case study - cva with bleeding (medicine ward)
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City of Manila
UNIVERSIDAD DE MANILA
(Formerly City College of Manila)
A. Villegas St. Mehan Garden, Ermita, Manila
In partial fulfillment of the requirement in
Related Learning Experience
Gat Andres Memorial Medical Hospital – Medicine Ward
A Case Study on
CEREBROVASCULAR ACCIDENT with BLEEDING
Submitted to:
Ms. Sandra Loberiano, RN(Clinical Instructor)
Submitted by:
Marie Joy AbelleraMel Acol
Mary Anne AmbolarioJohn Elison AmoresAlyssa Marie Andres
Mica Sheena BautistaRhodelyn Bonifacio
Melvin BufeteJonelyn Carlos
Jhon Calvin ClementeAbegail Conopio
Maria Andrissa Damiar
Group 1 of Nr-31
December 19, 2009
ACKNOWLEDGEMENT
The Researchers would like to acknowledge Gat Andres Bonifacio Memorial Medical
Center for granting us permission to conduct a case study.
To all doctors and staff nurses of medicine ward, for the openhanded assistance and
services they showed.
To the researcher’s loving parents for expressively and economically supporting the
career the researchers have been taking.
The researchers also greatly acknowledge Mr. Romeo R. Orcasitas’ significant other,
for cooperation and willingness she showed.
To the researchers’ Clinical Instructor, Ms. Sandra Loberiano, for sharing her
knowledge, observation and generous cooperation, for the suggestion she gave to secure
information that made a valuable involvement to our case study.
Above anything else, to Almighty God who has given the researchers the guidance and
knowledge to achieve this study.
The Researchers
TABLE OF CONTENTS
Objectives of the Study
Introduction
Nursing Health History
Biographical Data
Chief Complaint
Present Health History
Past Medical History
Family Medical History
Lifestyle
Social Data
Psychological Data
Patterns of Health Care
Physical Assessment
Review of System
Gordon’s Typology of Functions of Health Pattern
Anatomy and Physiology
Pathophysiology
Laboratory and Diagnostic Studies
Medication and Drug Study
Nursing Care Plan
Medical Record
Discharge Plan
Summary
Conclusion
OBJECTIVES OF THE STUDY
General Objective:
At the end of the case study, the Researchers would be able to develop and evaluate
clinical assessment to effectively manage the patient through determining significant signs and
symptoms, history and main etiology of the disease.
Specific Objectives:
To know the risk factors that would contribute to the causation of the disease.
To determine the physiologic changes undergone by the patient with regards to the
condition.
To recognize the health history of the patient as basis for evaluating the disease
condition.
To be familiar of the medical and surgical procedures being done to the patient.
To formulate appropriate nursing intervention and effective care plan in the course
study.
To acquire beneficial knowledge that may improve the researcher’s foundation in
relation to the disease.
INTRODUCTION
Cerebrovascular accidents are the problems that result from inadequate blood supply to
the brain. CVA or in Layman’s term, “stroke” is probably the first disorder that comes to the
mind in considering cerebrovascular disorders.
A cerebrovascular accident or stroke is infarction of a specific portion of the brain due to
insufficient blood supply. It can occur from an occlusion of one of the major vessels feeding the
brain, a partial or complete obstruction of a major intracranial vessel, or it can also be a
hemorrhage within the brain. The blood vessels affected determines the area and extent of
infarction.
The third most common cause of death in most countries is CVD disorders,
approximately 0.5 to 1.0 per 1000 people. The narrowing or complete closure of one of the
vessels supplying the brain is the most common cause of this accident. Furthermore,
thrombosis, embolism and hemorrhage are included. Thrombosis is the most common cause
of stroke and is usually due to atherosclerosis or the fat or lipid deposition in the major vessel
of the cranium. It may occur anywhere along carotid artery and its branches; a common site is
at bifurcation of the common carotid into the internal and external carotid arteries. Cerebral
embolism is the occlusion of the cerebral vessel by emboli and some fragments of clotted
blood, tumor, fats, bacteria and even air. Intracerebral hemorrhage results from rupture of a
cerebral vessel that causes the bleeding into brain tissue.
There are risk factors prior to the recurrence of CVA such as hypertension,
polycythemia, hypercholesterolemia, smoking, oral contraceptives use, emotional stress,
obesity, family history of stroke and age. This condition may alter the original circulation of
blood, then leads to stroke. In line with this, as we all know almost all of the illicit drugs, alcohol
and nicotine found in cigarettes are one of the potent vasoconstrictor.
Stroke depends primarily on the location of the lesion or infracted tissue. If the brain
stem is affected, blood pressure fluctuations altered respiratory patterns and cardiac
dysrythmias are all possible.
Coma can follow stroke from various causes; strokes due to occlusal disease
(thrombus, embolus) rarely caused sudden death. When sudden death thus occurs it is usually
due to heart failure. Respiratory infection and brain stem failure are two primary causes of
death with stroke.
In lieu of the forgoing study, the Researchers presented this case study to enhance the
level of competency not only for the health care providers and the health institution itself, but
also for the knowledge enhancement of ordinary people.
NURSING HEALTH HISTORY
A. Biographical Data
Name: Romeo R. Orcasitas
Age: 43 years old Sex: Male
Address: 809 La Suerte st. Binondo, Manila
Marital Status: Married
Occupation: Messenger (F & N International Freight Forwarder Corporation)
Religious Preference: Roman Catholic
Health Care Financing: Phil. Health, SSS
B. Chief Complaints
Mr. Orcasitas, a 42 year old male patient who was admitted on December 11,
2009 at Gat Andres Bonifacio Memorial Medical Hospital was complaining of left sided
weakness.
C. Present Health History
The patient is having Cerebrovascular Accident (CVA) or commonly known as
stroke. According to Mr. Orcasitas’s significant other which is his wife, the symptoms
started on December 11, 2009 (Friday). It was unexpected and the patient experienced
vomiting, watery sputum with presence of blood and also noticed urine with slightly dark
yellow in color. After a while, the patient had lost its consciousness. The patient also
experienced pain in his nape (left side) on the same day and this accident with signs
and symptoms occurred all of a sudden. The client was drinking alcoholic beverages
before the symptoms manifested. Factors that aggravate the problems are fatigue and
during alcohol drinking as stated by Mrs. Orcasitas.
D. Past Medical History
During his childhood the client had chicken pox, measles, and mumps. He also
had Immunizations like BCG, OPV, AMV, and DPT. The client has no allergy neither he
experienced any accidents or injuries. On December 11, 2009 the client experienced
loss of consciousness which is also a reason of his hospitalization.
E. Family Medical History
Cardiac problems, most pronounced is hypertension for his father side.
F. Lifestyle
Patient doesn’t smoke but he’s drinking alcohol beverages every after work. He
is workaholic at the same time. His hobbies are watching TV and listening to music of
Pepe Smith. He is fond of eating meat, vegetables, fish, and fatty foods and drinks 8
glasses a day. Furthermore, he has no usual food patterns although he eats frequently.
During the course of his condition, CVA, patient was ordered to have OF.
G. Social Data
He is a high school graduate and currently working at F & N International Freight
Forwarder Corporation as a messenger. With regards of his health care, he is regularly
paying for health insurance at Phil. Health. Mr. Orcasitas has three children; a 9 and 6
year old female and an 8 year old male. According to his significant other, he is the one
who handle when he is sick. In addition, health care service like health centers is
geographically accessible for him but not even visit then ever since.
H. Psychological Data
According to the wife of Mr. Orcasitas, the main stressors of the patient is stress
regarding his children, work and financial problems. During this time, the time when he
got stressed, he usually drinks alcoholic beverages as his way to cope to those
stressors. When he has problem, he usually don’t share it to others and he is a serious
person but he loves to share jokes with others.
I. Patterns of Health Care
Mr. Orcasitas has been hospitalized at the Gat Andres Bonifacio Memorial
Medical Center last December 11, 2009 because of diagnosed Cerebrovascular
Accident. His healthcare providers are his physician and nurses on duty. His primary
care provider is himself. According to his significant other, he was cared properly when
he was hospitalized and the health care provider did not neglect him in any way that it
can be.
PHYSICAL ASSESSMENT
General Survey:
Body build, height and weight in relation to the patient’s age is proportional; patient is
conscious and coherent; partially assisted during hospitalization.
Vital Signs:
Blood Pressure: 140/90 mmHg
Temperature: 37.1oC
Respiratory Rate: 21 resp/min
Pulse Rate: 70 bpm
Body Part Tools Normal Findings Interpretation
Skin and Nails Inspection,
Palpation
Varies from light to
deep brown;
uniform skin
temperature and
within normal range;
skin turgor; normal
nail texture; highly
vascular and pink
color of nails
Normal
Hair Inspection Evenly distributed
hair; thick and silky;
no infections or
infestations;
variable amount of
hair
Normal
Head Inspection,
palpation
Rounded; smooth
skull contour;
uniform
consistency;
symmetric facial
features and
movement
Normal
Eyes Inspection,
palpation
Penlight
Eyebrows
symmetrically
aligned; skin intact;
no discharge; no
discoloration;
transparent; shiny
and smooth cornea;
pupils are black in
color; round and
smooth; coordinated
ocular movements
and move in unison.
Normal
Ears
Inspection,
palpation
Symmetrical; auricle
aligned with outer
canthus of the eye,
firm, and not tender.
Normal
Nose
Inspection,
palpation
External nose is
symmetric and
straight; no
Normal
discharge; uniform
in color
Mouth
Inspection,
palpation
Lips are pink in
color; soft and
moist; gums is pink,
moist and pink in
texture.
Normal
Neck
Inspection Muscles equal in
size and head
centered;
coordinated and
smooth head
movements with no
discomfort; equal
muscle strength; not
palpable lymph
nodes.
Normal
Thorax and lungs
Stethoscope,
inspection and
palpations
Chest symmetric;
supine vertically
aligned, skin and
chest wall is intact;
full and symmetric
chest expansion;
costal angle is less
than 90 degrees.
Normal
Abdomen Inspection,
auscultation,
palpation,
percussion
Uniform in color; no
evidence of
enlargement of liver
or spleen;
symmetric
movements caused
by palpations;
audible bowel
sounds; no
Normal
tenderness in
abdomen; relaxed
with smooth and
consistent tension.
Male genitals and
inguinal areas
Palpation Penile skin intact;
foreskin is easily
retractable; penis is
smooth; semi firm
and slightly movable
over the underlying
structures; scrotal
skin is darker in
color; and appears
asymmetric;
inguinal area with
no swelling and
palpable bulges.
Normal
REVIEW OF SYSTEM
CVA is directly affecting the nervous system of the body which is composed of different
parts. This condition is manifested primarily by its level of consciousness. Based on the case
study, the patient experienced weakness at his left side, vomiting, and pain at his nape area.
GORDON’S TYPOLOGY OF FUNCTION OF HEALTH PATTERN
Pre
Hospitalization
During
Hospitalization
Post
Hospitalization
Eating Pattern
The patient is fond of
eating fatty and salty
foods.
The patient is now on
NGT taking osteorized
feeding at 1800 kcal
in 6 equal feedings in
24 hours.
During post
hospitalization the
patient is expected to
eat healthy foods like
vegetables and fruits
(diet modifications).
Drinking Pattern
He is fond of drinking
softdrinks and liquor
and less intake of
water.
Patient is in
osteorized feeding,
and water intake is
taken via nasogastric
tube.
During post
hospitalization the
patient is expected to
drink 8-10 glasses of
water and less intake
of alcoholic
beverages.
Elimination Pattern
His eliminating pattern
usually ranges from 1-
2 times a day.
Urine output
measured in urine bag
is approximately 250
ml per day and
bowel elimination is 2-
3 times a day.
The patient is
expected to have a
good elimination
pattern in connection
with diet and lifestyle
modification.
Sleeping PatternNot good sleeping
pattern, light sleeper.
During hospitalization,
sleeping pattern is
enhanced through
comfort provided by
nurse on duty.
The patient is
expected to have a
good sleeping pattern.
Activity/ Exercise The patient really
likes to watch
television and listen to
the music of Pepe
Smith
During hospitalization,
patient is in bed and
partially assisted by
significant others.
The patient is
expected to bring
back his usual daily
activity such as
watching television
and listening to music.
Furthermore, routine
exercise must be
promoted for good
tone of the body.
Coping Stress/ Tolerance Pattern
When the patient is
having problems, he
usually drinks liquor to
cope and eventually
forget his problems as
stated by his
significant other.
During hospitalization,
patient is always
praying for fast
recovery as his way to
manage the stress
brought by the
condition.
Patient is expected
during post
hospitalization to have
good stress
management skills.
Spiritual Pattern
The patient is a God-
fearing person and
attends the mass
every Sunday.
Patient always pray
for the fast recovery
and therefore more
time is allotted for the
spiritual pattern.
The patient is
expected to
established a more
stronger relationship
to God.
ANATOMY AND PHYSIOLOGY
(Nervous System)
The nervous system integrates and monitors the countless actions occurring
simultaneously throughout the entire human body. Therefore, every task, no matter how
menial, accomplished by a person is a direct result of the components of the nervous
system. These actions can be under voluntary control, like touching a computer key, or
can occur without your direct knowledge, like digesting food, releasing enzymes from
the pancreas, or other unconscious acts.
It is difficult to understand all the complexities of the nervous system because the
field of neuroscience has rapidly evolved over the past 20 years. Moreover, answers to
new questions are being found almost daily. However, a thorough knowledge of the
individual components of the nervous system and their functions will lead to a better
understanding of how the human body works and facilitate the acquisition of knowledge
in the future.
The nervous system consists of two parts; the central nervous system (CNS)
consists of the brain and spinal cord and the peripheral nervous system (PNS) consists
of nerve outside the CNS.
Nerves of the PNS are classified in three ways. First, PNS nerves are classified
by how they are connected to the CNS. Cranial nerves originate from or terminate in the
brain, while spinal nerves originate from or terminate at the spinal cord. Second, nerves
of the PNS are classified by the direction of nerve propagation. Sensory (afferent)
neurons transmit impulses from skin and other sensory organs or from various places
within the body to the CNS. Motor (efferent) neurons transmit impulses from the CNS to
effectors (muscles or glands). Third, motor neurons are further classified according to
the effectors they target. The somatic nervous system (SNS) directs the contraction of
skeletal muscles. The autonomic nervous system (ANS) controls the activities of
organs, glands, and various involuntary muscles, such as cardiac and smooth muscles.
The autonomic nervous system has two divisions; the sympathetic nervous
system is involved in the stimulation of activities that prepare the body for action, such
as increasing the heart rate, increasing the release of sugar from the liver into the blood,
and other activities generally considered as fight-or-flight responses (responses that
serve to fight off or retreat from danger) and the parasympathetic nervous system
activates tranquil functions, such as stimulating the secretion of saliva or digestive
enzymes into the stomach and small intestine.
Generally, both sympathetic and parasympathetic systems target the same
organs, but often work antagonistically. For example, the sympathetic system
accelerates the heartbeat, while the parasympathetic slows the heartbeat. Each system
is stimulated as is appropriate to maintain
homeostasis.
The brain is an organ located in the skull.
It weighs about 3 pounds. The senses
(taste, smell, sight, hearing, and touch),
emotions, thoughts, and movement are
controlled by the brain. The right side of
the brain controls the left side of the body and the left side of the brain controls
the right side of the body.
There are three main part of the brain: the cerebrum, the cerebellum, and the
brain stem. Cerebrum controls higher brain functions and has four lobes, each with
different functions:
Frontal lobe: executive function, decisions, personality, language, planning, movement
Parietal lobe: intelligence, reasoning, sensation, reading
Occipital lobe: vision
Temporal lobe: language, behavior, hearing, vision, emotions, memory
Cerebellum controls balance, coordination, and fine muscle control.
The Spinal cord starts at the brain stem and goes to the tail bone. It is about as
wide as your little finger and extends the length of your back. Messages are carried
from the spinal cord to and from the brain to the rest of the body. Nerves extend from
the spinal cord on each side and go to the parts of the body. The brain and spinal cord
are protected by bony structures: the skull and the spinal column.
Meninges are membranes that cover and protect the brain and spinal cord.
There are three layers of meninges: Dura mater (closest to the bone), Arachnoid loosely
around the brain, Pia mater is closely attached to the brain and spinal cord surface.
Cerebrospinal Fluid (CSF) cushions the brain and spinal cord. It is a clear, water-
like fluid, also called spinal fluid, found between the arachnoid and pia mater. It is made
within the four ventricles of the brain. The area in the lateral ventricles that makes spinal
fluid is called the choroid plexus. About 20cc of spinal fluid is made but not absorbed
each hour. There is about 140 cc (about ½ can of soda) of spinal fluid that surrounds
the brain and spine. The brain and spinal cord are bathed and cushioned by this spinal
fluid, which flows and circulates around the brain and spine.
PATHOPHYSIOLOGY
Risk Factors: Sedentary Lifestyle Substance Abuse Increased lipid and fats in food Increased sugar and carbohydrate intake Obesity Lack of Exercise
HypertensionArterioschlerosis
HyperlipidemiaDiabetes Mellitus
Thrombi Formation
Atheroschlerosis
Dislodged Thrombus from Sire of Attachment(Emboli)
Emboli Obstruction in Cerebral Blood Vessel
Increased Pressure in Cerebral Blood Vessel
Transient Ischemic Attack
Cerebral Blood Vessel Leakage
Cerebral Blood Vessel Leakage
Spasm of Adjacent Vessel
Brain Tissue Compression
Cerebrovascular Accident with Bleeding(Neurologic Deficits)
LABORATORY AND DIAGNOSTIC STUDIES
Electrolytes Result Form
Constituent Result Normal Values Interpretation
Sodium 134.2 mmol/L 135-145 Indicates water excess.
Potassium 4.30 mmol/L 3.4-4.0 Indicates decreased kidney functioning.
Chloride 92-102
Calcium 2.02-2.6
Rationale:
Serum electrolytes are taken in order to know whether the patient has electrolyte
imbalance (excess or deficit in the plasma level of a specific ion). It is important to keep a
balance of electrolytes in the body, because they affect the amount of water in our body, blood
acidity (pH), muscle action, and other important processes.
Clinical Chemistry
Conventional S.I. Unit
Constituent ResultNormal Value
ResultNormal Value
Interpretation
Alkaline Phosphatase
(ALP)____ U/L 35-129 ____ U/L 35-129
ALT/SGPT 27.6 U/L 10-50 27.6 U/L 10-50Indicates normal liver functioning.
AST/SGOT 25.8 U/L 0-38 25.8 U/L 0-38Indicates normal liver functioning.
Cholesterol 206.5 mg/dl
0-200 5.4 mmol/L
0-52 Indicates risk for heart attack and
stroke.
Creatinine 0.93 mg/dl
0.5-1.2 82.2 mmol/L
44-106 Indicates decreased kidney
functioning.
Glucose (FBS) ___ g/dl 74-106 ___ g/L 4.11-5.9
Total Protein ___ g/dl 6.4-8.3 ___ g/L 64-83
Albumin ___ g/dl 3.4-4.8 ___ g/L 34-48
Globulin ___ g/dl 3.0-3.5 30-35
A/G Ratio 1.1-1.8 1.3 mmol/L
1.1-1.8
Triglycerides 117 mg/dl
0-200 0.30 mmol/L
0-2.26 Has normal level of triglycerides to be used as energy of
the body.
Uric Acid (BUA) 5.0 mg/dl 2.4-7.0 7.6 mmol/L
0.14-0.41 Indicates that the body is handling the breakdown of
purines well.
Urea Nitrogen (BUN)
14.7 mg/dl
6-20 5.2 mmol/L
2.1-7.1 Indicates normal kidney excretion.
Sodium 137.2 mg/dl
135-145 137.2 mmol/L
135-145 Indicator of normal water balance.
Potassium 3.80 mg/dl
3.4-4.0 3.80 mmol/L
3.4-4.0 Indicates normal kidney functioning.
Chloride __ mg/dl 92-102 mmol/L 92-102
Rationale:
This test helps provide information about the body's metabolism. It gives health care
providers the information about how the patient’s kidneys and liver are working, and can be
used to evaluate cholesterol, and calcium levels, among other things.
Urinalysis – Clinical Urinalysis
Physical Characteristics Interpretation
COLOR Light yellow Indicates normal urine color.
TRANSPARENCY Slightly hazy Normal transparency.
REACTION 6.5
SPECIFIC GRAVITY 1.020 Kidneys are able to concentrate urine.
Chemical Chemistry
Albumin (+++)
Sugar negative
Occult blood
Bilirubin
HCG Titer
Cells:
RBC 10-20/hpf
Pus cell 0-3/hpf
Squamous cells (+)
Yeast cells
Renal cells
Bacteria
Mucous Threads (++)
Crystals
Amorphous Urate (+)
Uric Acid
Ca Oxalate
Amorphous PO4
Triple PO4
Rationale:
The urinalysis is used as a screening and/or diagnostic tool because it can help detect
substances or cellular material in the urine associated with different metabolic and kidney
disorders. It is also used to detect urinary tract infections (UTI) and other disorders of the
urinary tract.
Clinical Chemistry
Conventional S.I. Unit
Constituent ResultNormal Value
ResultNormal Values
Interpretation
Alkaline Phosphatase
(ALP)____ U/L 35-129 ____ U/L 35-129
ALT/SGPT 27.6 U/L 10-50 27.6 U/L 10-50Indicates normal liver
functioning.
AST/SGOT 25.8 U/L 0-38 25.8 U/L 0-38Indicates normal liver
functioning.
Cholesterol 206.5 mg/dl
0-200 5.4 mmol/L
0-52 Indicates risk for heart attack and
stroke.
Creatinine1.22 mg/dl
0.5-1.2107.8
mmol/L44-106
Indicates decreased kidney functioning.
Glucose (FBS) ___ g/dl 74-106 ___ g/L 4.11-5.9
Total Protein ___ g/dl 6.4-8.3 ___ g/L 64-83
Albumin ___ g/dl 3.4-4.8 ___ g/L 34-48
Globulin ___ g/dl 3.0-3.5 30-35
A/G Ratio 1.1-1.81.3
mmol/L1.1-1.8
Triglycerides117
mg/dl0-200
0.30 mmol/L
0-2.26
Has normal level of triglycerides to be used as energy of
the body.
Uric Acid (BUA) 5.0 mg/dl 2.4-7.07.6
mmol/L0.14-0.41
Indicates that the body is handling the
breakdown of purines well.
Urea Nitrogen (BUN)
21.3 mg/dl
6-20 mmol/L 2.1-7.1Indicates normal kidney excretion.
Sodium __ mg/dl 135-145 mmol/L 135-145
Potassium __ mg/dl 3.4-4.0 mmol/L 3.4-4.0
Chloride __ mg/dl 92-102 mmol/L 92-102
Rationale:
This test helps provide information about the body's metabolism. It gives health care
providers the information about how the patient’s kidneys and liver are working, and can be
used to evaluate cholesterol, and calcium levels, among other things.
Hematology
Result Normal Range Interpretation
Hemoglobin 133 gm/l 120-180Has normal oxygen
carrying capacity of the blood.
Hct .435 0.370-0.540Has normal pack of
RBC/ blood viscosity.
Electrolyte count x109/L 4.0-6.0
Leucocyte count 18.1 x109/L 4.6-10.0Indicates acute
infection/ inflammatory response.
Differential Count
Neutrophils Bands 0-0.05
Segmenter .92 0.60-0.70
Lymphocytes .08 0.20-0.40Indicates increased
WBC capacity.
Monocytes 0-0.07
Eosinophils 0-0.08
Basophils 0-0.1
Cell Indices
MCV 820-920
MCHC 27.0-31.0
Platelet count 340-360
Reticulocyte count 385 x109/L 150-450
Coagulation time x10-5 5-15
Hemoglobin 133 gm/l 120-180Has normal oxygen
carrying capacity of the blood.
Hct .435 0.370-0.540Has normal pack of
RBC/ blood viscosity.
Rationale:
Hematology is the study of blood and its disorders. Hematology tests can help diagnose
anemia, hemophilia, blood-clotting disorders, and leukemia. It is actually a panel of tests that
examines different parts of the blood. It also helps to determine the general health status of the
patient.
Medications and Drug Study
Generic
NameClassification Indication Contraindication
Dosages and
RouteSide Effects
Nursing
Responsibilities
Mannitol Diuretic Reduction of
intracranial
pressure and
brain mass.
Active intracranial
bleeding,
hypersensitivity,
anuria, severe
pulmonary
congestion,
edema, severe
dehydration,
progressive heart
failure and renal
failure.
Oliguria,
prevention
Adult: IV 50
– 100g 5% -
25% sol
Renal failure
Adult: IV 50
– 200 g/24
hr, adjusted
to maintain
output of
30-50 mg/hr
Pulmonary
congestion, fluid
and electrolyte
imbalance,
electrolyte loss,
dryness of mouth,
thirst, marked
diuresis, urinary
retention, edema,
headache, blurred
vision,
convulsions,
nausea, vomiting,
rhinitis, arm pain,
skin necrosis,
chills, dizziness,
Monitor blood
pressure.
Check for
hypervolemia,
urinary tract
obstruction
and signs of
fluid
imbalance.
dehydration,
hypotension,
tachycardia, fever
and angina-like
chest pains.
Amlodipine Calcium-
channel
Blockers
Treat high blood
pressure or
chest pain.
Sick sinus
syndrome, 2nd- or
3rd-degree heart
block,
hypertension less
than 90 mm Hg
systolic,
hypersensitivity
Angina
Adult: PO 5
– 10 mg
q.d.
Hypertension
Adult: PO
5mg q.d.
initially, may
increase up
to 10mg/day
Headache and
edema (swelling)
of the lower
extremities,
dizziness,
flushing, fatigue,
nausea, and
palpitations
Assess cardiac
status: B/P,
pulse,
respiration,
ECG
Teach pt. do
not break,
open, crush, or
chew sust rel
caps
Nimodipine Cardiovascular
drugs
Improvement of
neurologic
deficits after
No known
contraindications
Adult: 60
mg PO q4
for 21 days.
Headache,
psychic
disturbances,
Use cautiously
for pt with
hepatic failure
subarachnoid
hemorrhage
from ruptured
congenital
aneurysm
Begin
therapy
within 96
hours after
subarachnoi
d
hemorrhage
decreased blood
pressure,
flushing, edema,
tachycardia
Monitor blood
pressure and
heart rate
Clarithromycin Semi-synthetic
macrolide
antibiotic
Treatment of
mild to
moderate
infections
caused by
susceptible
strains of the
designated
microorganisms
Hypersensitivity
to this drug or
macrolide
antibiotics
Adult: PO
250-500 mg
bid for 7 –
14 days:
500mg bid
continues
for M. avium
(mac)
Diarrhea, nausea,
abnormal taste,
dyspepsia,
abdominal
pain/discomfort,
and headache.
Assess I & O
ratio: report
hematuria,
oliguria in renal
disease
Assess skin
eruptions,
itching
Administer
adequate
intake of fluids
(2 L)
Adult: PO Monitor blood
Losartan Anti-
hypertensive
Hypertension,
alone or in
combination
Hypersensitivity 50mg q.d.
alone or 25
mg qd when
used in
combination
Dizziness,
insomnia, anxiety,
confusion,
abnormal dreams,
migraine, tremor,
vertigo
pressure.
Assess
edema in feet,
legs q.d.
Skin tugor,
dryness of
mucous
membrane for
hydration
status
Cefuroxime Broad-
spectrum
antibiotic
Serious lower
respiratory tract,
urinary tract,
skin, bone joint,
gonococcal
infection;
septicemia,
meningitis
Hypersensitivity
to
cephalosporins,
infants <1 mo
Adult &
child: PO
250mg q
12h; may
increase to
500mg q
12h in
serious
infections
Adult: IM/IV
750mg-1.5g
Headache,
dizziness,
weakness,
paresthesia,
fever, chills
Assess bowel
pattern q.d.; if
severe
diarrhea
occurs, drug
should be
discontinued;
may indicate
pseudomemb
ranous colitis
Assess for
q8h for 5-10
days
allergic
reactions
NURSING CARE PLAN
Assessment Diagnosis Rationale Planning Intervention Rationale evaluation
S: "balisa sya sa tingin ko" as stated by the significant other
O: pt. is consciousshowed slow reaction the pt. eyes is shallow and dark spot around the orbital area
V/SB/P: 160/100RR: 23PR: 94T: 36.6
Altered sleeping pattern related to present condition as evidenced by slowed reaction and irritability.
Due to present condition the sleep pattern was altered that makes the pt. irritable and refuse to cooperate.
After a series of nursing intervention the pt. will be able to adjust sleeping pattern as usual.
1. established rapport
2. offer back massage
3. recommend divertional activities
4. provide calm quiet environment
5. position client comfortably in bed
to established trust and cooperation
for relaxation and comfort
to reduce irritation and to relax
to enhance sleep
For comfort and relaxation.
After a series of nursing intervention the patient was able to adjust sleeping pattern as usual.
Assessment Diagnosis Rationale Planning Intervention Rationale Evaluation
S: "masakit ang batok nya kapag nagagalaw ko sya patagilid" as verbalized by the significant others
O: consciuos impaired ability to move side to sidefacial grimace of L7 out of L10
VSBP:140/100RR:24PR:94T:36.0
impaired mobility due to present illness
Due to decreased muscle strength related to his present illness the patient have impaired mobility.
After a series of Nursing Intervention the pt. will be able to increased muscle strength as seen in his initiative to move and was able to move from complete assistance to partially assist.
1. established rapport
2. maintained proper hygiene
3. give body massage
4. ROM exercise was doneturn the client every 2hr
elicited trust and cooperation
for relaxation and comfort
to stimulate blood flow
to increase muscle strength and prevent muscle atrophyto prevent pressure sore
After a series of nursing intervention the pt has gained muscle strength that enables him to improve his mobility as evidence by his initiative to do independently.Facial grimace was lessening as evidence by L4 from L7 facial grimace scale.
Assessment Diagnosis Rationale Planning Intervention Rationale Evaluation
S:”nahihirapan na siyang magsalita, puro ungol na lang.” s verbalized by the significant other
O:conscioussocial behavior is altered due to NGT insertiondysfunctional interaction with others
VSBP:160/100RR:23PR:94T:36.6
impaired social interaction due to communication barriers cause by neurological condition as evidence by inability to communicate that altered his social behavior
due to present neurological condition the client has an altered communication process that cause his impaired social interaction
pt. elicited and expressed desire in achieving positive changes in social behaviors and interpersonal relationship
1. established rapport
2. established therapeutic relationship to the pt
3. divertional activity was introducedposition the client
to gain trust and cooperation
to alleviate the level of discomfort and increased social interaction
to encourage pt to involve such activityfor comfort and relaxation
After as series of nursing intervention the client is able to increase his social behavior as evidence by his initiative to cooperate and communicate well.
MEDICAL RECORD
Room No. 617
Patient’s Name: Orcasitas, Romeo
Age: 43 years old
Sex: Male
Address: 809 La Suerte St. Binondo, Manila
Diagnosis: CVA with Bleeding
December 11, 2009
6:00 am
11:00 am
received patient lying in bed conscious and coherent with
significant other
with IV fluid PNSS 1L x 12o at 600 ml level intact, NGT,
and foley catheter intact
morning care performed
comfort provided by changing lines
vitals signs taken and recorded as follows:
BP = 140/100 mmHg
HR = 71 bpm
RR = 20 resp/min
Temp = 37.1 oC
due meds taken at 9:30 am
vitals signs taken and recorded as follows:
11:30 am
12:00 am
BP = 140/90 mmHg
HR = 70 bpm
RR = 22 resp/min
Temp = 36.7 oC
seen and examined by Dra. Dela Cruz with orders made
health teachings rendered are as follows:
mannitol 100 ml TIV given
endorsed patient with IV fluid PNSS 1L x 8o at 400 ml level
Jhon Calvin V. Clemente
UDM, SN
DISCHARGE PLAN
Medications - home meds should be taken as prescribed on exact dosage, time,
and frequency via NGT.
- Cefuroxime 750mg/OD q8
- Clarithromycin 500mg/tab BID
- Amlodepine 10g/tab OD
- Losartan 50g/tab OD
- Simvastatin 1 tab OD HS
- Citicholine 500g TID q6
Exercise - prefer PROM exercise due to left sided weakness. It should be done at
least every morning.
Treatment - continue take home medications
- TCB after one week OPD at medicine department, 1pm
Health Teachings - render health teachings to the SO regarding:
- proper PROM
- positioning q2 to avoid decubitus ulcer
- good oral care
- bed bath at least OD
- hand washing before and after NGT feeding.
Out-Patient Department - TCB after 1 week for follow-up check-up to ensure the
continuing management and treatment.
Diet - continue OF as ordered.
- eat healthy foods and drink plenty of water
Spiritual - always pray to almighty god for spiritual support
SUMMARY
The study focused on the condition how stroke occurs and the damage causes to
the patient. A stroke can occur anywhere in the brain or just outside it in cases of
subdural or subarachnoid. The symptoms that the patient experienced are due to his
right hemisphere of the cerebrum damage, the result is the weakness on his left side of
the body. It interfere the patient ability to walk, talk, eat and perform other self care
tasks in the later stage of the condition. Brain stem strokes are the most devastating
and life threatening because they can disrupt the involuntary functions, essential to life.
In line with this topic, the Researchers made a case presentation focusing to
stroke. The name of the patient is Mr. Romeo R. Orcasitas, a 43 year old male and
working as a messenger in F&N INT’L. FREIGHT FORWARDER CO. currently. Aside
from the biographical data, the researchers also collected the patient’s diet and lifestyle,
habits, social data, psychological data, family background and health history and any
information that can be used to enhance the study. Mr. Orcasitas is an alcohol drinker,
since then until the time he was admitted, but he never tries to be a smoker. With
regards to his diet, he eats anything he wants like meat, vegetables, and fish but most
often he eats fatty or oily foods. Mr. Orcasitas is separated and currently living with his
children. His role as a guardian and provider is sufficiently met. According to him, his
major stressors in his life were family matters, work, and financial problems; he copes
with these problems by talking to his neighbors and preparing for a drinking session.
The researchers also inquired the patient history of present illness. Mr. Orcasitas
is having a cerebrovascular accident (CVA) bleed or commonly known as stroke.
According to Mr. Orcasitas significant others, signs and symptoms manifested at a
sudden. They observed that Mr. Orcasitas vomited and experienced loss of
consciousness. They conclude that this disease exists due to too much work and too
much abused of his body. The condition was diagnosed that moment when he was
admitted to the hospital, Friday, December 11, 2009. They also noticed that there was
sputum expelled by the patient which at first was in a watery form with blood but
eventually becomes viscous with white phlegm. The discharge which is urine was
slightly dark yellow in color. Mr. Romeo Orcasitas took an alcohol beverage before he
was admitted. The factors that cause the problem are too much intake of alcohol drinks,
too much intake of salty and fatty foods, and too much work and too much abused of his
body.
From the relevant information gathered by the researchers from Mr. Orcasitas,
they were able to identify the possible cause of the disease and predisposing factors
that contributed to the patient’s condition. This knowledge aided in rendering proper
management and in providing quality nursing care plan.
CONCLUSION
In summary content and analysis of the study, the researchers were able to drive
the following conclusions. The patient’s sedentary lifestyle greatly affects and
aggravates the conditions itself. With the diet of high in fats and salty foods, this can
cause hypertension and lipid deposition in the major vessel of the brain. On the latter
part of this fat and lipid deposition is atherosclerosis. With the lifestyle of alcohol
drinking and cigarette smoking, the patient’s susceptibility to this condition is increased.
Alcohol and nicotine found in cigarettes are potent vasoconstrictor.
As part of the nursing duties and responsibilities, health teachings like diet and
lifestyle modification must be rendered to promote health. Certain restrictions should be
emphasized and the threats of these if not followed.
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