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Associate in Health Science Education Fort Bonifacio, Taguig City, Metro Manila College of Nursing and Allied International Health Studies

An Experiential Case Analysis of Stroke In Partial Fulfillment of the Requirements In Related Learning Experience 106

Presented to: Mr. Basilio Jacinto RN MAN Presented by: Manalo, Dianne Eve



N-412 Semester SY 2011-2012

. she also has high blood pressure that day. The childhood diseases that she acquired are mumps. BIOGRAPHIC DATA Name: Mrs. PAST HISTORY The client received 2 immunizations only (BCG and DPT) because the family is not aware of its importance. FAMILY HISTORY OF ILLNESS The clients’ father and mother have a history of hypertension. CHIEF COMPLAINT “Nanghina ang kaliwag bahagi ng akng katawan”. the patient felt weak on the left side of her body. so they decided to go to the hospital for further management and treatment D.There were no known food or medication allergy.NURSING HEALTH HISTORY A.HISTORY OF PRESENT ILLNESS One day prior to admission. and chicken pox and sore eyes . A P Address: balayan muntinlupa Age: 52 yrs old Sex: F Race: Filipino Marital Status: Married Occupation: Housewife Religious Orientation: Roman Catholic Health Care Financing: Phil health B. The client commonly had cough and fever. as verbalizes by the patient C. She does not smoke or drink alcohol E. measles. Client has no history of accidents or injuries.

She cannot perform the things she likes and usually do. When signs and symptoms arise they sought medical consultation. .HEALTH PERCEPTION PATTERN BEFORE HOSPITALIZATION DURING HOSPITALIZATION The client experienced The client still feels left sided body weakness on the left side of her weakness body when she does some household task like gardening. meat. She’s fond of eating processed food like corned beef. She does not perform self-breast examination. and fish. Occasionally she eats vegetables and fruits. pito-pito(7 different kinds of leaves). She manages it by having a period of rest in bed. G. Client believed that proper diet. exercises. She used a lot fish sauce. She is still uncomfortable with her state of health because it greatly affects her daily activities. chicken). tocino. and adequate financial support are the things needed to maintain proper health diet and no vices are factors of having a healthy body. The client also believed in “albularyo” and use herbal medicines such as lagundi. guava leaves. chicharon and fried dish (porkchop. NUTRITIONAL AND METABOLIC PATTERN PRIOR TO HOSPITALIZATION The client’s typical food intake is composed of rice. anything with preservatives.

DURING HOSPITALIZATION Client usually defecate at least 1-2x a day semi formed stool with the presence of blood which is light brown to brown. 3-FEEDING 3-GROOMING 3-TOILETTING 3-GENERAL MOBILITY 4-COOKING 3-BED MOBILITY 4-BATHING 3-DRESSING 4-HOME MAINTENANCE . She spends her days with minimal cleaning like gardening and watching TV. I. Her appetite was good and drinks 6 glasses of water daily. Client wound heals well and she wears complete upper and lower dentures but this doesn’t affect her food intake. H. In the hospital the client instructed to Perform ROM by the health care provider. She has difficulty in defecation with excessive sweating. ELIMINATION PATTERN BEFORE HOSPITALIZATION Client usually defecates at least 2-3 times of soft and watery stool consisting of small amounts which is light brown color with presence of blood (fresh blood).MSG when cooking. A client doesn’t perform any routine exercise. DURING HOSPITALIZATION Client shows tiredness and limited movement. with discomfort or difficulties and experienced excessive sweating. Client urinates 6x a day which is yellowish. Client urinates 4x a day which is yellow in color w/out any discomfort. She walks short distances as form of her color w/out any discomfort. ACTIVITY-EXERCISE PATTERN BEFORE HOSPITALIZATION The client said that her activities at home were limited because she has experience high blood pressure. She also played with her grand daughter and grandsons.

By means ofgood conversation they can easily fixed family problems. The client sleeps inadequately at night. When things are not so well. she still experience left sided body weakness and high blood pressure. She also monitor her vital signs during the night. She doesn’t take provider give medication and any sleep medications. afternoon for about 1 hour. N. she finds her husband to be the most helpful person in talking things . Through demonstration she could easily learn things. O. COPING STRESS TOLERANCE PATTERN The client was observed to be withdrawn but the behavior improved as evidenced by her socialization with other people. When family experienced difficulty of caring for the client they just take it as trials given by god. L. SEXUALITY-REPRODUCTIVE PATTERN The client is done in stage of menopausal. COGNITIVE-PERCEPTUAL PATTERN The client does not have any hearing difficulty and can’t remember past events She has a visual problem –far-sightedness. K.SLEEP-REST PATTERN BEFORE HOSPITALIZATION DURING HOSPITALIZATION The client sleeps for 8-9 The client sleeps is lessen to 6 hours usually from 8pm-5am but hours due to abdominal pain and not continuous because of prompt interrupted when the health care abJdominal pain. decreased sexual activity is not a problem because they were already old. They spent most of their time by taking care of each other and with that they are showing their love for one another. According to the client. There is no sexual activity. They have harmonious relationships with the family and their neighbors. Abdominal pain is the one which alters her comfort and she manages it with taking prescribed medications. SELF PERCEPTION AND SELF CONCEPT PATTERN The client said that her condition was not improve. Client feels that she lose some weight. She takes naps in the does take naps during afternoon. ROLE-RELATIONSHIP PATTERN The client lives in extended family. M. Financial problems and health condition usually makes her worried. When these things are encountered the client diverts her attention through talking to a family member and praying.J. They live peacefully even there are hardship and difficulties that arrives to their lives.

VALUE-BELIEF PATTERN The client is a Roman Catholics usually go to the church to attend mass every Sundays. When big problems encountered.over. She helps spread the word of god through catechism. she always prays and ask assistance with the Lord. Some of the time they failed to attain what they want and try other alternatives in solving it. P. first Friday of the month and novena. . She is very active in participating religious activities.

00 265 81 0.02-0. 2011 HEMOGLOBIN HEMATOCRIT RBC WBC NEUTROPHILS 138 0. avoid the use of equipment containing latex Restrict medications that may affect test result.12 0.LAB EXAM DONE ACTUAL NORMAL FINDINGS FINDINGS ANALYSIS AND INTERPRETATIO N NURSING RESPONSIBILITIE S Make a request Explain the procedure to the patient Hematology July 10.44 5-10 g/L 0.20-0.5 mil/mm3 8.1 0.86 0.38-50 % Normal findings Normal findings Normal findings Tell the patient that this test requires blood sample Explain to the patient that he may experience discomfort from needle puncture and tourniquet Note any recent procedures that may interfere with the results If the patient has an allergic reaction to latex.00-0.01 % 150-350 g/l 86-100 fl Low MCV may indicate hypochromic anemias 0.5-5.25 4.43 125-160 g/dl 0. If they must be continued note this on the lab request Instruct patient to cooperate fully and follow instructions 5.01-0.02 0.60 % Normal findings Increased neutrophils may indicate possible infection Slight decrease in lymphocyte indicates defective lymphatic circulation Normal findings LYMPHOCYTES 0.40 % EOSINOPHILS MONOCYTES BASOPHILS PLATELET COUNT MCV 0.06 % 0.08 % Normal findings Normal findings Normal findings .40-0.

NCP 1 Assessment Subjective: •Client said. participation in his ADL’s and ↓ right arm numbness Short term goals met: The client is able to participate on the therapeutic regimen as evidenced by verbalization of understanding of the situation. client will be able to participate in therapeutic regimen Expected outcome: • Verbalize understandi ng of the situation Intervention Independent: 1. Give rest periods to activities 5. Support affected part with pillows 4. therapy. “namamanhid yung kanang kamay ko. Observe movement when client is unaware 3.” Objective: • Limited range of motion (client can’t fully extend his right arm and hold up his right shoulder) • Limited ability and difficulty to perform gross motor skills like extending and lifting of the right arms •Unsteady gait •Slowed movement •Right arm Diagnosis Impaired physical mobility r/t neuromuscul ar damage involvement (Right arm numbness) as evidenced by ↓ motor control Planning Long term: After 4 days of nursing intervention. client will be able to ↑ physical mobility Expected outcome: • Demonstrat e resumption of activities • Participate in ADL’s • Maintain or ↑ muscle control Short term: After 8 hrs of nursing intervention. pero nagagalaw ko naman siya medyo hirap lng ako. and he is able to participate in the interventions rendered by the nurse . Encourage adequate fluids and right diet as necessary to the client Rationale Independent: 1. To help reduce fatigue Evaluation Long term goals met: Client is able to ↑physical mobility as evidenced by resumption of activities. To note any incongruence with the reports of abilities 3. Reduce risk of pressure ulcers 4. To establish comparative baseline 2. Determine degree of immobility 2.

and O2 demand .

absence of painful accessory use of -Keep room and prevent nasal flaring. manifested Numbness of on spasm as OBJECTIV stimulus of a painful will position. Decreased by painful stimuli allergic to stimulus. response to -use of decreased reactions immediate. from injury Determine as breathing response is of safe and free accessory -nasal flaring evidenced response to exercise. the care is given including patient will rate. breathing.ASSESSMEN T SUBJECTIVE : NURSING DIAGNOSI S PLANNIN G INTERVENTIO N RATIONAL E EVALUATIO N Disturbed GOAL GOAL tactile sensory At the end Identify patient To assess At the end of “ na perception of the shift with condition causative the shift mamanhid related to patient that can affect factors patient and Interventi and binti ko” altered and sensing. n. or delayed stimuli when muscle accessory well irritation. depth verbalize and effort. Promote a from dust determine sound upon stable or pollution. lessened GOAL MET the right side stimuli Objective: characterizE experiencehot/cold. response airway n the client orthopnic awareness expansion. caregivers deficit on chart are aware Administere Provide safety d medicines To prevent measures as as ordered. relatives to Dependent bring familiar -Give objects. injury needed (side rails) . -wheezing breathing. encourage breathing as OBJECTIVES diminished Patient will of -Encourage excretion of evidenced by difficulty gait/mobility To note Altered sense -restless breath bebreathing free deep secretions. related interventiosensory in an lung the client needs the patient. caring. significant Assessment Diagnosis Planning Rationale Evaluation on and sensory significant interpreting others was (As reception others will communicating able to verbalized by as Ineffective verbalize Subjective: After 1 stimuli Independen After 8 hours verbalize the patient) “Mahirap evidenced airway awareness hour of t -to promote of awareness of nursing huminga” as by clearance of nursing sensory Evaluate client effective -Place intervention. -to avoid appropriate muscles when from injury. sensory OBJECTIVE: verbalized by decreased to needs. -to difficulty of of the body -irritable ed by lessened dull/sharp.thedecreased use whether Kept patient of balance sounds. effectivene is Touching inhalation After 8 environment ssan of hours of -Monitor nursing important nursing Provide tactile intervention respiratory part of interventiostimulation as s. talk to supplement and touch the al oxygen client frequently as prescribed Record via nasal So that perceptual cannula. decreased effort in Encourage breathing. and presence breathing muscles ventilated of calm during and free -to breathing. patterns.

inhibiting tubular reabsorbption of water and electrolytes.dr ug elevates plasma osmolality. Q6 Action Indicatio n Contraindicat ion Advers e reactio n Seizure -Edema -Heart Failure -Urine retentio n Blurred Vision -chills Nursing respons ibilities Generic name: Mannitol Brand name: Osmitrol Drug classificatio n: Diuretics Increase osmotic Pressure of glomerular filtrate. frequen cy 75 ml. route. increasing water flow exracellular fluid To reduce intracellul ar or intracrani al pressure Contraindicate d to patient hypersensitive to drug -monitor vital sign -to relieve thirst give frequent mouth care -don’t give electrolyt e free solution withbloo d .Drug Dosage.

brain cells begin to die. If the supply of blood is restricted or stopped. Types of stroke There are two main causes of strokes: ischaemic (accounting for over 80% of all cases): the blood supply is stopped due to a blood clot • • haemorrhagic: a weakened blood vessel supplying the brain bursts and causes brain damage There is also a related condition known as a transient ischaemic attack (TIA). where the supply of blood to the brain is temporarily interrupted.INTRODUCTION A stroke is a serious medical condition that occurs when the blood supply to part of the brain is cut off. causing a . the brain needs the oxygen and nutrients provided by blood to function properly. the less damage is likely to happen. Strokes are a medical emergency and prompt treatment is essential because the sooner a person receives treatment for a stroke. This can lead to brain damage and possibly death. Like all organs.

The best way to prevent a stroke is to eat a healthy diet. High-fat foods can lead to the build-up of fatty plaques in your arteries and being overweight can lead to high blood pressure. A low-fat. high-fibre diet is recommended. Foods high in saturated fat include: • • • • • • • • • meat pies sausages and fatty cuts of meat butter ghee: a type of butter that is often used in Indian cooking lard cream hard cheese cakes and biscuits foods that contain coconut or palm oil. However. exercise regularly and avoid smoking and excessive consumption of alcohol. There are two types of fat: saturated and unsaturated. including plenty of fresh fruit and vegetables (five portions a day) and whole grains. a balanced diet should include a small amount of unsaturated fat. You should limit the amount of salt that you eat to no more than 6g (0. which will help reduce your cholesterol levels. TIAs should be treated seriously as they are often a warning sign that a stroke is coming.2oz) a day because too much salt will increase your blood pressure. olive and vegetable oils Exercise . rapeseed.'mini-stroke'. Six grams of salt is about one teaspoonful. Foods high in unsaturated fat include: • • • • oily fish avocados nuts and seeds sunflower. You should avoid food containing saturated fats because these will increase your cholesterol levels. Diet A poor diet is a major risk factor for a stroke.

as blood pressure is normally expressed. This is known as the diastolic pressure. Or. while waiting for the next contraction. The recommended level of cholesterol is 5mmol/litre (5 millimoles per litre of blood). at least 150 minutes (2 hours and 30 minutes) of moderateintensity aerobic activity (i. Blood pressure is measured using two figures.Combining a healthy diet with regular exercise is the best way to maintain a healthy weight. Regular exercise may be impossible in the first weeks or months following a stroke but you should be able to begin exercising once your rehabilitation has progressed. It will also lower your cholesterol level and keep your blood pressure at a healthy level. Having a healthy weight reduces your chances of developing high blood pressure. cycling or fast walking) every week is recommended.e. If you are recovering from a stroke. a level between 90/60mmHg and 120/80mmHg. . a healthy blood pressure is a systolic pressure of 90-120 millimeters of mercury (mmHg) and a diastolic pressure of 60-80mmHg. The second figure represents the pressure of the heart as it expands and fills with blood. One figure represents the pressure of the heart as it contracts to pumps blood around the body. For most people. you should discuss possible exercise plans with the members of your rehabilitation team. Regular exercise will make your heart and blood circulatory system more efficient. For most people. This is known as the systolic pressure.