serious skin
Frequency : q 8 CAP. cephalosphorins, or reactions can occur.
31
Brand name: beta-lactamase
inhibitors.
Use cautiously to
patients with
bleeding tendencies,
uremia, hypokalemia,
and allergies to other
drugs.
Generic: Route: IV drips The precise Indicated as Hypersensitivity to Instruct the
Levetiracetam mechanism by adjunctive therapy in levetiracetam. patient to take
which levetiracetam the treatment of partial medication as
Dose: 500mg exerts is anti- onset seizures. directed.
Brand: Keppra epileptic effect is
unknown. Do not
discontinue
Frequency: Q 12
abruptly; may
hrs
cause increase in
frequency of
seizures
Generic: Route: IV Increase blood flow CVA in acute and Hypersensitivity Monitor BP,
and oxygen recovery phase. Disorder of Cardiac PR, HR
Citicoline Pacemaker acitivity
consumption in the carefully.
Dose: brain. and conduction
Assess allergic
reaction like GI
disturbances.
Frequency: Q 8hrs Give only the
prescribed
dose.
Generic: Route: IVTT Valproic acid is Sole and adjunctive Contraindicated with Give drug with
Valproic Acid sometimes used therapy in simple and hypersensitivity to food to prevent
Dosage: 500 mg together with other complex absence valproic acid, GI upset.
Brand name: seizure medications. seizures; acute hepatic disease, or
32
depacon Frequency: Valproic acid is also treatment of manic significant heaptic Monitor ammonia
Q 12 used to treat manic episodes associated impairment. levels and
episodes related to with bipolar discontinue if
bipolar disorder disorder; prophylaxis there is clinically
(manic depression), of migraine significant
and to prevent headaches; elevation in level.
migraine headaches. adjunctive therapy
Monitor serum
for multiple seizure
levels of valproic
disorders.
acid and other
anti-epileptic
drugs given
concomitantly,
especially during
the first week of
the therapy.
Monitor CBC,
platelet count and
bleeding time.
Generic: Route: IVTT Gastric acid-pump Short-term treatment Contraindicated Arrange for
inhibitor: suppresses of active duodenal with further
Omeprazole
gastric acid secretion ulcer; first line therapy hypersensitivity to evaluation of
Dose: 40mg by specific inhibition in omeprazole are its patient after
of the hydrogen components 8weeks of
Brand: treatment
potassium ATP as therapy for
Omenol Frequency: OD enzyme system at the gastroesophageal gastro reflux
secretory surface of reflux disorders; not
the gastric parietal intended for
cells. disease (GERD). maintenance
therapy.
34
CONCEPT MAP
NON-MODIFIABLE FACTORS:
MODIFIABLE FACTORS:
AGENON-MODIFIABLE
(86 Y.O) FACTORS:
FAMILY HISTORY
DIET (MEAT EATER)
VASOCONSTRICTION (HYPERTENSION, STROKE)
RACE (ASIAN)
RISK FOR
SEIZURE Lactic acidosis
INJURY pH level = 6.0
35
BRAIN TISSUE
PARALYSIS NECROSIS DEATH
Small artery
Embolic strokes
stroke
↑ BODY
TEMPERATURE
MEDICATIONS:
NURSING DIAGNOSIS:
Amlodipine 5 mg OD
Ineffective breathing pattern Piperacillin + Tazobactam 4.5
Impaired Skin Integrity mg q 8
LEGEND:
Altered Body Temperature : Levetiracetam 500 mg IV q 12
Hyperthermia Omeprazole 40 mg IV OD - PATHOPHYSIOLOGY
Risk for Aspiration Paracetamol 300 mg IV RTC
Tolilac 125 mg IV bolus q 4 - DIAGNOSTIC TESTS
36
NURSING CARE PLAN
Table 8
Planning
Nursing Nursing
Assessment (Desired or Expected Rationale Evaluation
Diagnosis Interventions
Outcomes)
Objective Data: Ineffective After 8 hours of nursing Independent: After 8 hours of
Breather mask Breathing interventions the client will a) Assess and record a) The average rate of nursing intervention
attached with Pattern r/t be able to: respiratory rate respiration for adults is the client was able
15L /min unknown cause a. Patient maintains an and depth at least to:
10 to 20 breaths per
Cheyne-Stokes effective breathing every 4 hours.
pattern, as evidenced minute. It is important Remains free of
by relaxed breathing to take action when injuries.
Vital Signs at normal rate and there is an alteration in
PR: 62 bpm depth and absence of the pattern of breathing Explains methods to
RR:17-30 bpm dyspnea. to detect early signs of prevent injury.
BP:70/40 mmHg b. Patient’s respiratory respiratory
O2Sat: 82% rate remains within Identifies factors
compromise.
established limits. that increase risk for
injury.
b) Observe for b) Unusual breathing
breathing patterns patterns may imply an Relates intent to
underlying disease practice selected
process or dysfunction. prevention
Cheyne-Stokes measures.
respiration signifies
Patient increases
bilateral dysfunction in
daily activity, if
the deep cerebral or feasible.
diencephalon related
with brain injury or
metabolic
abnormalities
c) Assess for use of
37
accessory muscle. c) Work of breathing
increases greatly as
lung compliance
decreases.
d) Utilize pulse
oximetry to check
d) Pulse oximetry is a
oxygen saturation
helpful tool to detect
and pulse rate.
alterations in
oxygenation initially
e) Evaluate skin
color, temperature, e) Lack of oxygen will
capillary refill; cause cyanosis coloring
observe central to the lips, tongue, and
versus peripheral fingers. Cyanosis to the
cyanosis. inside of the mouth is a
medical emergency!
Collaborative:
f) Provide
respiratory f) Provide oxygen to the
medications and system.
oxygen, per
doctor’s orders.
Sig: Breather
mask attached
with 15L /min
38
NURSING CARE PLAN
Table 9
NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS
Objectives Impaired Physical After 8 hours of Independent:
Mobility r/t nursing interventions, a) Establish rapport. a) To promote After 8 hours of
neuromuscular patient will be able to cooperation. nursing
involvement improve and increase b) Monitor vital signs. b) To have a baseline interventions, the
secondary to CVA strength and function data. patient was able to:
infarct of affected body part.
c) Note emotional/ c) To assess functional Improve and
behavioral responses ability. increased
to problems strength and
of immobility. function of
affected body
d) Determine d) To assess expected part.
readiness to engage level of participation.
in activities.
h) Involve SO in care
39
assisting them to
learn ways
of managing
problems of
immobility.
i) Provide restful
environment for
patient.
40
NURSING CARE PLAN
Table 9
Planning
Nursing Nursing
Assessment (Desired or Expected Rationale Evaluation
Diagnosis Interventions
Outcomes)
Objective Data: Ineffective After 8 hours of nursing Independent: After 8 hours of
Capillary Refill (<2 tissue perfusion interventions the client will a) Assess for sign a) Particular clusters of nursing
secs) r/t secondary to be able to: of decreased signs and symptoms intervention the
Chest X-ray result: hypotension c. Show no further tissue perfusion. occur with differing client was able to:
minimal worsening/ causes. Evaluation of
cardiomegaly repetition of Ineffective Tissue Remains free of
atherosclerotic deficits. Perfusion defining injuries.
aorta d. Maintain maximum characteristics
tissue perfusion to provides a baseline for Explains methods
Vital Signs vital organs, as future comparison. to prevent injury.
PR: 62 bpm evidenced by warm
RR:17-30 bpm and dry skin, present b) Check rapid b) Electrolyte/acid-base Identifies factors
BP:70/40 mmHg and strong changes or variations, hypoxia, that increase risk
O2Sat: 82% peripheral pulses, continued shifts and systemic emboli for injury.
T: 37.9 vitals within in mental status. influence cerebral
patient’s normal perfusion. In, addition, Relates intent to
range, balanced it is directly related to practice selected
I&O, normal cardiac output. prevention
measures.
c) Assist with c) Gently repositioning
position patient from a supine Patient increases
changes. to a side lying position daily activity, if
can reduce the risk for feasible.
orthostatic BP
changes. Older
patients are more
susceptible to such
drops of pressure with
41
d) Do not elevate position changes.
legs above the d) With arterial
level of the insufficiency, leg
heart. elevation decreases
arterial blood supply
to the legs.
42
NURSING CARE PLAN
Table 9
44
e) CVA in acute
and recovery
phase.
NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS
Objectives Risk for injury related After 8 hours of nursing Independent: After 8 hours of
to loss of large or interventions, patient will a) Provide privacy. a) 'The patient who nursing
Vital signs: has an
small muscle be able to: interventions, goals
f) T – 37.8 – 39.3 coordination aura/warning of
were fully met as
impending seizure
secondary to seizure Attain or sustain may have time to evidenced by:
no injury during seek a safe,
seizure activity. private place. The patient
sustained no
b) Keep padded side b) Minimizes injury
Will adhere with injury during
rails up with bed in should frequent
safety measures seizure activity.
lowest position. or generalized
and identifies Adhered with
seizures occur
hazards of non- while client is on safety
compliance. bed helps localize measures.
the cerebral area
Will verbalize the of involvement
importance of and may be useful
lifestyle changes in chronic
conditions in
to reduce risk
helping patient
factors and and significant
protect self from other prepare
45
for or manage
c) Document pre seizure seizure activity.
activity, presence of
aura, or unusual c) Helps localize
behaviour, type of the cerebral
seizure activity, such area of
as location and involvement
duration of motor and may be
activity, and LOC, eye useful in
activity, respiratory chronic
impairment and conditions in
cyanosis, and helping patient
frequency of and significant
recurrence. other prepare
for or manage
d) No attempt should be seizure activity.
made to restrain the
patient during
seizure.
d) Muscular
contractions
are strong and
e) Stay with the client
restrain can
during and after produce injury.
seizure and perform
e) Promotes
neurological and vital
patient safety
signs check post
and reduces
seizure, weakness or
sense of
motor deficits, BP,
isolation during
RR&, PR.
the event.
46
Document
postictal state 3
Collaborative: time and
Administered medications completeness
as ordered. of recovery to
normal state.
f) Mannitol 150 mL IV
push q6
f) To reduce
intraocular or
intracranial
pressure on
g) Valproic Acid 500mg
cerebral edema.
IVTT q12
g) Sole and
adjunctive
therapy in
simple and
complex
absence
seizures
47
NURSING CARE PLAN
Table 9
NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS
Objectives: Impaired Physical a) Establish a) To promote
Mobility r/t After 8 hours of rapport. cooperation. After 8 hours of
Body immobility neuromuscular nursing interventions, b) Monitor vital b) To have a nursing
involvement patient will be able to signs. baseline data. interventions, the
secondary to CVA improve and increase c) Note emotional/ c) To assess patient was able to:
infarct strength and function behavioral functional ability.
of affected body part. responses to Improve
problems and
of immobility. d) To assess expected increased
d) Determine level strength
readiness to of participation. and
engage in e) To promote function of
activities. optimal level affected
e) Turning every 2 of function and body part.
hours. prevent
complications.
f) To prevent
occurrence
f) Provide for safety of injury.
measures
including fall
prevention. g) Limits fatigue,
maximizing
g) Identify energy participation.
conserving
technique.
h) Involve SO in
care assisting
them to learn
48
ways
of managing
problems of
immobility.
i) Provide restful
environment for
patient.
49
DISCHARGE PLAN
OBJECTIVES:
1. To give awareness to the client to religiously take the prescribed medications on time,
and to know its side effects and to follow the instructions given.
2. To have knowledge about the type of food to be eaten and avoided and to aim to have
well-balanced diet;
3. And to avoid unplanned readmission to the hospital by taking note of the instructions
Be Respectful
First of all, it should be noted that even though the patient has passed away, they should still be
treated with respect. This is especially true around family members and loved ones. This is
definitely not the time to stick with strictly "business" and not show any compassion and
understanding.
50
The family and loved ones may have customs that you are unfamiliar with. There are many
different cultures with different backgrounds and religious beliefs. They may mourn differently
Do not under any circumstances interrupt them during their practices. The only exceptions would
Whenever the time seems right, ask them if they need anything. Make sure they know that you
are available if they do need anything and let them know that they can stay for as long as they
please.
Do not rush them out of the room so you can begin the physical part of the post-mortem care.
What's important right now is that the family is as comfortable as possible. After you are sure
that they have left and are completely done with their visit, you may begin.
Supplies Needed
A body bag
3 patient labels
A hospital gown
51
One of the tags will go on the patient's big toe
1. If there is a sign that you are supposed to place outside of the door in the hallway, make
5. Remove all sheets, blankets, and the gown from the patient.
6. Remove any drains and tubes from them such as IVs and foley catheters, and heart
monitors. If you are unsure of whether something should be removed or this is beyond
7. Dentures and glasses should go in a container and placed to the side. They should later be
8. Give the bed bath like you would if the patient was still alive. Just because they can't feel
anything doesn't mean you shouldn't be thorough or should be extra rough on them.
9. Some facilities require you to put a fresh hospital gown on them while others want them
to be placed in the body bag naked. Check your policy or ask your supervisor if you are
10. You should now tie one of the name tags onto the patient's big toe.
11. You will have to unfold the body bag and unzip it all of the way.
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12. Then roll up half of the bag longways.
13. One of you should then turn the patient on their side.
14. The other caregiver should then tuck the old linens underneath the patient and place the
15. Tuck the fitted sheet under the patient as far as possible
16. Now tuck the rolled end of the bag underneath the patient. Make sure the bag is placed in
such a way so the patient will be able to fit. This means the bag should reach past their
17. Then turn the patient onto their other side and finish putting on the fitted sheet and unroll
19. Don't forget to tie the two zippers together with another name tag.
20. Stretch the flat sheet over the bed completely covering the body bag. Out of respect, you
do not want visitors in the hallways to clearly see the person in a bag while they are taken
to the morgue.
21. Don't forget that dentures and glasses go in the body bag with the patient and the last
name tag should go with the patient's remaining belongings. Make sure the belongings
22.
Rigor Mortis
If the patient has been dead for a few hours, a process called rigor mortis may have set in. This
means that they will be stiff and harder to move around. When this happens, it is still possible to
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If their mouth is wide open, you should gently close it and place a rolled-up towel underneath
their chin. Doing this will prevent their mouth from staying open after rigor mortis sets in.
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REFERENCES
Global Health Estimates. Geneva: World Health Organization (2012). Available from:
Hinkle & Cheever (2018). Medical-Surgical Nursing. 14 edition. Wolters Kluwer: New
York.
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