TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

Fernandez, Dexter Ivan T. March 20, 2021

BSN 3A – A4 Perception and Coordination
Activities

EVALUATION ACTIVITIES:
Critical Thinking Exercises:

Activity 1
Scenario A: You are caring for a patient after a large ischemic stroke. The patient has hemiplegia and is beginning
to experience shoulder pain on the side affected by the stroke.
1. Identify the priority nursing interventions that can be implemented to prevent shoulder pain.
a. For a patient that experiences shoulder pain, the nurse should not be positioning the patient by
lifting the patient using the affected arm. This will aggravate the pain from the patient because of
the pressure being exerted to the arm and shoulder joint of the patient. Also, assessment of the
patient pain is necessary. As a nurse, we can utilize the PQRST assessment to the patient. We
can also determine the level of pain by using numerical pain scale. By this assessment, we can
provide timely and relevant nursing intervention that will address the patient pain. Administration of
medication can also lessen the pain that the patient is feeling. Elavil can be administered; however,
we should assess for the cognitive status of our patient because this can induce cognitive
problems. Antiseizure medication is also found effective in treating pain. Medication such as
Lamictal can be administered.

2. What health education can you provide to the patient for interventions that can be done at home
once discharged?
a. Providing health education is very important, specially to the family and relatives of the patient
because they will be the one who will take care to the patient once discharged. Proper patient’s
movement is position should be included to health teachings. While seated, the affected arm
should be supported by a pillow in order to avoid exerted pressure on it. If the patient is
ambulatory, the use of arm sling should be instructed because dangling extremities would
aggravate the pain by exerting too much weight on it. Proper exercise can also be instituted to the
patient daily activities. This measure will lessen the pain felt by the patient, however, too much
activities, especially extraneous one should be avoided. The patient should also elevate the
affected hand to prevent the development of dependent edema. The patient should also instruct
about taking pain medication if pain is already unbearable or as necessary.

Activity 2
Scenario B. A 78-year-old woman is brought to the emergency department by ambulance. She was found on the
floor of her bedroom by her daughter in a confused state, and she could not move her left leg. A diagnosis of stroke
is suspected.
1. When taking the nursing history, describe the risk factors would you assess?
a. In assessing the patient risk factor for having stroke, several factor should be considered.
Advanced age is one of the risk factors for having a stroke. Gender and race are also included
because men are more affected than women. Asian islander group is also risk factor because they
have a higher relative risk of developing stroke. The aforementioned risk factors are those that are
non-modifiable or cannot be changed to an individual. For the modifiable risk factors. A thorough
health history taking of the patient should be done. We should assess if the patient has any history

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 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

of hypertension. If there is any, we should ask if the patient has her hypertensive maintenance and
for how long does, she is taking it. The BMI of the patient should also be considered because
obesity can increase the risk of developing stoke to the patient. Also, history of alcohol intake and
smoking history should be taken, and determine the length of time does the patient has taking any.
Comorbidities can also contribute to the risk of developing stroke. Diabetes mellitus is one of it as
well as hypercholesterolemia.

2. The diagnosis of ischemic stroke is confirmed. What medical management would you expect to
receive from the physician for acute ischemic stroke?
a. Medical management should be carried out immediately after the medical diagnosis has been
confirmed. Thrombolytic therapy should be anticipated to receive by the patient. However,
thrombolytic therapy has several criteria in order to be rendered from the patient such as onset of
stroke should not be more than 3 hours prior to the administration of therapy. Tissue plasminogen
activator work in inducing fibrinolysis. The minimum dosage of it is 0.9mg/kg and should not
exceed 90mg. 10 percent of the total medication will be the loading dose that should be
administered in 1 minute. The rest of the dosage should be administered over an hour using
infusion pump for an accurate infusion. After all of the medication has been administered, flushing
of normal saline solution should be done to make sure all of the medication has been administered.
However. If the patient does not meet the criteria for t-PA treatment, anticoagulant administration
should be expected. Administration of osmotic diuretics such as mannitol should also be expected
if increased intracranial pressure due to large ischemic stroke happened. Elevation of the head
should also be done to promote venous return. Establishing a patent airway by intubation is a
must. Blood pressure should also not exceed to 180/100mmHg as well as maintaining of normal
PaCO2 is important.

3. Formulate nursing care plan to address patient’s acute ischemic stroke.

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 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective data: Impaired physical Short term goal: 1. Determine the 1. This will provide the Short term goal:
- “Nahihirapan siyang mobility related to After four to six hours of causative factors of nurse in planning After six hours of
gumalaw lalo at generalized body rendering proper the problem of the proper and relevant rendering proper
hindi niya maigalaw weakness and nursing care and patient referring to intervention to be nursing care and
yung kalahati ng hemiparesis intervention, the patient the medical rendered to patient intervention, the patient
katawan niya” as and significant others diagnosis and significant others
verbalized by the will verbalize 2. Explain to the 2. Providing accurate verbalized
significant others understanding of patient and information to understanding of
situation and relatives the current patient and family situation and showed
Objective Data: willingness to situation will increase willingness to
- Generalized body participate in treatment understanding of participate in treatment
weakness as regimen the condition, thus regimen, as evidenced
evidenced by little increases by:
to no movement Long term goal: compliance to - “kaya pala siya
and physical After seven to ten days treatment regimen nagkaganyan dahil
activities of rendering proper 3. Ascertain the 3. To boost client’s sa stroke niya,
- Lethargic nursing care and patient’s perception confidence and dapat pala umiwas
- GCS score of 13/15 intervention, the patient of activities that is compliance in na siya sa mga
- Limited range of will demonstrate ability necessary for daily performing ADL bisyo niya para
motion to the right to enable resumption of living gradually hindi na maulit yan”
side of the body activities 4. Assess the 4. It is important to as verbalized by
- Functional level of patient’s ability to assess the the significant
4-Dependent perform activity for activities that the others
daily living patient can and - “gawin natin lahat
cannot do to know para lang bumalik
where and how to yung lakas niya,
begin gradual kawawa naman
resumption of siya kung ganyan
activities nalang” as

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 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

5. Observe for any 5. Independent verbalized by the

independent movement is a sign significant others
movement of the of patient’s
client which readiness to Long term goal:
supports activities resume ADL, thus After ten days of
que to begin rendering proper
intervention nursing care and
6. Assist the client in 6. Assisting the intervention, the patient
doing ADL and patient is necessary demonstrated ability to
provide teachings to avoid any resume the activities for
regarding accidents, as well daily living, as
independent as providing proper evidenced by:
performance of the techniques and - GCS score of 15/15
activities teachings - Compliance to
7. Provide assistive 7. This will help the treatment regimen
equipment as patient and nurse to as evidence by
necessary such as achieve proper willingness to
roller pad in changing of participate in the
changing positions positions daily regimen
8. Encourage the 8. To boost the - Gradual resumption
patient and provide confidence and of activities with
reassurance in compliance of the assistance of
performing ADL patient in treatment individual –
9. Provide adequate 9. To provide proper dependent
diet to the patient nutrition and energy
as well as proper to the patient GOAL MET
hydration
10. Administer 10. To provide
medication as pharmacologic
ordered by the treatment to the
physician patient

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