Professional Documents
Culture Documents
Submitted to:
Clinical Instructor
Submitted by:
Norlainie B. Pangandaman
TABLE OF CONTENTS
I. INTRODUCTION …………………………………………………………1
A. HEALTH HISTORY……………………………………………….2
A.3 Medications
A.4 Diet
A. NURSING EDUCATION
B. NURSING PRACTICE
C. NURSING RESEARCH
X. APPENDICES ………………………………………………………………...
I. INTRODUCTION
as a delivery man of sand and gravel, was born on October 26, 1972, in
disease infarct and was referred for medical management in the hospital. There
since childhood at the local health center. He only completed the adult
drunk alcohol for most of his life since his teenage years. He continues to
drink alcohol and smoke cigarettes regularly. Patient appears to have been at
his baseline state of health until a day prior to admission when he developed
infarct. This also intends to help the patient achieve the maximum level of
works as a collector and delivery man of sand and gravel. He was admitted via
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2023, at 5:33 pm. From the emergency room, the patient was then transferred
to the medical surgical floor room MM-8. Upon admission, the patient’s
height is 160 cm and weight is 53.6 kg. The patient was under the care of Dr.
A. HEALTH HISTORY
patient’s chart.
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The patient verbalized that he does not recall any health history
artery disease (CAD), kidney disease, and cancer in their family. The
B. PHYSICAL ASSESSMENT
tinnitus or vertigo.
Mouth - Patient has dark gums with no presence of mouth sore and no
signs of lesions.
Throat & Neck - Positive hoarseness of voice and sore throat in the
seen.
140/100 mmHg.
history of jaundice.
swollen joints.
extremities.
Nutrition - Low fat, low cholesterol, full diet appropriate for patient’s
condition.
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near the creek and describes his home as rural, safe, clean, not
dried duhat leaves) and two bottles of beer daily. He admits that he still
coconut volley game. He also adds that even if it were not time for
thinking, and memory. The three main parts of the human brain are the
The cerebrum is divided into the right and left hemispheres and is the
largest part of the brain. It contains folds and convolutions on its surface, with
the ridges found between the convolutions called gyri and the valleys between
the gyri and sulci (plural of sulcus). If the sulci are deep, they are called
fissures. Both cerebral hemispheres have an outer layer of gray matter called
Located in the posterior cranial fossa, above the foramen magnum, the
balance. It comprises the cerebellar cortex and deep cerebellar nuclei, with the
cerebellar cortex being made up of three layers; the molecular, Purkinje, and
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peduncles.
anterior to the cerebellum, between the base of the cerebrum and the spinal
cord.
Each side of the brain has different lobes (sections). While all the lobes
work together to ensure normal functioning, each lobe plays an important role
movement, speech, and intellect. The parts of the frontal lobes that
gyrus. The parts of the brain that play an important role in memory,
Occipital lobes: These lobes in the back of the brain allow people to
Parietal lobes: The parietal lobes are near the center of the brain. They
receive and interpret signals from other parts of the brain. This part of
the brain integrates many sensory inputs so that people can understand
the environment and the state of the body. This part of the brain helps
Temporal lobes: These parts of the brain are near the ears on each
side of the brain. The temporal lobes are important in being able to
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Limbic lobes: The limbic lobe sits deep in the middle portions of the
brain. The limbic lobe is a part of the temporal, parietal and frontal
lobes. Important parts of the limbic system include the amygdala (best
Insular lobes: The insular lobes sit deep in the temporal, parietal and
PATHOPHYSIOLOGY
CEREBROVASCULAR DISEASE
Disease are the body functions: Geriatric Depression Scale (CDS), Fugi Meyer
Scale (FMS), Ashworth Modified Scale (AMS), Hand Grip Strength (HGS),
Ability (ABILHAND), Time “Up and Go” Test (TUG), Natural Gait Speed
(NGS), Maximal Gait Speed (MGS); these activities are divided into two
parts: Environmental and Personal Factors. These factors test individuals with
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obstacles. Furthermore, it might be the first that reflects the real value of the
A. MEDICAL MANAGEMENT
artery is punctured, usually in the leg, and a needle is inserted into the
needle and into the artery. It is then threaded through the main vessels
ray that projects the images on a TV monitor). The contrast dye is then
injected into the neck area through the catheter and X-ray pictures are
taken.
placed on the skin where the transducer (a handheld device that directs
placed. The gel helps transmit the sound to the skin surface. The
waveforms are obtained. There are no known risks, and this test is
structures. Bone, blood, and brain tissue have very different densities
on a CT scan for several hours or days and the individual arteries in the
blood vessels of the head and neck and is increasingly being used
waves to the artery or vein being tested) and the skin over the veins of
if the venous system is normal. Both the superficial and deep venous
systems are evaluated. There are no known risks, and this test is
nerve tissue and clear pictures of the brainstem and posterior brain. An
MRI of the brain can help determine whether there are signs of prior
provide an image of the arteries in the head and neck. The MRA shows
the actual blood vessels in the neck and brain and can help detect
clot has to be given within 4.5 hours from when symptoms first started
if given intravenously. The sooner these drugs are given, the better.
Quick treatment not only improves the chances of survival but also
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standard treatment for ischemic stroke. This drug restores blood flow
the cause of the stroke, it may help people recover more fully from a
as soon as possible:
The time window for this treatment is somewhat longer than for
○ Removing the clot with a stent retriever. Doctors can use a device
for people with large clots that can't be completely dissolved with
injected TPA.
Other procedures
but include:
blocking a carotid artery and may reduce the risk of ischemic stroke. A
balloon is then inflated to expand the narrowed artery. Then a stent can
A.3 Medications
diuretics, ACE inhibitors, beta blockers and other medications that are
A.4 Diet
result of loss of appetite, problems using the arms and hands, memory
Following these dietary and nutritional advice may help your loved one
heal if they just suffered a stroke. These are ways to ensure that your
loved one takes food, offering recipe ideas for soft meals that are
simple to chew and swallow, dietary advice for stroke victims with
stroke. Whole Grains and cereals also contain fiber and folate.
A. Salt. Too much salt can raise your blood pressure. Read
labels and choose lower salt options. Don’t add salt when
labels and choose lower sugar options. Even foods you may not
butter or avocado.
B. NURSING MANAGEMENT
DISCHARGE PLAN
ASSESSING:
1.) The patient will be able to assess the - Teach the patient on how to take
vital signs and closely monitor the blood blood pressure, the normal range for his
pressure. condition, and the importance of
monitoring blood pressure.
(Williams et.al.,2019)
2.) The patient will be able to assess - Encourage the patient to restrict
nutritional food intake. sodium and fat intake to prevent
worsening the condition. (West,2016)
3.) The patient will develop and adhere to - Encourage the patient to exercise like
an appropriate exercise regimen. cardio and strength training to help
lower the blood pressure. (WHO, 2022)
4.) Observe for the presence of any - Discuss with the significant other the
individual who can help and assist the importance of someone monitoring the
patient with his activities of daily living. patient.
(Doenges et.al, 2016)
PLANNING:
- Advise patient to lessen physical
1.) Plan for continuity of care. stress and tension that affect blood
pressure and the course of
hypertension. (Comerford et.al, 2021)
2
4.) Plan for any recreational activities for - Encourage patient to have an
the patient as tolerated. appropriate exercise or activities
regimen to help manage hypertension.
(Arroyo et.al, 2021)
5.) Plan for a return visit. - Encourage the patient to return for a
follow-up visit to ensure that there are
no complications and that his doctor
will monitor him. (Wimble , 2012)
IMPLEMENTING
Considerations: METHODS
EVALUATING:
VII. CONCLUSION
The loss of mobility with stroke increases with delayed treatment. The
hospital’s stroke or emergency department. The ‘golden hour’ or the first hour
from the time stroke symptoms appear is critical for a stroke patient. Doctors
can quickly treat the patient with an effective clot-busting drug (in case of
ischemic stroke). This decreases the chances of brain damage and stroke-
A stroke is associated with many risk factors, some of which are non-
modifiable like age and race. Modifiable risk factors related to lifestyle like
Overall, the patient had a difficult start following his stroke. He was
not placed in an appropriate intensive rehab facility possibly due to his low
tolerance of activity and co-morbidities. Though there could have been both
the patient's case was managed well. Through medical and nursing
With intensive therapy, the patient will be able to ensure the greatest potential
VIII. RECOMMENDATION
healthy diet appropriate for his condition, and perform physical activity
independently or within the limits of the disease to reduce the risk of another
stroke.
2. Due to the diagnosis, the patient and their significant other/s should keep
3. The patient and their significant other/s should reach their physician if
healing and rest. Safety measures for risk of falls must be implemented.
A. NURSING EDUCATION
mortality and disability among stroke victims, some may not have the
of stroke services that offer the best in clinical care to patients and their
B. NURSING PRACTICE
important times in the continuum of care for stroke patients and their
crucial.
C. NURSING RESEARCH
significant gaps in nursing research about acute stroke care have come
outcomes, such as lower patient fall rates and fewer specific hospital-
are yet unstudied. One small study found that registered nurses with
based care for stroke patients and their families continues to be nursing
research.
X. APPENDICES
UNIVERSITY
UNIVERSITY OF CEBU OF CEBU – BANILAD
UNIVERSITY
- BANILAD OF CEBU - BANILAD
Gov. M. Cuenco Ave, Cebu City, 6000 P h ilip p ine s M. Cuenco Ave, Cebu City, 6000 Philippines
COLLEGE OF NURSING
College of Nursing
Gov.
College of Nursing
CEBU CITY Telephone No: (032) 231- 8631
Telephone No: (032) 231- 8 6 31
I. PATIENT’S PROFILE
Received patient lying on bed, awake, conscious, responsive, afebrile with weakness
and fatigability noted. Patient has ongoing IVF #5 PNSS 1L @ 90 cc/hr infusing well
at right hand.
Right sided weakness, headache, elevated blood pressure, cough, lower back pain.
A. MEDICAL/SURGICAL HISTORY
If remarkable:
________________________________________________________________________
No previous hospitalization
X. REVIEW OF SYSTEMS
ADDITIONAL INFORMATION
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STEPS FINDINGS
SKIN
1. Odor No odor noted
2. Color Even skin color, brown complexion,
no pigmentation noted
3. Lesions No lesions noted
4. Texture Normal, warm, dry
5. Temperature Warm to touch
6. Thickness Fair complexion
7. Mobility Mobile
8. Turgor When skin is pinched, it goes back
immediately to its previous state
9. Edema No edema noted
HEAD AND FACE
1. Inspect and palpate the head for Head is firm, proportional to size,
size, shape, and configuration. midline, no palpable mass noted
2. Note consistency, distribution, and Hair is black, thin, and fairly
color of hair. distributed
3. Observe face of symmetry, facial Face is symmetrical, skin is smooth,
features, expressions, and skin no moles or freckles seen
condition.
4. Check function of CN VII: Have CN VII is intact as patient can smile,
the client smile, from, show teeth, frown, show teeth, blow out cheeks,
blow out cheeks, raise eyebrows, raise eyebrows, and tightly close eyes
and tightly close eyes.
5. Evaluate function of CN V: using
the sharp and dull sides of a paper CN V is intact as patient can feel
clip, rest sensation of forehead, sensation of touch.
cheeks and chin.
6. Palpate the temporal arteries for No tenderness noted
elasticity and tenderness.
7. As the client opens and close her
mouth, palpate the No swelling or tenderness noted
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EYES
1. Determine Function:
Test vision using Snellen Chart 20/20 vision
Test visual Fields Visual field for each eye is intact in
all directions
Assess corneal light reflex Cornea are centered on both pupils
Perform cover and position tests Not performed due to unavailability of
instrument
2. Inspection external Eye:
Position and alignment of the Eyeball is aligned at center
eyeball in the eye socket
Bulbar conjunctiva No unusual discharge noted
Lacrimal apparatus No swelling noted, puncta patent
Cornea, Lens, Iris, and Pupil Transparent cornea, iris is visible, has
deep black round pupils
3. Test pupillary reaction to light Pupil constrict when looking at near
object, and dilates at far
4. Test accommodation of pupils PERRLA (pupils are equal, round,
reactive to light and accommodation)
5.
Retinal background for color and no lesions noted
lesion
Fovea centralis (sharpest area of Not performed due to unavailability of
vision) and macula instrument
Anterior chamber for clarity Anterior chamber is clear with no
redness noted.
EARS
1. Inspect the auricle, tragus, and No lesions, discolorations, no purulent
lobule for shape, position, lesions discharge, and no bony protrusion
discolorations, and discharge. noted.
2. Palpate the auricle and mastoid No tenderness noted.
process for tenderness.
3. Use the otoscope to inspect:
External auditory canal for color Not performed due to unavailability of
and cerumen (ear wax) instrument – otoscope
Tympanic membrane for color, Not performed due to unavailability of
shape, consistency, and landmarks. instrument – otoscope
4. Test hearing:
Whisper Test Patient has no problem with hearing.
Weber’s Test Not performed due to unavailability of
instrument – tunning fork
Rinnes’ Test Not performed due to unavailability of
instrument – tunning fork
NOSE AND SINUSES
1. Inspect the external nose for color, Appeared symmetrical, straight and
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12. Test rapid alternating movements IV line on the right hand, left hand
of hands. able to do alternating movements
without difficutly.
13. Ask the patient to close her eyes; The patient can feel sensation
test sensation.
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XII. REFERENCES
Books
Nursing
& Wilkins.
Journals
https://doi.org/10.3390/ijms21207609
http://www.ncbi.nlm.nih.gov/pubmed/16028727
Maldonado KA, Alsayouri K. Physiology, Brain. [Updated 2023 Mar 17]. In:
https://www.ncbi.nlm.nih.gov/books/NBK551718/
McCormack, J., & Reay, H. (2013). Acute stroke research: Challenges and
doi:10.7748/ns.2013.04.27.32.39.e7142.
Organised inpatient (stroke unit) care for stroke. (2013). The Cochrane
Library. https://doi.org/10.1002/14651858.cd000197.pub3
Other sources
https://my.clevelandclinic.org/health/body/22638-brain
Treatments. (n.d.).https://www.aans.org/en/Patients/Neurosurgical-
Conditions-and-Treatments/Cerebrovascular-Disease.
https://strokefoundation.org.au/what-we-do/for-survivors-and-carers/
after-stroke-factsheets/diet-after-stroke-fact-sheet#:~:text=And
%20drink%20plenty%20of%20water,crisps%20and%20other
%20savoury%20snacks.
https://www.mayoclinic.org/diseases-conditions/stroke/diagnosis-
treatment/drc-20350119
Webdev. (2020, April 27). How to Help Your Loved One With Eating and
https://www.accessiblehomehealthcare.com/blog/stroke-recovery-diet-
nutrition-tips
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19
Address: Purok 1-
Fatima, Ubay
Bohol, 6315
Nationality: Filipino
Religion: Islam
EDUCATIONAL BACKGROUND
Major: Nursing
20
Nationality: Filipino
day Saints
EDUCATIONAL BACKGROUND
Major: Nursing
Nationality: Filipino
EDUCATIONAL BACKGROUND
Major: Nursing
22
Address: Poblacion,
Pinamungajan,
Cebu City
Nationality: Filipino
EDUCATIONAL BACKGROUND
Major: Nursing
23
Address: South
Poblacion, City
of Naga, Cebu
Nationality: Filipino
EDUCATIONAL BACKGROUND
Major: Nursing