Tomas Claudio Colleges

MORONG, RIZAL
Nursing Program

CASE STUDY IN MEDICAL WARD: “TITLE”

(CARDIOVASCULAR ACCIDENT: HEMORRHAGIC STROKE)

Submitted by:
Estrella, Ella Mae O.

Submitted to:
Melbert B. Reyes, RN, RM, MAN

October 2022
 I. Objectives

a. General Objectives

This case study aims to identify and recognize the general health problems and

disease condition of a client with diagnosis of Cardiovascular Disease specifically

Stroke. After 36 hours of exposure to Rizal Provincial Hospital System Medical Ward,

student nurse will be able to apply necessary care and proper intervention for the

wellness of the client.

b. Specific Objectives

At the end of this case study, student nurse will be able to:

Knowledge:

1. Describe the clinical significance and learn the initial management of

Cardiovascular Disease specifically Stroke.

2. Identify nursing problems and develop an effective nursing care plan, health

teaching, leaned towards goal attainment.

3. List and recall the student nurse’s knowledge through researching about the

nature of the disease, sign and symptoms, its diagnosis, and treatment.

Skills:

1. Implement an effective utilization of nursing care process especially for client’s

problem as identified in the assessment.

 2. Demonstrate skills that is appropriate to health attitudes and practices to function

as an effective student nurse.

3. Demonstrate critical thinking skills necessary for providing safe and effective

nursing care.

Attitude:

1. Develop and establish rapport and good interpersonal relationship with the client

to gain cooperation in rendering appropriate nursing care.

2. Develop a warm environment between the student nurses and client for a better

working relationship towards improvement of health status.

3. Execute client care with utmost sincerity and appropriateness.

At the end of this case study, the client will be able to:

Knowledge:

1. Describe self-awareness about their condition.

2. Identify possible factors that may contribute or impose risk to condition.

3. Identify the importance of the treatments given.

4. State importance of lifestyle and how it affects their condition.

Skills:
 1. Demonstrate changes in behavior for a healthy lifestyle aimed to improve

condition.

2. Execute complete adherence to treatment.

Attitude:

1. Express awareness on the needs and condition of their present status.

2. Show involvement in promoting on her general health.

II. Introduction

Background of the Study

Cardiovascular disease (CVD) is a general term for conditions affecting the heart

or blood vessels. It includes stroke, which occurs when a blood vessel that carries

oxygen and nutrients to the brain is either blocked by a clot or bursts (or ruptures).

Stroke remains the second-leading cause of death and the third-leading cause of death

and disability combined (as expressed by disability-adjusted life-years lost - DALYs) in

the world. Stroke is considered the third leading cause of deaths with a crude death

rate of 58.1 per 100,000 (equivalent to 60,277 deaths), next to the diseases of the heart

and malignant neoplasms, among Filipinos. In 2019, Rizal had the highest number of

deaths by heart diseases in the Philippines' CALABARZON region, accounting for just

under 3.3 thousand out of approximately 22.5 thousand cases in this region. Adults

aged 55 years and older are more likely to suffer from a stroke. Men are also at more
risk due to the difference in lifestyle and habits. People with heart disease hypertension,

and diabetes greatly increase the chances of stroke.

III. Health History

Client’s Profile

Personal Data

Name: Client XXX

Address: Teresa, Rizal

Age: 66 years old

Sex: Male

Civil Status: Widowed

Religion: Roman Catholic

Nationality: Filipino

Admitting Physician: Dra. Cawicaan

Chief Complaint: Body weakness

Admitting Diagnosis: t/c CVD Infarct

Final Diagnosis: Cardiovascular Disease - Stroke

a. History of Present Illness

Hours prior the admission of Client XXX, he was doing some chores at his

sister’s house. As he was lifting a heavy wood, he suddenly felt numbness all over

his body and he then collapsed on the floor. His relative also stated that Client XXX

has his left body paralyzed when he was already at the hospital, when client
 complained of not being able to move his left hand and leg. In addition, presence of

facial drooping is observed while they were on the way to the hospital.

b. History of Past Illness

 Medical History – Hypertension

 Surgical History – None

 Prescribed Medications – Have Losartan as his maintenance for his

hypertension.

 Childhood Illness– Chickenpox

 Immunizations – Fully Vaccinated against COVID-19

 Allergies – No known food or food allergies.

IV. 13 AREAS OF ASSESSMENT

I. Psychosocial Status

Client XXX is a 66-year-old male, currently residing at Teresa, Rizal. He works

full-time as a barangay official and is a basketball coach as a part-time job. The age of

the client indicates that he belongs in the last stage of Erik Erikson's Psychosocial

Theory, with its conflict as Integrity vs. Despair. In here, the key conflict centers on

questioning whether or not the individual has led a meaningful, satisfying life. When

asked, Client XXX stated that he felt no regret in his life. With statement of his son

"Okay naman kami pamilya namin, nabigay naman ni Tatay lahat ng makakaya nya

para magkaroon kami ng maayos na buhay at maganda naman relasyon ng pamilya

namin." It can be concluded through the relative’s statement that Client XXX has a
sense of contentment and that he can face the end of life with a sense of wisdom and

no regrets.

II. Mental & Emotional Status

Client was seen awake, and when asked, is oriented to place and person, but is

disoriented to time. As his left side of the body is paralyzed, he has a hard time

conversing and performing ADLs. Using the Glasgow Coma Scale, with each behavior,

his scores are 4,3,3, with a total of 10. He can spontaneously open and close his eyes,

however, his verbal responses are at times has inappropriate responses, and words are

discernible, due to paralysis of left side of the body, and his motor response showed

abnormal flexion. It is observed that client has a decorticate posture, especially in his

right hand. When relative is asked about emotional status, he stated that client is

sometimes irritable and that there are moments when he is crying due to the situation.

III. Environmental Status

Client is oriented to the environment and is familiar with the room set-up. He has

intravenous access on his right arm for his IV fluids that may potentially expose him to

infection if not taken care of and lines sometimes limit his general mobility. Relative

claims that they dispose their garbage properly. Alcohol was available at bedside for

disinfection. No unnecessary noise was noted during interview. The room has 2 bed

capacity, so disturbances were not adamant. The floor was also well maintained and

non-slippery. No scatter rugs were seen. Other than that, patient has no complaints of

uneasiness or discomfort concerning his environment. The home environment, as

reported by relative, is a concrete type of house with 2 rooms and one comfort room. It

is located near the road, thus, making his house expose to dust and noise.
 IV. Sensory Status

A. Visual Status

Client’s relative stated that he doesn’t use any corrective lenses, however, during

assessment, squinting behavior is noted when presented with a word in a paper to read.

He also has pale palpebral conjunctiva, which indicates dehydration. In addition, he is

able to move eyes without tenderness, pain or difficulty.

B. Auditory Status

Upon assessment, no visible lumps or lesions noted, corrective devices used

such as hearing aids and discharges were noted. However, client appears to have

difficulty comprehending uttered words. This could be because of his approaching old

age. Since as suggested by Wear and Tear Theory, the effects of aging caused

progressive damage to cells and body systems over time.

C. Olfactory Status

The client has intact sense of smell as manifested by the ability to distinguish

familiar odor such as alcohol during assessment. No epistaxis was noted, however,

there are presence of mucus in his nostrils. Nose was seen to be symmetrical, since the

paralysis doesn't affect the placement of his nose.

D. Gustatory Status

Client is using dentures (both upper and lower). In the course of his condition, it

was advised to remove his dentures to prevent the risk of aspiration. During the

assessment, using different food such as kalamansi, sugar, coffee, and salt, it was used

by the client to test his sense of taste. It revealed no reports of decrease in taste. And to

support the claim, it was tested twice in his left side of the tongue (since his paralysis is
on that part) and he stated that he can still distinguish its taste. He has difficulty in

masticating, so mechanical soft diet is utilized by the client.

E. Tactile Status

Facial sensations aren’t intact and asymmetrical on both sides. When the bell of

the stethoscope is placed on the client's skin, on the right side, he felt the coldness, as

well as when touched with warm hands, and when skin was pinched. However, he isn't

able to perceive heat, cold, and pain sensations on his left side of the body.

V. Motor Status

Client is flat on bed, with limited movement. Because of stroke, his left

extremities are paralyzed. He can only perform ADLs with the assistance of others. His

reduced motor function can occur as a result of injury to the cerebral cortex, motor

pathway, peripheral nerve or muscle. He has muscle strength of 2/5 on right upper and

right lower extremities which means that he has limited movement against gravity and

some resistance. Furthermore, there are tremors noted on the upper right extremity.

Peripheral pulses were present such as radial. No crepitus noted upon flexion of joints.

His left side of the body is slightly cold to touch, meanwhile, his right extremities are

slightly warmer than the opposite side.

VI. Nutritional Status

The client has a soft, low sugar diet as ordered by the physician. He is usually

served with food containing soup or mashed food in general and requires assistance

when eating. Client understands food as a source of energy and relative also stated that

he has no religious restrictions about food as well as allergies. There is a big change in

the appetite in eating during the hospitalization and health deviation, since client has
difficulty swallowing and masticating. Because of that, relative stated that there is an

observed weight loss of the client.

VII. Elimination Status

Client's frequency of urination is estimated to be 4 times at approximately normal

cc per 24 hrs. (As reported by relative). He uses the bathroom with assistance and

privacy is observed. No pain was reported felt during urination and defecation.

Urinalysis revealed clear and dark yellow urine with a specific gravity of 1.015 is used

as an indicator of the kidneys ability to excrete concentrated urine. As particle

increases, so does the specific gravity. Moreover, relative revealed that there are no

moments of bed-wetting as client is aware of when he's going to urinate and he

immediately tell it to him for assistance.

VIII. Fluid and Electrolyte Status

Client consumes an estimated 4-5 glasses of water. He is hooked to PNSS 1L, to

run for 10 hours, and regulated at 80cc/hour. The result of his electrolyte test results

normal ranges of Sodium (at 142.0mmol/L) and Potassium (at 3.7mmol/L). There are

signs of dehydration as evidenced by dry skin and chopped lips. Skin turgor is

perceived to indicate dehydration too, since when skin in lower arm was pinched, it

returned to normal position later than normal. (>3 seconds.)

IX. Circulatory Status

Client XXX has pulse rate of 72 beats per minute and a blood pressure of 130/80

mmHg while positions on supine. He has a normal capillary refill of 2 seconds on right

finger and 3 seconds on left. In assessing the extremities' color, warmth, movement,

sensation (CWMS), it is noted that the there is a difference in each side of extremity. In
the right, client can still feel pain when initiated, is slightly warmer to touch, and can be

moved freely. Meanwhile, on the left side, the extremity when touched feels slightly

cold, and it cannot distinguish pain, since it is paralyzed. Client also has hypertension.

During different shifts, it was endorsed that the usual blood pressure of the client ranges

to 130-140mmHg systolic and 80-100mmHg diastolic. In line with that, client is taking

his amlodipine to normalize blood pressure.

X. Respiratory Status

He has a respiratory rate of ranging to 17-21 breaths per minute if to look at his

records, with no use of accessory muscles noted. Chest wall symmetrically expands

with each respiration and no retractions seen. There are also no observation of nasal

flaring or retractions when breathing. Furthermore, there are no records of unexpected

sounds during breathing.

XI. Temperature Status

Client's temperature is 36.3C (on the right), per axillary upon the last initial vital

signs taking. As per the client's record, there are no reports of temperature ranging

above normal. In addition, when relative is asked, he added that client hasn't experience

fever ever since admission. When temperature was checked in the left side in which it is

paralyzed, it revealed a still normal result of 36.1. The ward is adequately ventilated and

client is using blanket whenever he feels cold.

September 19, 2022 35.6C

September 20, 2022 36.1C

September 21, 2022 36.3C

 XII. Integumentary Status

The client's skin appears to be dry; his capillary refill returned in 2 seconds after

pinching. When tried in his left hand, it went back after 3 seconds which is considered

still as normal. His hair is noted to be terminal in the scalp, eyelashes, and eyebrows

with no parasite infestation.

XIII. Comfort and Rest Status

The client's relative stated that he has no difficulty sleeping, since the room

occupies only 2 bed and it is on 2nd floor, thus no loud noises are heard.

V. Laboratory Examination

URINALYSIS RESULT
TYPE OF EXAMINATION RESULT NORMAL VALUES INTERPRETATION

Macroscopic Test:
Color Dark Yellow Pale yellow – deep Indicates dehydration.
amber
Transparency Clear Clear - Light yellow Normal
WBC 0-2/HPF 2-5 hpf Normal

HEMATOLOGY RESULT

TYPE OF RESULT NORMAL INTERPRETATION

EXAMINATION VALUES
Hemoglobin L162.00 140-175 g/L -

Hematocrit H 0.50
L 0.36-0.45 vol% High blood pressure leading to stroke
affects hematocrit level because of
increase blood clot formed.
Red Blood Cells L5.14 4.1-5.1 x10^12/L -

MCV H 97.00 80-96 fL This indicates that red blood cells are
slightly larger than normal.
MCHC L 32.40
L 33.00-36.00g/dL This indicates that there is a higher-
than-normal concentration of
 hemoglobin in the red blood cells.
Platelet Count H294 150-450 x10^9/L -
Neutrophils H0.51 0.40-0.65% -
Lymphocytes H 0.37
L 0.28-0.35% Indicates an infection
Monocytes 0.07 0.02-0.06% -
Eosinophils H 0.05 0.01-0.04% Indicates systemic inflammation and
physiologic stress

ELECTROLYTES RESULT
TYPE OF EXAMINATION RESULT NORMAL VALUES INTERPRETATION
Sodium (Na) 142.0 135.0-145.0 Normal
mmol/L mmol/L
Potassium (K) 3.73 3.50- 5.10 mmol/L
mmol/L Normal

CLINICAL CHEMISTRY RESULT

TYPE OF RESULT NORMAL INTERPRETATION
EXAMINATION VALUES
Fasting Blood sugar H 7.15 mmol/L 4.10-5.90 This indicates diabetes.
mmol/L

VI. Diet Therapy

DIET INDICATION RATIONALE

Soft Diet Mechanically altered diets consist To stabilize nutrition and choosing
of foods that can be safely and healthy and best suited foods for stroke
successfully swallowed. Foods are clients can help control blood pressure,
mechanically altered by whipping, body weight, and reduce a person's risk
blending, grinding, chopping, or of having another stroke.
mashing so that they are easy to
chew and swallow. Foods that are
in large chunks or pieces or that
are very hard and cannot be
chewed easily are to be avoided.

VII. Fluid Therapy

FLUID/IVF INDICATION RATIONALE

 PLAIN NSS
The following are primary  Extracellular fluid
indications for the use of normal replacement (e.g.,
saline infusion that have been dehydration,
approved by the FDA:  hypovolemia,
hemorrhage,
 Treatment of the presence sepsis)
of fluid loss

VIII. Anatomy and Physiology

1. The circle of Willis is an important junction of arteries at the base of the brain.
2. The main function of the circle of Willis is to provide a collateral blood flow
between the anterior and posterior arterial systems of the brain. Additionally,
it offers the alternate blood flow pathways between the right and left cerebral
hemispheres.
3. Each carotid artery branches into an internal and external carotid artery. The
internal carotid artery then branches into the cerebral arteries. This structure
allows all of the blood from the two internal carotid arteries to pass through
the circle of Willis.
4. One of the unique features of the circle of Willis is that its continuous structure
creates a redundant blood supply in the brain. If one ICA is blocked, blood
can still reach the corresponding ACA through the other segments of the
circle of Willis—this is possible because of the circle of Willis' redundant blood
supply.
5. A stroke is an interruption of blood flow in an artery. It prevents blood from
reaching its destination in the brain. This causes the affected region to lose
function. Despite the redundant blood supply made possible by the
connecting arteries in the circle of Willis, a stroke is possible. If blood flow
through one of the ACAs or one the PCAs is blocked after it leaves the circle
of Willis, then a stroke can occur.
IX. ANaphy
 X. Theoretical Framework

Patient care will be provided thoroughly if this theory, namely, Dorothea Orem's

Self-Care Deficit Theory is utilized in this condition, which is stroke. According to Orem,

nursing is derived from actions deliberately selected and performed by nurses to help

individuals or groups under their care to maintain or change conditions in themselves or

their environments. Nursing’s special concern is the individual’s need for self-care

action and the provision and management of it on a continuous basis in order to sustain

life and health, recover from disease or injury, and cope with their effects. Which is

necessary for a stroke patient, since half of their body is paralyzed, they have to acquire

knowledge on what to do especially when performing ADLs.

The goal of patient care aside from providing it since they aren't capable of doing

so is to restore function as close as possible to pre-stroke levels or develop

compensation strategies to work around a functional impairment. Basic assumptions of

this framework are (a) self-care which is necessary for survival; (b) people want to

perform self-care; (c) in most situations people have the ability to perform self-care (self-

care agency); (d) people will perform self-care when they are able to do so; (e) people

who are unable to perform self-care (self-care deficit) are candidates for nursing; and (f)

people who are unable to perform self-care will return to self-care when able. In
application for stroke patients, what the diagram shows at the very top is self-care, and

in the bottom, is nursing agency. Since stroke patient is dependent to others when

performing ADLs, it is here where nurses interfere and provide patient care as well as

health teachings. They will do the client's basic functions to fulfill their deficit. Once the

client is getting better, they can now attend to their self-care agency and self-care

demands interchangeably. And once they have it carry out, stroke patient can now

establish their own self-care. This then warrants the need for nursing intervention

through the nursing system, which in turn is empowered by the nurse-patient

relationship. The end result of all of this is the maintenance, restoration, or preservation

of health.