cerebrovascular accident
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Angeles University FoundationAngeles City
College of Nursing
“Cerebrovascular Accident Infarct Right hemisphere”
In Partial Fulfillment of the Requirements in NCM RLE 102
OB- Pedia Ward, Balitucan District Hospital
Submitted by:
Ano Carl Elexer C.
Balilo, Noel Leonicio
Dizon, Requelito
Estrada, Florence Ancel
BSN III-1 Group 1
Submitted To:
Fe Pagado R.N., M.N.
February 21, 2009
I. Introduction
Many studies were conducted regarding cerebrovascular accidents tackling
different aspects of cerebrovascular accident such as; the cause, precipitating factors,
predisposing factor, and its prevalence throughout the world as one of the top ten
leading causes of morbidity.
Cerebrovascular accident (CVA) is the medical term for what is commonly
termed a stroke. It refers to the injury to the brain that occurs when flow of blood to
brain tissue is interrupted by a clogged or ruptured artery, causing brain tissue to die
because of lack of nutrients and oxygen.
The severity associated with cerebrovascular accident can best be demonstrated
by the following facts: CVA is the leading cause of adult disability in the world. Two –
thirds of strokes appear among 65 year old and above. Stroke affects more men than
women and most of the cases are among African American. (Accessed on:
http://www.wikidoc.org/index.php/Cerebrovascular_accident)
A. Current Trends about the Disease Condition
Blunt cerebrovascular injuries can be diagnosed using whole body 16 multi-
detector CT (MDCT); there's no need for an additional neck MDCT angiography
examination according to a recent study conducted by researchers at the University of
Maryland Medical Center and R. Adams Cowley Shock Trauma Center, both in
Baltimore, MD. The study showed that whole body MDCT is just as accurate as neck
MDCTA. Blunt cerebrovascular injuries are uncommon but potentially devastating
injuries that can lead to stroke and death. These include dissections,
pseudoaneurysms, and arteriovenous fistulae.
For the study, the researchers identified 108 blunt trauma patients that were
examined with either whole-body MDCT or neck MDCTA followed by angiography over
a 23-month period. From this group, 77 whole body MDCT and 48 neck MDCTA
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examinations were compared with the results that were pulled from the reports of
correlative angiography.
According to the study, angiography confirmed blunt cerebrovascular injuries in
83 patients with 25 of those showing injury to more than one of the four major arteries
(carotid or vertebral). In the neck, where injuries were most common, each technique
showed low sensitivity for blunt carotid (69% for whole-body MDCT and 64% for
MDCTA) and blunt vertebral artery injuries (74% for whole-body MDCT and 68% for
MDCTA), but specificities were high for both carotid (82% for whole-body MDCT and
94% for MDCTA) and vertebral artery injuries (91% for whole-body MDCT and 100% for
MDCTA). The two techniques diagnosed blunt cerebrovascular injuries with statistically
comparable accuracy. Routine use of whole-body MDCT would facilitate diagnosis and
treatment of asymptomatic blunt cerebrovascular injuries in patients without typical risk
factors for injuries. (Accessed on: http://www.eurekalert.org/pub_releases/2008-03/arrs-
wbm032808.php)
B. Reasons for choosing such case for presentation
Initially the researchers have difficulty of an appropriate case for presentation
since most of the cases present on the institution are common illness such as Acute
Gastroenteritis and Bronchopneumonia where in there is a lot of information available
regarding these diseases.
With that problem in hand, the group decided to ask permission to their clinical
instructor to utilize a medical case, and with the approval of their clinical instructor, the
group came up into a medical case of a 58 years old widowed female with a diagnosis
of Cerebrovascular infarct right hemisphere with accompanying past illnesses of active
renal disease, hypertension and Diabetes mellitus.
Objectives
After the completion of the study, the researchers shall be able to:
Identify and differentiate risks for cerebrovascular accident
Be updated with the latest trends in the treatment of cerebrovascular accident
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Perform a comprehensive assessment of Cerebrovascular accident
Enumerate the different signs and symptoms of Cerebrovascular accident
List down the different diagnostic procedures that would help in the diagnosis of
Cerebrovascular accident.
Identify and understand different types of medical treatment necessary for the
treatment of Cerebrovascular accident.
Formulate nursing care plans utilizing the nursing process
Formulate conclusions based on the findings and enumerated a
recommendations concerning Cerebrovascular accident.
Nurse Centered Objectives:
At the end of the study, the researchers:
Shall have critical thinking skills necessary for providing safe and effective
nursing care.
Shall have a comprehensive assessment and implement care base on our
knowledge and skills of the condition
Shall have familiarized us with effective inter-personal skills to emphasized
health promotion and illness prevention.
Shall have imparted the learning experience from direct patient care.
Patient/Family Centered Objectives:
At the end of this study, the patient/family will be able to:
1. Identify measures that could minimize the risk of occurrence of the disease.
2. Identify possible risk factors that may have contributed to the development of
Cerebrovascular accident.
3. Increase awareness on the risk factors of Cerebrovascular accident.
4. Develop the family’s support system and distinguish their respective roles in
improving patient’s health status.
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5. Involve them in promoting the health care of the patient.
5
II. Nursing Assessment
A. Personal Data
1. Demographic data
Mrs. Kitty Sanrio is a 58 year old widow, Filipino who was born on
September 18, 1951 in Magalang, Pampanga.
She is the second child among the 3 siblings of Disney family and all
of them are married. She, together with her youngest daughter Po, currently
resides at San Francisco, Magalang, Pampanga. She is religiously affiliated
as a Roman Catholic. She is presently unemployed but used to be an eatery
vendor. When she was 35 years old she smokes 1 pack of cigarette per day,
yielding a pack year history of 23, she was forced to quit smoking due to her
present illness. She was admitted at Balitucan District Hospital in Magalang
with an admitting diagnosis of cerebrovascular infarct right hemisphere with
chief complaints of left sided weakness.
2. Socio-economic and Cultural Factors
Mrs. Kitty Sanrio was able to finish her high school education but she
was able to pursue a vocational course on dressmaking. She is religiously
affiliated to Roman Catholic. As mentioned the family believed on the
common practices of the Catholics which her daughter termed as “apis –apis”
they also believe in manghihilot. With regards to their sanitary condition of
their home it was reported that Mrs. Sanrio always does the housekeeping.
In the year 2007, Mrs. Sanrio used to work as an eatery vendor that
was specifically year ago before she was been diagnosed of renal disease
last 2008, at present her daughters support her daily expenses including
household bills.
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B. Pertinent Family Health History
Disney Family
7
Father † Mother†
Daughter 1
Mr. Sanrio †Mrs. Sanrio
Sister 2Sister 1
Daughter 4Daughter 3Daughter 2
Renal Failure
Legend:
Heart Attack
HPN
CVA, HPN, DM, Renal
Disease
Normal
Epilepsy
Liver Cancer
Upon interview it was reported that Mrs. Sanrio’s father died of renal failure at the
age of 82, her mother died of heart attack at the age of 89. Mrs. Sanrio has two sisters,
both of them also has hypertension. Mrs. Sanrio’s husband died 8 years ago at the age
of 52 due to liver cancer. 3 years after, specifically 2005, Mrs. Sanrio was diagnosed
Diabetes Mellitus type 2. At the year 2008, she was diagnosed of renal disease and
hypertension by accident. Her four daughters do not have any major illness except for
her youngest daughter which has epilepsy which was diagnosed at the age of 15.
C. History of Past Illness
Upon interview, her daughter told the student nurses that Mrs. Sanrio was
diagnosed of Diabetes Mellitus Type II in the year 2004, and she is taking Diamicron as
her medication, according to her mother is also fond of eating foods which are rich in fat
and cholesterol. She has also mentioned that Kitty cannot eat without putting extra salt
on her food. Information relayed by Tinky Winky states that Kitty undergone an incision
and drainage surgery due to thumbtacks pricks which became infected and developed a
large pus filled lesion in the year 2008. Together with that during her stay on the
hospital, it was found out that Kitty has a renal disease; Tinky Winky was not able to
specify the exact diagnosis given by the physician, it has also found out that she has a
hypertension. In line with this, Kitty managed her renal disease with Bactrim and Eprex.
She is also taking Capoten and Neobloc for her Hypertension. Mrs. Sanrio wears a
prescribed eyeglass for 3 years now with a grade of 200 as mentioned by Tinky winky.
D. History of Present Ilness
As narrated by Tinky winky at the district hospital 2-3 days prior to Kitty’s
admission she is already complaining of headache, and they regarded it as the usual
headache associated with high blood pressure. They have just managed it with her
medicines for hypertension. The symptoms persisted for another day and managed it
the same way.
January 27, 2009 1:30 am, Kitty woke them up with complains of numbness on
her body and blurry vision “dudurut ya kanu lawe”, she doesn’t want anybody to touch
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her as she can feel that her conditions aggravates every time someone will touch her.
According also to Tinky winky upon seeing her mother, she have noticed that there is an
obvious asymmetry on her mother’s face “balamu mekubit ya lupa, balamu babalag ya
lupa” and slurring of speech, she then had an idea that it may be a stroke.
They planned to bring Kitty to a private hospital, but Mrs. Sanrio disagreed
insisting that she wants to be admitted at the district hospital. So after a few hours of
debate, they have decided to bring her to the District Hospital. Upon consult, she was
advised to stay at the hospital on January 27, 2009 with admitting diagnosis of CVA
infarct right Hemisphere, with accompanying illnesses of renal disease, hypertension
and diabetes mellitus.
A. Physical Examination
January 27, 2009 (lifted from chart)
Patient has chief complaints of left sided body weakness, conscious, alert, (+)
facial asymmetry, normal rate and regular rhythm, clear breath sounds,
normoactive bowel sounds, GCS= 15, BP= 200/100 mmHg, PR= 85, RR= 16
General Appearance - Initial [(January 29, 2009)]
Patient is wearing a black with floral design clothing, with unkempt hair,
appears weak; patient has halitosis, conscious and coherent. She is lying on bed
with an ongoing IVF of #2 D5 0.3 NaCl 500 cc x 20 - 21 µgtts/ min infusing well
on the right metacarpal vein currently at 50 cc level, patient has an indwelling
Foley catheter attached to urine bag with current urine out put of 2000 ml.
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5/5
5/5
1/5
1/5
R L
Patient has the following vital signs:
T= 35.8 ° C
P= 79 bpm
R= 20 cpm
BP= 190/90 mmHg
Upon the assessment of her head, the researchers noted a normal finding,
characterized by symmetrical skull, no presence of nodules and lesions, and with
hair properly distributed.
Upon the assessment of the client’s face, most of the findings are of
normal findings characterized by pupils which are equally round in shape,
reactive to light and accommodation, with her right eyebrows evenly distributed
and symmetrically aligned. With eyelashes of normal growth, there are no
purulent or any discharges seen on the client’s eyes. No periorbital edema noted,
cornea is transparent and shiny. Ears are of normal findings. Nose is also of
normal findings.
Further more upon the assessment of the throat and the mouth, the
researchers have noted the following manifestations: lips that are dark and dry,
difficulty of swallowing, tongue which deviates towards the right side. Gums are
pale. There are no abnormal findings found upon the assessment of the neck.
The patient does not have any reports of chest pain upon assessment;
there were no presence of murmurs heard upon auscultation of the heart rate.
With the gastrointestinal assessment, abdomen is soft and not tender, there were
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5/5
5/5
0/5
4/5
R L
5 bowel sounds/ min/ quadrant upon auscultation, there were no presence of
organomegaly upon palpation.
The client was observed with no ROM and sensation on the upper left
extremity, there were no presence of edema and with a capillary refill of less than
3 sec, it was also noted that her both lower extremities has scars specifically on
the dorsal right lower extremity. It was also noted that the client has weakness on
the left lower extremity.
January 31, 2009
General Appearance
Patient is wearing a dark blue with floral design clothing, with unkempt hair,
appears weak, conscious, lethargic. She is lying on bed with an ongoing IVF of
#5 D5 0.3 NaCl 500 cc x 20 - 21 µgtts/ min infusing well on the right metacarpal
vein currently at 150 cc level, patient has an indwelling Foley catheter attached to
urine bag with current urine out put of 100 ml and currently undergoing bladder
training.
Patient has the following vital signs:
T= 36° C
P= 63 bpm
R= 18 cpm
BP= 170/60 mmHg
Upon the assessment of her head, the researchers noted a normal finding,
characterized by symmetrical skull, no presence of nodules and lesions, and with
hair properly distributed.
Upon the assessment of the client’s face, most of the findings are of
normal findings characterized by pupils which are equally round in shape,
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R L
1/55/5
5/5 4/5
reactive to light and accommodation, with her right eyebrows evenly distributed
and symmetrically aligned. Patient has eyelashes of normal growth, with dried
exudates, with a prescribed eyeglasses “200 ya gradu ing salamin na”. No
periorbital edema noted, cornea is transparent and shiny. Ears are of normal
findings. Nose is also of normal findings.
Further more upon the assessment of the throat and the mouth, the
researchers have noted the following manifestations: lips that are dark and dry,
with visible cracking of the lips, difficulty of swallowing, tongue which deviates
towards the right side. Gums are pale. There are no abnormal findings found
upon the assessment of the neck.
The patient does not have any reports of chest pain upon assessment;
there were no presence of murmurs heard upon auscultation of the heart rate.
With the gastrointestinal assessment, abdomen is soft and not tender, there were
5 bowel sounds/ min/ quadrant upon auscultation, there were no presence of
organomegaly upon palpation.
The client was observed with no ROM and sensation on the upper left
extremity, there were no presence of edema and with a capillary refill of less than
3 sec, it was also noted that her both lower extremities has scars specifically on
the dorsal right lower extremity. It was also noted that the client has weakness on
the left lower extremity.
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F. Diagnostic and Laboratory Procedures
DIAGNOSTIC OR LABORATORY PROCEDURES
DATE ORDERED AND DATE
RESULTS IN
INDICATIONS OR PURPOSES
RESULTSNORMAL VALUES
ANALYSIS AND INTERPRETATIO
N
CLINICAL CHEMISTRY
FBS
Date Ordered:1/27/09
Date Results
In:1/28/09
A fasting blood sugar
test measures the amount of sugar in your blood after
you fast for at least eight hours or
overnight. It is a test that is
routinely done in all clients
with possible cardiovascular disorders to
determine blood glucose
levels.
117mg/dL
70- 105 mg/dL
A fasting blood sugar level 117mg/ dL
which is obviously above the
normal limits.This justifies the patients
current health condition of
Type II Diabetes
Mellitus as reflected on
the pathophysiolo
gy.
FBS, Blood: Pre-test:1. Inform the patient that the test is used to assist in the evaluation of fasting
hypoglycemia2. Obtain a history of the patient’s complaints, including a list of known allergens such
as allergy to latex.3. Obtain a history of the patient’s endocrine system and results of previously
performed laboratory tests, surgical procedures, and other diagnostic procedures.4. Note any procedures that can interfere with the test results.5. Obtain a list of medications patient is taking, including herbs, and nutritional
supplements.
Intra-test;1. Ensure that the patient has complied with dietary or medication restrictions and other
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pretesting preparations.2. Instruct the patient to cooperate fully and to follow directions. Direct patient to
breathe normally and to avoid unnecessary movement.3. If the patient has a history of severe allergic reaction to latex, care should be taken
and to avoid the use of equipment containing latex.4. Observe Standard precautions.5. After obtaining the specimen, promptly transport to the laboratory for processing and
analysis.
Post-test:1. Observe venipuncture site for bleeding or hematoma formation. 2. Instruct the patient to report signs and symptoms of hypoglycemia or hyperglycemia.3. Emphasize that good glycemic control delays the onset of and slows the progression
of diabetic retinopathy, nephropathy, and neuropathy.4. Reinforce information regarding the test results and address concerns voiced by the
family or the patient.
Potassium
Date requested
:1/27/09
Date results in:1/28/09
It is checked in order to assess
a known and suspected disorder
associated with renal disease,
glucose metabolism,
trauma or burns.
3.6 mmoL/L
3.5 – 5.3 mmoL/L
The potassium electrolyte level is within normal
range.
Potassium, blood, Before
1. Check the doctor’s order2. Explain the procedure3. Explain the purpose and what to expect4. No food or fluid restrictions
During
1. Do not take the blood sample from hand or arm with receiving IVF2. The tourniquet should be less on a minute3. Do not squeeze the punctured site rightly4. Wipe away the first drop of blood5. Collect 2ml venous blood in a lavender top tube
After
1. Observed and record vital signs.2. Check injection sites for bleeding, infection, tenderness or thrombosis.3. Report untoward reaction to the physician.4. Apply warm compress to ease discomfort, as ordered.5. Encourage relaxation by allowing client to discuss experiences and verbalize
14
feelings.6. Interpret results and provide counsel appropriately. Provide health teachings
regarding proper lifestyle changes and symptoms that may warrant immediate medical attention.
Creatinine
Date requested
:1/27/09
Date results in:1/28/09
The creatinine test is used to
diagnose impaired kidney function and to determine renal
(kidney) damage.
41mg/dL 0.6 – 1.2 mg/dL
The creatinine level is
significantly above the
normal limits which is a
result of renal impairment
related to the client’s active renal disease.
BUA
Date requested
:1/27/09
Date results in:1/28/09
The blood uric acid test
measures the amount of uric acid in a blood
sample. Increased level of uric acid in the blood is
brought by too much uric acid
is being produced or if
the kidneys are not able to
remove it from the blood normally.
8.5 mg/ dL
2.0 – 6.0 mg/dL
The uric acid level is
significantly above the
normal limits this also gives justification to
the deteriorating
function of the renal system.
BUN Date requested
:1/27/09
Date results in:1/28/09
Blood urea nitrogen (BUN) measures the
amount of urea nitrogen, a
waste product of protein
metabolism, in the blood. Urea
is formed by the liver and
64 mg/dL 7-18 mg/ dL
The BUN level is significantly
above the normal limits
which denotes an impairment
in renal function
15
carried by the blood to the kidneys for excretion.
Because urea is cleared from
the bloodstream by the kidneys, a test measuring how much urea
nitrogen remains in the blood can be used as a test
of renal function.
However, there are many
factors besides renal disease
that can cause BUN
alterations, including protein
breakdown, hydration
status, and liver failure.
Creatinine, BUN, BUA, Blood,
Prior:
1. Select vein for venipuncture (usually antecubital space).2. Apply tourniquet several inches above intended venipuncture site3. Clean venipuncture site (with povidone iodine or alcohol, allow area to dry).
During:
1. Perform venipuncture by entering the skin with needle at approximately a 15-degree angle to the skin, needle bevel up.
2. If using a Vacutainer, ease tube forward in holder once in the vein. If using a syringe, pull back on the barrel with slow, even tension as blood fills the syringe.
3. Release tourniquet when the blood begins to flow.
16
After:
1. After the blood is drawn, place cotton ball over site; withdraw the needle and exert pressure. Apply bandage if needed.
2. Properly dispose contaminated materials.3. Record the date and time of blood collection. Attach a label to each blood tube.4. Relay results to the doctor.
LIPID PROFILE
HDL
Date requested
:1/27/09
Date results in:1/28/09
This is a blood test that
measures a kind of fat
(lipid) in the blood. The HDL
test helps check your risk
for heart disease or
atherosclerosis, which is a hardening,
narrowing, or blockage of the
arteries.
87mg/dL30mg/dL >
The LDL level is within the
normal range
CHOLESTEROL
Date requested
:1/27/09
Date results in:1/28/09
Used to estimate risk of developing a
disease specifically
heart disease. Because high
blood cholesterol has
been associated with
hardening of the arteries,
heart disease and a raised risk of death from heart
attacks.
351 mg/dL
140-250mg/dL
The client has an increased cholesterol
level which is one of the
precipitating factor of the
client’s Hypertension.
LDL Date requested
:1/27/09
Date
The LDL test measures how
much low-density
lipoprotein (LDL) you have in your blood.
219 mg/dL
<178 mg/dL
This is also one of the
factors that aggravates or triggers the
client’s hypertensive
17
results in:1/28/09
Too much LDL in the blood
can clog arteries.
episodes.
Triglycerides
A test to determine the
cholesterol level circulating
in the bloodstream
209 mg/dL
10-190mg/dL
This is also one of the
factors that aggravates or triggers the
client’s hypertensive
episodes.
Total Cholesterol Test: (NSG. Implications) Pretest:1. Inform the patient that the test is used to assess and monitor risk for coronary artery
disease.2. Obtain history of the patient’s past health history and previously performed laboratory
tests, surgical procedures, and other diagnostic procedures.3. Instruct the patient to withhold drugs and alcohol known to alter cholesterol levels for
12 to 24 hours before specimen collection.4. Fasting 6 to 12 hours before specimen collection is required if triglyceride
measurements are included; it is recommended if cholesterol levels alone are measured for screening.
Intratest:1. Ensure that the patient has complied with the dietary restrictions and pre testing
precautions.2. If the patient has a history of severe allergic reaction to latex, care should be taken to
avoid the use of equipment containing latex.3. Instruct the client to cooperate fully and to follow directions.4. Observe Standard Precautions.5. Remove the needle and apply pressure dressing over the puncture site.6. Immediately transport the specimen to the laboratory for processing and analysis. Post-test:1. Observe venipuncture site for bleeding or hematoma formation.2. Instruct the patient to reduce intake of foods high in saturated fats and cholesterol
and triglyceride levels. (E.g. red meats, eggs, and dairy products are major sources of saturated fats and cholesterol.
3. Consider social and cultural beliefs and practices of the client.4. Recognize anxiety related to test results. Discuss the implications of abnormal test
results on the patient’s lifestyle. 5. Provide teaching and information regarding the clinical indications of the test results.
BLOOD HEMATOLOGY
18
Hemoglobin (Hgb)
Date requested
:1/27/09
Date results in:1/28/09
- to monitor Hgb value in
the RBC- to suggest the
presence of body fluid
deficit due to elevated Hgb
level
8.0mg%12-16 mg
%
The patient having a
decreased hemoglobin
level with accompanying signs of pallor indicates that the client has
anemia.
Hematocrit (Hct)
Date requested
:1/27/09
Date results in:1/28/09
To aid diagnosis of
abnormal states of
hydration, polycythemia and anemia.
- It measures the
concentration of RBC within
the blood volume and is
expressed as a percentage.
27.0 vol%37-47 vol
%
The hematocrit
level is below the normal
range, which denotes a decreased
concentration of RBC in the
blood or hemodilution.
WBC
Date requested
:1/27/09
Date results in:1/28/09
The test is performed to find out how many white
blood cells you have. Your
body produces more white blood cells
when you have an infection or
allergic reaction, even when you are under general
stress
4900/ cu. mm
5-10 x 103mm
The WBC count is below
the normal limits a
decrease or increase in the
WBC count denotes
infection or inflammation.
Neutrophils/ Segmenters
Date requested
:1/27/09
To detect presence of
infection in the body
76% 50-70% The Neutrophils is
above the normal limits
indicating infection.
19
Date results in:1/28/09
Lymphocytes
Date requested
:1/27/09
Date results in:1/28/09
To detect presence of
infection within the body.
24% 25-40%
The number of lymphocytes is
slightly decreased
which indicates infection
Eosinophils
Date requested
:1/27/09
Date results in:1/28/09
To detect presence of
infection within the body.
1% 1-4%
The eosinophils count is within
the normal range
Nursing Implications for Blood Hematology Test: Pretest:1. Inform the patient that the test is used to evaluate numerous conditions inflammation,
infection, and response to chemotherapy.2. Obtain a history of the patient’s complaints (such as allergies and sensitivity to latex.3. Obtain a history of the patient’s gastrointestinal, hematopoietic, immune, and
respiratory systems, as well as results of previously performed laboratory tests, surgical procedures, and other diagnostic procedures.
4. Obtain a list of medications the patient is taking, including herbs, nutritional supplements, and nutraceuticals.
5. Review the procedure with the patient. Explain the duration of the procedure and inform the client that there may be some discomforts during the procedure.
6. Consider the patient’s cultural beliefs and practices and it is important to provide psychological support before, during, and after the procedure.
Intratest:1. Avoid using equipment containing latex if the patient has allergy to it.2. Instruct the patient to cooperate fully and to follow directions. Direct the patient to
breathe normally and to avoid unnecessary movement.3. Observe Standard precautions.4. Remove the needle, and apply a pressure dressing over the puncture site.5. Promptly transport the specimen to the laboratory for processing and analysis.
20
Post-test:1. Observe venipuncture site for bleeding or hematoma formation. Apply paper tape or
other adhesive to hold pressure bandage in place.2. Instruct the patient to limit salt intake, alcohol intake and cut down smoking.
3. Reinforce information regarding the test results and address any concerns voiced by the patient or family.
IMAGING
CXR APL
Date requested
:1/27/09
Date results in:1/30/09
X-rays - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. Chest radiographs may depict segmental or lobar infiltrate but they more commonly reveal a diffuse, fine, reticulogranular pattern, much like what is observed in RDS. Pleural effusions may also be observed.
Chest Roentgen
ogram reveals minimal
hazy infiltrates on both lower lung
fields. Heat and
great vessels are of normal
size and configurat
ion.
Hemidiagphragms, sulci, and
other visualized including
chest structures
are unremark
able.
Remarks:Pneumon
itis , bilateral
Normal anatomical feature of the lungs. Without signs of effusion, and other abnormal findings.
The chest x- ray denotes abnormal
features of the patient lungs, it shows that her
both lung parenchyma are inflamed.
Nursing Implication
BEFORE:
21
1. Explain the purpose of the CXR to the mother.2. Inform the mother whether they will be transported to the radiology department or
have the x-ray done at bedside (portable CXR).3. Tell the mother that the test will take only a few minutes and is painless
DURING:1. Provide a lead apron for any person who must hold the patient during the procedure.2. Provide extra blankets for patient chilled from exposure during CXR.
AFTER:No aftercare is generally required following a chest x - ray. Immediately following the exam,
the technologist will continue to watch the patient for patient’s respiratory pattern.FECALYSIS
FECALYIS
Date requested
:1/27/09
Date results in:1/30/09
This was done to the patient
as a screening for
abnormalities within the
gastrointestinal tract including bleeding and
parasitic infection.
Color:Brown
Consistency:Soft
Trichiuris:0-1/hpf
Color:Brown
Consistency:Soft
Trichiuris:none
Amoeba:None
Hookworm:None
Pus Cells:None
RBC:None
Bacteria:None
Fecalysis shows that the patient
has a positive parasitic
infestation specifically
trichiuris
Nursing Implication
Prior:1. Explain the procedure to the client in order to gain her 2. Inform the client that there is no need for NPO.3. Educate the patient on the proper way of collecting fecal matter4. Prepare the container for the stool.
During:1. Provide privacy.2. Assist the patient if unable to get her stool sample on her own.3. Instruct the patient to prevent contamination of the stool and not to add water to the
stool specimen, to prevent alteration of results.22
After:1. Continue taking the medications that were stopped prior to the procedure.
URINALYSIS
URINALYSIS
Date requested
:1/27/09
Date results in:1/29/09
This was done to the patient
as a screening for
abnormalities within the
urinary system as well as for
system problems that may manifest through the urinary tract.
Color:Yellow
Appearance:
Clear
Ph: Acidic
Pus Cells:
4-6/HPF
Red Cells:
6-8/HPF
Albumin: 4
Glucose: rare
Color:Yellow
Appearance:
Clear
Ph: Acidic
Pus Cells:none
Red Cells:none
Albumin: negative
Glucose: negative
Urinalysis shows that patient is
manifesting pyuria
indicating infection within the
urinary tract. She also
manifests red blood cells on
her urine indicating a problem on the kidney
filtration; this is supported
by albuminuria
and glucosuria.
Nursing Implication
Prior:5. Explain the procedure to the client in order to gain her 6. Inform the client that there is no need for NPO.7. Educate the patient on the proper way of collecting urine (clean catch midstream
specimen).8. Prepare the container for the urine.
During:4. Provide privacy.5. Assist the patient if unable to get her urine sample on her own.6. Instruct the patient to prevent contamination of the urine and not to add water to the
urine specimen, to prevent alteration of results.
After:1. Refrigerate the specimen.2. Continue taking the medications that were stopped prior to the procedure.
23
III. ANATOMY AND PHYSIOLOGY
The Cardiovascular System
The heart and circulatory system make up
the cardiovascular system. The heart works as a
pump that pushes blood to the organs, tissues,
and cells of the body. Blood delivers oxygen and
nutrients to every cell and removes the carbon
dioxide and waste products made by those cells.
Blood is carried from the heart to the rest of the
body through a complex network of arteries,
arterioles, and capillaries. Blood is returned to the
heart through venules and veins.
The one-way circulatory system carries
blood to all parts of the body. This process of
blood flow within the body is called circulation.
Arteries carry oxygen-rich blood away from the heart, and veins carry oxygen-poor
blood back to the heart. In pulmonary circulation, though, the roles are switched. It is the
24
pulmonary artery that brings oxygen-poor blood into the lungs and the pulmonary vein
that brings oxygen-rich blood back to the heart. (Rod R. Seeley et. al, Essentials of
Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
Twenty major arteries make a path through the tissues, where they branch into
smaller vessels called arterioles. Arterioles further branch into capillaries, the true
deliverers of oxygen and nutrients to the cells. Most capillaries are thinner than a hair. In
fact, many are so tiny, only one blood cell can move through them at a time. Once the
capillaries deliver oxygen and nutrients and pick up carbon dioxide and other waste,
they move the blood back through wider vessels called venules. Venules eventually join
to form veins, which deliver the blood back to the heart to pick up oxygen.
Vasoconstriction or the spasm of smooth muscles around the blood vessels causes and
decrease in blood flow but an increase in pressure. In vasodilation, the lumen of the
blood vessel increase in diameter thereby allowing increase in blood flow. There is no
tension on the walls of the vessels therefore, there is lower pressure. (Rod R. Seeley et.
al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
Various external factors also cause changes in blood pressure and pulse rate. An
elevation or decline may be detrimental to health. Changes may also be caused or
aggravated by other disease conditions existing in other parts of the body.
The blood is part of the circulatory system. Whole blood contains three types of
blood cells, including: red blood cells, white blood cells and platelets.
These three types of blood cells are mostly manufactured in the bone marrow of
the vertebrae, ribs, pelvis, skull, and sternum. These cells travel through the circulatory
system suspended in a yellowish fluid called plasma. Plasma is 90% water and contains
nutrients, proteins, hormones, and waste products. Whole blood is a mixture of blood
cells and plasma.
Red blood cells (also called erythrocytes) are shaped like slightly indented,
flattened disks. Red blood cells contain an iron-rich protein called hemoglobin. Blood
gets its bright red color when hemoglobin in red blood cells picks up oxygen in the
25
lungs. As the blood travels through the body, the hemoglobin releases oxygen to the
tissues. The body contains more red blood cells than any other type of cell, and each
red blood cell has a life span of about 4 months. Each day, the body produces new red
blood cells to replace those that die or are lost from the body.
White blood cells (also called leukocytes) are a key part of the body's system for
defending itself against infection. They can move in and out of the bloodstream to reach
affected tissues. The blood contains far fewer white blood cells than red cells, although
the body can increase production of white blood cells to fight infection. There are
several types of white blood cells, and their life spans vary from a few days to months.
New cells are constantly being formed in the bone marrow.
Several different parts of blood are involved in fighting infection. White blood cells
called granulocytes and lymphocytes travel along the walls of blood vessels. They fight
bacteria and viruses and may also attempt to destroy cells that have become infected or
have changed into cancer cells. (Rod R. Seeley et. al, Essentials of Anatomy and
Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
Certain types of white blood cells produce antibodies, special proteins that
recognize foreign materials and help the body destroy or neutralize them. When a
person has an infection, his or her white cell count often is higher than when he or she
is well because more white blood cells are being produced or are entering the
bloodstream to battle the infection. After the body has been challenged by some
infections, lymphocytes remember how to make the specific antibodies that will quickly
attack the same germ if it enters the body again.
Platelets (also called thrombocytes) are tiny oval-shaped cells made in the bone
marrow. They help in the clotting process. When a blood vessel breaks, platelets gather
in the area and help seal off the leak. Platelets survive only about 9 days in the
bloodstream and are constantly being replaced by new cells.
Blood also contains important proteins called clotting factors, which are critical to
the clotting process. Although platelets alone can plug small blood vessel leaks and
26
temporarily stop or slow bleeding, the action of clotting factors is needed to produce a
strong, stable clot.
Platelets and clotting factors work together to form solid lumps to seal leaks,
wounds, cuts, and scratches and to prevent bleeding inside and on the surfaces of our
bodies. The process of clotting is like a puzzle with interlocking parts. When the last part
is in place, the clot is formed.
When large blood vessels are cut the body may not be able to repair itself
through clotting alone. In these cases, dressings or stitches are used to help control
bleeding.
In addition to the cells and clotting factors, blood contains other important
substances, such as nutrients from the food that has been processed by the digestive
system. Blood also carries hormones released by the endocrine glands and carries
them to the body parts that need them. (Rod R. Seeley et. al, Essentials of Anatomy
and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
Blood is essential for good health because the body depends on a steady supply
of fuel and oxygen to reach its billions of cells. Even the heart couldn't survive without
blood flowing through the vessels that bring
nourishment to its muscular walls. Blood also
carries carbon dioxide and other waste
materials to the lungs, kidneys, and digestive
system, from where they are removed from
the body. (Rod R. Seeley et. al, Essentials of
Anatomy and Physiology 5th edition,
McGraw-Hill Int. NY 10020 2005)
The Endocrine System
The endocrine system is made up of
glands that produce and secrete hormones.
These hormones regulate the body’s growth, 27
metabolism (the physical and chemical processes of the body), and sexual development
and function. The hormones are released into the bloodstream and may affect one or
several organs throughout the body. (Rod R. Seeley et. al, Essentials of Anatomy and
Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
The role of the endocrine system is to maintain the body in balance through the
release of hormones which transfer information and instructions from one set of cells to
another. Many different hormones move through the bloodstream, but each type of
hormone is designed to affect only certain cells.
Hormones are chemical messengers created by the body. They transfer
information from one set of cells to another to coordinate the functions of different parts
of the body. Hormones can act on some specific cells because they themselves do not
actually cause an effect. It is only through binding with a receptor (part of the cell
specifically designed to recognize the hormone) like a key into a lock - that causes a
chain reaction to occur, changing the activity of the cells. If a cell does not have a
receptor for a hormone then there will be no effect. Also, there can be different
receptors for the same hormone, and so the same hormone can have different effects
on different cells. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5 th
edition, McGraw-Hill Int. NY 10020 2005)
The major glands of the endocrine system are the pituitary, thyroid, parathyroids,
adrenals, pineal body, thymus, and the reproductive organs (ovaries and testes). The
pancreas is also a part of this system; it has a role in hormone production as well as in
digestion. A gland is a group of cells that produces and secretes chemicals. A gland
selects and removes materials from the blood, processes them, and secretes the
finished chemical product for use somewhere in the body. The endocrine gland cells
release a hormone into the blood stream for distribution throughout the entire body.
These hormones act as chemical messengers and can alter the activity of many organs
at once. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5 th edition,
McGraw-Hill Int. NY 10020 2005)
28
The hypothalamus controls all the processes undergone by the anterior and
posterior pituitary glands. It initiates the production of hormones by the APG. The APG
is controlled by releasing hormones which are chemical signals produced by the nerve
cells of the hypothalamus, causing either stimulation or inhibition of hormone
production. Secretion of hormones by the PPG is controlled by nervous system
stimulation of nerve cells in the hypothalamus. Parathyroid glands secrete parathyroid
hormone which is essential for the regulation of blood calcium levels. Adrenal glands
produce epinephrine and norepinephrine which are fight-or-flight hormones that prepare
the body for vigorous physical activity. Testes and ovaries produce hormones that are
responsible for secondary sex characteristics, spermatogenesis, and oogenesis. The
thymus gland secretes thymosin which aids in the synthesis of WBC for fighting
infection. This gland decreases in size in some older adults. The pineal body releases
melatonin that is thought to decrease the secretion of LSH & FSH by decreasing the
release of hypothalamic-releasing hormones. The thyroid gland, located on either side
of the trachea, is controlled by the thyroid stimulating hormone releases by the anterior
pituitary gland, which was initially stimulated by the TSH releasing hormone from the
hypothalamus. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition,
McGraw-Hill Int. NY 10020 2005)
The pancreas is also part of the body's hormone-secreting system, even though
it is also associated with the digestive system because it produces and secretes
digestive enzymes. The pancreas produces two important hormones, insulin and
glucagon. They work together to maintain a steady level of glucose, or sugar, in the
blood and to keep the body supplied with fuel to produce and maintain stores of energy.
The pancreas completes the job of breaking down protein, carbohydrates, and fats
using digestive juices of pancreas combined with juices from the intestines, secretes
hormones that affect the level of sugar in the blood, and produces chemicals that
neutralize stomach acids that pass from the stomach into the small intestine by using
substances in pancreatic juice. It contains Islets of Langerhans, which are tiny groups of
specialized cells that are scattered throughout the organ.
29
In humans, the pancreas is a 15-25 cm (6-10 inch) elongated organ in the
abdomen adjacent to the small intestine and lies toward the back. It has three regions: a
head (abuts a part of the duodenum), body (at the level of L2 of the spine) and tail
(extends toward the spleen). (Rod R. Seeley et. al, Essentials of Anatomy and
Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
The pancreatic duct (also called the duct of Wirsung) runs the length of the
pancreas and empties into the second part of the duodenum at the ampulla of Vater.
The common bile duct usually joins the pancreatic duct at or near this point. Many
people also have a small accessory duct, the duct of Santorini, which extends from the
main duct more upstream (towards the tail) to the duodenum, joining it more proximal
than the ampulla of Vater.
The pancreas is supplied arterially by the Pancreaticoduodenal arteries and the
splenic artery: the splenic artery supplies the neck, body, and tail of the pancreas; the
superior mesenteric artery provides the inferior pancreaticoduodenal artery; and the
gastroduodenal artery provides the superior pancreaticoduodenal artery.
Venous drainage is via the pancreaticoduodenal veins which end up in the portal
vein. The splenic vein passes posterior to the pancreas but is said to not drain the
pancreas itself. The portal vein is formed by the union of the superior mesenteric vein
and splenic vein posterior to the neck of the pancreas. In some people (some books say
40% of people); the inferior mesenteric vein also joins with the splenic vein behind the
pancreas (in others it simply joins with the superior mesenteric vein instead). (Rod R.
Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY
10020 2005)
The pancreas is a compound gland in the sense that it is composed of both
exocrine and endocrine tissues. The exocrine function of the pancreas involves the
synthesis and secretion of pancreatic juices. The endocrine function resides in the
million or so cellular islands (the islets of Langerhans) embedded between the exocrine
units of the pancreas. Beta cells of the islands secrete insulin, which helps control
30
carbohydrate metabolism. Alpha cells of the islets secrete glucagon that counters the
action of insulin.
There are four main types of cells in the islets of Langerhans. They are relatively
difficult to distinguish using standard staining techniques, but they can be classified by
their secretion: Beta cells secretes Insulin and Amylin lower blood sugar, Alpha Cells
secretes Glucagon raise blood sugar, Delta Cells secretes Somastotatin inhibit
endocrine pancreas, PP Cells secretes pancreatic polypeptide which inhibits exocrine
pancreas
The islets are a compact collection of endocrine cells arranged in clusters and
cords and are crisscrossed by a dense network of capillaries. The capillaries of the
islets are lined by layers of endocrine cells in direct contact with vessels, and most
endocrine cells are in direct contact with blood vessels, by either cytoplasmic processes
or by direct apposition. There are two main types of exocrine pancreatic cells,
responsible for two main classes of secretions: Centroacinar cells secretes bicarbonate
ions, Basophilic cells secretes digestive enzymes such as pancreatic amylase,
pancreatic lipase. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5 th
edition, McGraw-Hill Int. NY 10020 2005)
The Nervous System
The nervous system is a network of
specialized cells that communicate information
about an animals surroundings and its self, it
processes this information and causes reactions
in other parts of the body. It is composed of
neurons and other specialized cells called glia,
that aid in the function of the neurons.
The nervous system is divided broadly
into two categories; the peripheral nervous
system and the central nervous system. Neurons
31
generate and conduct impulses between and within the two systems. The peripheral
nervous system is composed of sensory neurons and the neurons that connect them to
the nerve cord, spinal cord and brain, which make up the central nervous system. In
response to stimuli, sensory neurons generate and propagate signals to the central
nervous system which then process and conduct back signals to the muscles and
glands. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5 th edition,
McGraw-Hill Int. NY 10020 2005)
The neurons of the nervous systems of animals are interconnected in complex
arrangements and use electrochemical signals and neurotransmitters to transmit
impulses from one neuron to the next. The interaction of the different neurons form
neural circuits that regulate an organism’s perception of the world and what is going on
with its body, thus regulating its behavior. Nervous systems are found in many
multicellular animals but differ greatly in complexity between species
The central nervous system (CNS) is the largest part of the nervous system, and
includes the brain and spinal cord. The spinal cavity holds and protects the spinal cord,
while the head contains and protects the brain. The CNS is covered by the meninges, a
three layered protective coat. The brain is also protected by the skull, and the spinal
cord is also protected by the vertebrae. (Rod R. Seeley et. al, Essentials of Anatomy
and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
Brain is a part of the Central Nervous System, it plays a central role in the
control of most bodily functions, including awareness, movements, sensations,
thoughts, speech, and memory. Some reflex movements can occur via spinal cord
pathways without the participation of brain structures. (Rod R. Seeley et. al, Essentials
of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
The cerebrum is the largest part of the brain and controls voluntary actions,
speech, senses, thought, and memory.
The surface of the cerebral cortex has grooves or infoldings (called sulci), the largest of
which are termed fissures. Some fissures separate lobes.
32
The convolutions of the cortex give it a wormy appearance. Each convolution is
delimited by two sulci and is also called a gyrus (gyri in plural). The cerebrum is divided
into two halves, known as the right and left hemispheres. A mass of fibers called the
corpus callosum links the hemispheres. The right hemisphere controls voluntary limb
movements on the left side of the body, and the left hemisphere controls voluntary limb
movements on the right side of the body. Almost every person has one dominant
hemisphere. Each hemisphere is divided into four lobes, or areas, which are
interconnected.
The frontal lobes are located in the front of the brain and are responsible for
voluntary movement and, via their connections with other lobes, participate in the
execution of sequential tasks; speech output; organizational skills; and certain
aspects of behavior, mood, and memory.
The parietal lobes are located behind the frontal lobes and in front of the occipital
lobes. They process sensory information such as temperature, pain, taste, and
touch. In addition, the processing includes information about numbers,
attentiveness to the position of one’s body parts, the space around one’s body,
and one's relationship to this space.
The temporal lobes are located on each side of the brain. They process memory
and auditory (hearing) information and speech and language functions.
The occipital lobes are located at the back of the brain. They receive and process
visual information (Rod R. Seeley et. al, Essentials of Anatomy and Physiology
5th edition, McGraw-Hill Int. NY 10020 2005)
33
The urinary system is system of organs that
produces and excretes urine from the body. Urine is a
transparent yellow fluid containing unwanted wastes, mostly
excess water, salts, and nitrogen compounds. The major
organs of the urinary system are the kidneys, a pair of
bean-shaped organs that continuously filter substances
from the blood and produce urine. Urine flows from the
kidneys through two long, thin tubes called ureters. With the
aid of gravity and wavelike contractions, the ureters
transport the urine to the bladder, a muscular vessel. The
normal adult bladder can store up to about 0.5 liter (1 pt) of
urine, which it excretes through the tubelike urethra.
An average adult produces about 1.5 liters of urine
each day, and the body needs, at a minimum, to excrete
about 0.5 liter of urine daily to get rid of its waste products.
Excessive or inadequate production of urine may indicate illness and doctors often use
urinalysis (examination of a patient’s urine) as part of diagnosing disease. For instance,
the presence of glucose, or blood sugar, in the urine is a sign of diabetes mellitus;
bacteria in the urine signal an infection of the urinary system; and red blood cells in the
urine may indicate cancer of the urinary tract. (Rod R. Seeley et. al, Essentials of
Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
Kidney
s are
paired or gans w
hose fun ctions
include
34
removing waste products from the blood and regulating the amount of fluid in the body.
The basic units of the kidneys are microscopically thin structures called nephrons, which
filter the blood and cause wastes to be removed in the form of urine. Together with the
bladder, two ureters, and the single urethra, the kidneys make up the body’s urinary
system. Human beings, as well as members of all other vertebrate species, typically
have two kidneys. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th
edition, McGraw-Hill Int. NY 10020 2005)
Like kidney beans, the body’s kidneys are dark red in color and have a shape in
which one side is convex, or rounded, and the other is concave, or indented. The
kidneys of adult humans are about 10 to 13 cm (4 to 5 in) long and about 5 to 7.5 cm (2
to 3 in) wide—about the size of a computer mouse.
The kidneys lie against the rear wall of the abdomen, on either side of the spine.
They are situated below the middle of the back, beneath the liver on the right and the
spleen on the left. Each kidney is encased in a transparent, fibrous membrane called a
renal capsule, which helps protect it against trauma and infection. The concave part of
the kidney attaches to two of the body’s crucial blood vessels—the renal artery and the
renal vein—and the ureter, a tubelike structure that carries urine to the bladder. (Rod R.
Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY
10020 2005)
A primary function of kidneys is the removal of poisonous wastes from the blood.
Chief among these wastes are the nitrogen-containing compounds urea and uric acid,
which result from the breakdown of proteins and nucleic acids. Life-threatening illnesses
occur when too many of these waste products accumulate in the bloodstream.
Fortunately, a healthy kidney can easily rid the body of these substances.
In addition to cleaning the blood, the kidneys perform several other essential
functions. One such activity is regulation of the amount of water contained in the blood.
35
This process is influenced by antidiuretic hormone (ADH), also called vasopressin,
which is produced in the hypothalamus (a part of the brain that regulates many internal
functions) and stored in the nearby pituitary gland. Receptors in the brain monitor the
blood’s water concentration. When the amount of salt and other substances in the blood
becomes too high, the pituitary gland releases ADH into the bloodstream. When it
enters the kidney, ADH makes the walls of the renal tubules and collecting ducts more
permeable to water, so that more water is reabsorbed into the bloodstream. (Rod R.
Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY
10020 2005)
The hormone aldosterone, produced by the adrenal glands, interacts with the
kidneys to regulate the blood’s sodium and potassium content. High amounts of
aldosterone cause the nephrons to reabsorb more sodium ions, more water, and fewer
potassium ions; low levels of aldosterone have the reverse effect. The kidney’s
responses to aldosterone help keep the blood’s salt levels within the narrow range that
is best for crucial physiological activities. (Rod R. Seeley et. al, Essentials of Anatomy
and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
Aldosterone also helps regulate blood pressure. When blood pressure starts to
fall, the kidney releases an enzyme (a specialized protein) called renin, which converts
a blood protein into the hormone angiotensin. This hormone causes blood vessels to
constrict, resulting in a rise in blood pressure. Angiotensin then induces the adrenal
glands to release aldosterone, which promotes sodium and water to be reabsorbed,
further increasing blood volume and blood pressure.
The kidney also adjusts the body's acid-base balance to prevent such blood
disorders as acidosis and alkalosis, both of which impair the functioning of the central
nervous system. If the blood is too acidic, meaning that there is an excess of hydrogen
ions, the kidney moves these ions to the urine through the process of tubular secretion.
An additional function of the kidney is the processing of vitamin D; the kidney converts
this vitamin to an active form that stimulates bone development. (Rod R. Seeley et. al,
Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
36
Several hormones are produced in the kidney. One of these, erythropoietin,
influences the production of red blood cells in the bone marrow. When the kidney
detects that the number of red blood cells in the body is declining, it secretes
erythropoietin. This hormone travels in the bloodstream to the bone marrow, stimulating
the production and release of more red cells. (Rod R. Seeley et. al, Essentials of
Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
The respiratory system generally includes tubes, such as the bronchi, used to carry air
to the lungs, where gas exchange takes place. A diaphragm pulls air in and pushes it
out. Respiratory systems of various types are found in a wide variety of organisms.
Even trees have respiratory systems.
In humans, the respiratory system
consists of the airways, the lungs, and the
respiratory muscles that mediate the
movement of air into and out of the body.
Within the alveolar system of the lungs,
molecules of oxygen and carbon dioxide
are passively exchanged, by diffusion,
between the gaseous environment and
the blood. Thus, the respiratory system
facilitates oxygenation of the blood with a
concomitant removal of carbon dioxide
and other gaseous metabolic wastes from
the circulation. The system also helps to maintain the acid-base balance of the body 37
through the efficient removal of carbon dioxide from the blood. (Rod R. Seeley et. al,
Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
1. The SINUSES (frontal, maxillary, and sphenoidal) are hollow spaces in the bones
of the head. Small openings connect them to the nose. The functions they serve include
helping to regulate the temperature and humidity of air breathed in, as well as to lighten
the bone structure of the head and to give resonance to the voice.
2. The NOSE (nasal cavity) is the preferred entrance for outside air into the respiratory
system. The hairs that line the wall are part of the air-cleaning system.
3. Air also enter through the MOUTH (oral cavity), especially in people who have a
mouth-breathing habit or whose nasal passages may be temporarily obstructed, as by a
cold or during heavy exercise.
4. The ADENOIDS are lymph tissue at the top of the throat. When they enlarge and
interfere with breathing, they may be removed. The lymph system, consisting of nodes
(knots of cells) and connecting vessels, carries fluid throughout the body. This system
helps to resist body infection by filtering out foreign matter, including germs, and
producing cells (lymphocytes) to fight them.
5. The TONSILS are lymph nodes in the wall of the throat (pharynx) that often become
infected. They are part of the germ-fighting system of the body.
6. The THROAT (pharynx) collects incoming air from the nose and mouth and passes it
downward to the windpipe (trachea).
7. The EPIGLOTTIS is a flap of tissue that guards the entrance to the windpipe
(trachea), closing when anything is swallowed that should go into the esophagus and
stomach.
8. The VOICE BOX (larynx) contains the vocal chords. It is the place where moving air
being breathed in and out creates voice sounds.
9. The ESOPHAGUS is the passage leading from the mouth and throat to the stomach.
38
10. The WINDPIPE (trachea) is the passage leading from the throat (pharynx) to the
lungs.
11. The LYMPH NODES of the lungs are found against the walls of the bronchial tubes
and windpipe.
12. The RIBS are bones supporting and protecting the chest cavity. They move to a
limited degree, helping the lungs to expand and contract.
13. The windpipe divides into the two main BRONCHIAL TUBES, one for each lung,
which subdivide into each lobe of the lungs. These, in turn, subdivide further.
14. The right lung is divided into three LOBES, or sections. Each lobe is like a balloon
filled with sponge-like tissue. Air moves in and out through one opening -- a branch of
the bronchial tube.
15. The left lung is divided into two LOBES.
16. The PLEURA are the two membranes, actually one continuous one folded on itself,
that surround each lobe of the lungs and separate the lungs from the chest wall.
17. The bronchial tubes are lines with CILIA (like very small hairs) that have a wave-like
motion. This motion carried MUCUS (sticky phlegm or liquid) upward and out into the
throat, where it is either coughed up or swallowed. The mucus catches and holds much
of the dust, germs, and other unwanted matte that has invaded the lungs. You get rid of
this matter when you cough, sneeze, clear your throat or swallow.
18. The DIAPHRAGM is the strong wall of muscle that separates the chest cavity from
the abdominal cavity. By moving downward, it creates suction in the chest to draw in air
and expand the lungs.
19. The smallest subdivisions of the bronchial tubes are called BRONCHIOLES, at the
end of which are the air sacs or alveoli (plural of alveolus).
20. The ALVEOLI are the very small air sacs that are the destination of air breathed in.
The CAPILLARIES are blood vessels that are imbedded in the walls of the alveoli. 39
Blood passes through the capillaries, brought to them by the PULMONARY ARTERY
and taken away by the PULMONARY VEIN. While in the capillaries the blood gives off
carbon dioxide through the capillary wall into the alveoli and takes up oxygen from the
air in the alveoli. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th
edition, McGraw-Hill Int. NY 10020 2005)
Mechanics of Breathing
To take a breath in, the external intercostal muscles contract, moving the ribcage up
and out. The diaphragm moves down at the same time, creating negative pressure
within the thorax. The lungs are held to the thoracic wall by the pleural membranes, and
so expand outwards as well. This creates negative pressure within the lungs, and so air
rushes in through the upper and lower airways.
Expiration is mainly due to the natural elasticity of the lungs, which tend to collapse if
they are not held against the thoracic wall. This is the mechanism behind lung collapse
if there is air in the pleural space (pneumothorax). (Rod R. Seeley et. al, Essentials of
Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
Physiology of Gas Exchange
Each branch of the bronchial tree eventually sub-divides to form
very narrow terminal bronchioles, which terminate in the alveoli.
There are many millions of alveloi in each lung, and these are
the areas responsible for gaseous exchange, presenting a
massive surface area for exchange to occur over.
Each alveolus is very closely associated with a network of
capillaries containing deoxygenated blood from the pulmonary
artery. The capillary and alveolar walls are very thin, allowing
rapid exchange of gases by passive diffusion along concentration gradients.
CO2 moves into the alveolus as the concentration is much lower in the alveolus than in
the blood, and O2 moves out of the alveolus as the continuous flow of blood through the 40
capillaries prevents saturation of the blood with O2 and allows maximal transfer across
the membrane. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition,
McGraw-Hill Int. NY 10020 2005)
IV. THE PATIENT AND HIS ILLNESS
A. PATHOPHYSIOLOGY (BOOK BASED)
41
Production of glucose from protein
and fat stores
Production of glucose from protein
and fat stores
Wasting of lean body mass
Wasting of lean body mass
Weight lossWeight loss
FatigueFatigue
AcidosisAcidosis
Acetone breathAcetone breath
Inc. KetonesInc. Ketones
Impaired immune function
(decrease level of morphonuclear
leukocytes)
Inc. serum glucose level
Glycoprotein cell wall deposits
Inc. osmolarity due to glucose
Destruction of alpha and beta cells of the pancreas
Failure to produce insulin Production of excess glucagon
Polydipsia Polyphagia Polyuria
Weight Loss
Modifiable Factors Non Modifiable Factors
Age, Family History of CVA, Family History of DM, Sex
(Men), Race
Smoking, Obesity, Hypertension, High Cholesterol Level, Excessive Alcohol Consumption, Drug
Addiction, High Dose of estrogen OC, Diabetes Mellitus, Atrial Fibrillation, Type A personality,
Sedentary Life Style
42
Diabetic Nephropathy
Accelerated atherosclerosis
Hypertension
Increase LDL levels
Renal Disease
Small vessel disease
Neuropathy
Infection Delayed wound healing
Symmetrical loss of protective sensation
Numbness and tingling
in the extremities
Wasting of intrinsic muscle
Charcot changes in
joints
Autonomic neuropathy
Dry cracked skin
Gastro paresis
Impotence
Neurogenic bladder
Diabetic Retinopathy
Loss of vision Blindness
Cerebral ischemiaCerebral ischemia
Long term Eschemia
(>10-15mins)
Long term Eschemia
(>10-15mins)
Short term Eschemia
(<10-15mins)
Short term Eschemia
(<10-15mins)
Temporary Deficit
Temporary Deficit
Permanent Deficit
Permanent Deficit
Decreased Tissue perfusion (brain)
Decreased Tissue perfusion (brain)
HemiparesisHemiparesis
Loss of speechLoss of speech
Hemisensory lossHemisensory loss
Cerebral HypoxiaCerebral Hypoxia
Syncope/ VertigoSyncope/ Vertigo
CEREBROVASCULAR ACCIDENT
CEREBROVASCULAR ACCIDENT
ThrombusThrombus
EmboliEmboli
No permanent
damage
No permanent
damage
Irreversible damage
Irreversible damage
MID CEREBRAL ARTERY
MID CEREBRAL ARTERY
ANTERIOR CEREBRAL A.
ANTERIOR CEREBRAL A.
POSTERIOR CEREBRAL A.
POSTERIOR CEREBRAL A.
VERTEBROBASILAR ARTERY
VERTEBROBASILAR ARTERY
Source: Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005
B. PATHOPHYSIOLOGY (CLIENT BASED)
43Impaired immune
function (decrease level of
morphonuclear leukocytes)
Inc. serum glucose level
Glycoprotein cell wall deposits
Inc. osmolarity due to glucose
Destruction of alpha and beta cells of the pancreas
Failure to produce insulin Production of excess glucagon
Polyuria
Modifiable Factors Non Modifiable Factors
Production of glucose from protein
and fat stores
Wasting of lean body mass Fatigue
Hemiparesis/ Hemiplegia
Aphasia
DysarthiaDysphagia
Apraxia
Visual Changes
Ataxia
Agnosia Hemisensory loss
Horner’s Syndrome
Unilarteral Neglect
Incontinence
Hypertension (BP-200/100 -01/27/09), High Cholesterol Level (Total Chol: 351), Diabetes
Mellitus (Diagnosed with since 2004)
Age (58 yrs. Old), Family History of Cardiovascular diseases
(Mother of the patient died from heart attack), Family History of
DM,
Pneumonitis- radiology report (01-30-09)
FBS: 117 mg/dl (01/28/09)
01/29/09 -01/31/09
01/29/09 -01/31/09
Smoking (23 pack years)
Source: Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005
44
Accelerated atherosclerosis
Hypertension
Increase LDL levelsRenal
Affectation
Small vessel disease
Infection Delayed wound healing
Diabetic Retinopathy
Blurred Vision
Diabetic Nephropathy
Proteinuria
Pus Cell
Glucosuria
Cerebral ischemia
Short term Eschemia
(<10-15mins)
Temporary Deficit
No permanent
damage
Decreased Tissue perfusion (brain)
Hemiparesis
Slurred speech
Hemisensory loss
Cerebral HypoxiaVertigo
CEREBROVASCULAR ACCIDENT
ThrombusThrombus
EmboliEmboli
UrinalysisAlbumin: highSugar: rare
Pus cells: 46 /hpfRBC: 68 /hpf
(01/29/09)
BP- 200/100 (01/27/09)
Lab results:Total Chol: 351
HDL: 87LDL: 219
Triglycerides: 209(1/28/09)
01/27/09
01/27/09
01/27/09
01/27/09
01/27/09 -01/31/09
Decreased Production of Erythropoeitin
Decreased RBC production in the
bone marrowLab results:
Hemoglobin: 8 (F: 12-16)Hematocrit: 27 (F: 37-
47)(01/28/09)
Lab results:WBC: 4,900 Normal:
(5-10x103)(01/28/09)
Anemia
B. SYNTHESIS OF THE DISEASE
B.1. DEFINITION OF DISEASE
Stroke is a term used to describe neurologic changes caused by an interruption
in the blood supply to part of the brain. Two major types of stroke are ischemic and
hemorrhagic. Ischemic stroke is caused by thrombotic or embolic blockage of blood flow
to the brain. Bleeding into the brain tissue or the subarachnoid space causes a
hemorrhagic stroke. Ischemic strokes account for about 83% of all strokes. The
remaining 17% of strokes are hemorrhagic.
Cerebrovascular disorders are the third leading cause of death in United States
and account for about 164, 000 mortalities
annually. An estimated 550,000 strokes people 45
Hemiparesis (left upper extremities) Hemiplegia (left
lower extremities)
DysarthiaDysphagia
Apraxia
Ataxia Hemisensory loss Left upper extremities
MID CEREBRAL ARTERY
ANTERIOR CEREBRAL A.
POSTERIOR CEREBRAL A.
VERTEBROBASILAR ARTERY
01/29/09 -01/31/09
01/29/09 -01/31/09
01/29/09 -01/31/0901/29/09 -01/31/09
01/29/09 -01/31/09
01/29/09 -01/31/09
experience a stroke each year. When second strokes are considered in the estimates,
the incidence increases to 700, 000 per year in the united States alone. Stroke is a
leading cause of adult disability and leading primary diagnosis for long term care. More
than four million stroke survivors are living with varying degrees of disability in the
United States. Along with a high mortality rate, strokes produce significant morbidity in
people who survive them. (Joyce M. Black et al Medical Surgical Nursing 7th edition
Elsevier Suanders 2005)
Vascular Disease which includes C.V.A. is the second leading cause of death in
the Philippines with a total of 51,680 according to DOH 2004. Along with this are 37,092
who survived with it. (http://www.doh.gov.ph/kp/statistics/morbidity)
New therapies can now prevent or limit the extent can now prevent or limit the
extent of damage to brain tissue caused by acute ischemic stroke. Thrombolytic therapy
must be administered as soon as possible after onset of the stroke; a treatment window
3 hours from the onset of manifestations has been established. To convey this sense of
urgency regarding the evaluation and treatment of stroke, health care professionals now
refer to stroke as brain attack. Public education is focused on prevention, recognition of
manifestation, and early treatment of brain attack. (Joyce M. Black et al Medical
Surgical Nursing 7th edition Elsevier Suanders 2005)
Diabetes Mellitus is a chronic systemic disease characterized by either a
deficiency of insulin or a decreased ability of the body to use insulin Diabetes mellitus is
sometimes referred to as “high sugars” by both clients and health care providers. The
notion of associating sugar with diabetes is appropriate because the passage of large
amounts of sugar-laden urine is characteristic of poorly controlled diabetes. However
high levels of blood glucose are only one component of the pathologic process and
clinical manifestation associated with DM. DM can be associated serious complications,
but people with diabetes can take preventive measures to reduce the likelihood of such
occurrences. (Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier
Suanders 2005)
46
B.2. Modifiable and Non Modifiable Factors (Book Based)
1. Modifiable
a. Smoking –nicotine content of cigarettes causes vasoconstriction there by resulting
hypertension which may lead to CVA.
b. Hypertension –this is due to plaque deposits on the wall of the arteries which causes
narrowing of the blood vessel thereby causing hypertension which may lead to
hemorrhagic stroke.
c. Obesity –This is due to increase cholesterol in the body which may contribute plaque
formation that will narrow the blood vessel or may cause thrombus formation.
d. Hyperlipidemia –too much lipid in the blood may cause increase plaque formation
which may cause thrombus formation.
e. Drug addiction –This may cause vasopasm, hypertension, hypercoagulability and
cerebral eschemia which may cause CVA.
f. Excessive alcohol consumption –heavy alcohol consumption increases one’s risk of a
stroke, light or moderate alcohol may protect against ischemic stroke.
(Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005)
47
g. High dose Estrogen Oral Contraceptives –increases the risk of stroke in women.
h. Diabetes Mellitus –The mechanism is related to macrovascular changes in people
with diabetes mellitus. There is an increase viscousity of blood which may cause
formation of thrombus formation.
i. Atrial fibrillation –pulling of blood from poorly emptying atrial which leads to formation
of tiny clots in Left atrium which can move on the cerebral circulation.
j. Type A personality –stress causes hypertension thereby increasing chance of having
hemorrhagic stroke.
k. Sedentary lifestyle –increase of having DM and Obesity which one of the factors of
having CVA
(Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005)
2. Non-Modifiable
a. Age –Intracranial hemorrhage is most often secondary to hypertension and is most
common after age 50 years.
b. Family history of CVA – Family history of stroke increase one’s risk
48
c. Family history of DM –Family which has history of DM especially type 2 is high risk of
having stroke due to accelerated atherosclerosis.
d. Sex (Male) –Incidence of stroke in men is slightly higher than that of women.
e. Race – (more prevalent among African Americans than whites or Hispanics)
(Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005)
SIGNS AND SYMPTOMS (Book Based)
DIABETES MELLITUS
HYPERGLYCEMIA (INCREASED BLOOD SUGAR LEVEL)
Diabetes Mellitus type II may be due to lack of physiologically active insulin that
stimulates glucose uptake in the muscles and tissues. Therefore, it leads to an
accumulation of glucose in the intravascular space. The glucose is not utilized by the
body and it remains in the blood stream.
POLYURIA
49
Polyuria is an increased frequency of urination. This may be due to the osmotic diuretic
effect of the glucose, wherein it attracts water during urination.
When you have diabetes, excess sugar (glucose) builds up in your blood. Your kidneys
are forced to work overtime to filter and absorb the excess sugar. If your kidneys can't
keep up, the excess sugar is excreted into your urine along with fluids drawn from your
tissues. This triggers more frequent urination, which may leave you dehydrated.
POLYDIPSIA
Polydipsia is an increased thirst and fluid intake. This may be due to the activation of
the thirst center in the hypothalamus resulting from the intracellular dehydration or
volume depletion caused by excessive urine production.
POLYPHAGIA
Increased hunger and food intake. Because glucose cannot enter cells of the satiety
center of the brain without insulin, the satiety center in the hypothalamus is stimulated
resulting in a “hunger sensation” as if there were very little blood glucose, resulting in an
exaggerated appetite.
BODY MALAISE
This is due to the decreased glucose uptake by the tissues leading to decreased energy
production.
(Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005)
GLYCOSURIA
50
The kidney filters the blood, making it to its normal state. Glucose was filtered out and
excreted in the urine. Due to the excess glucose ad compared to the kidney threshold,
which results to the excretion of glucose in the urine.
BLURRED VISION
Diabetes can affect the lens, vitreous, and retina, causing visual symptoms. Visual
blurring may develop acutely as the lens changes shape with marked changes in blood
glucose concentrations. This effect, which is caused by osmotic fluxes of water into and
out of the lens, usually occurs as hyperglycemia increases.
WEIGHT LOSS
Despite eating more than usual to relieve constant hunger by the stimulation of satiety
center, weight loss may still exist. Without the glucose supplies, muscle tissues and fat
stores may deplete.
SLOW-HEALING SORE AND FREQUENT INFECTION
High levels of blood sugar impair your body's natural healing process and your ability to
fight infections. For women, bladder and vaginal infections are especially common.
TINGLING SENSATION/ NUMBNESS IN THE HAND AND FEET
Excess sugar in your blood can lead to nerve damage. You may notice tingling and loss
of sensation in your hands and feet, as well as burning pain in your arms, hands, legs
and feet.
51
PROTEINURIA
Testing the urine for microalbuminuria shows early nephropathy, long before it would be
on routine urinalysis,
ANEMIA
If there are renal affectations, this might bring to decrease production of erythropoietin
which brings to decrease production of RBC from the bone marrow that may result to
anemia.
CEREBROVASCULAR ACCIDENT
Clinical Manifestations
1. headache and vomiting – due to an increase ICP which causes cerebral
edema, and compressing the medulla oblongata
2. seizures – due to hyper-excitability of neurons because of irritation.
3. changes in mental status – affectation in the RAS
4. fever – affectation in the hypothalamus
5. ECG changes – problem with the medulla oblongata
Warning Signs
1. transient hemiparesis
2. loss of speech
52
3. hemisensory loss
4. vertigo/syncope
Specific Deficits
1. Hemiparesis/Hemiplegia – the former means weakness of one side of the body while
the latter means paralysis of one side of the body.
2. Aphasia – defects on using and interpreting symbols of language
3. Apraxia - a condition in which a client can move the affected part but cannot use it for
purposeful actions.
4. Homonymous Hemianopsia – a defective vision or vision loss in the same half of the
visual field.
5. Agnosia – a problem in interpreting visual, tactile or other sensory information.
6. Dysarthia – imperfect articulation condition.
7. Kinesthesia – alteration in sensation.
8. Incontinence – due to inattention, memory lapses, emotional factors, and inability to
communicate.
9. Shoulder pain – severe pain in the affected shoulder after CVA
10. Horner’s syndrome – paralysis of sympathetic nerves to the eye causing sinking of
the eyeball, ptosis of the upper eyelid, constriction of pupil, and lack of tearing in the
eye.
11. Unilateral neglect – inability to respond to stimulus on the contralateral side.
12. Dysphagia (01/29/09 -01/31/09) – difficulty of swallowing
53
13. Ataxia (01/29/09 -01/31/09) –Problem with motor coordination
B.2. Modifiable and Non Modifiable Factors (Client Based)
1. Modifiable
a. Smoking – (23 pack years) nicotine content of cigarettes causes vasoconstriction
there by resulting hypertension which may lead to CVA.
b. Hypertension – (BP-200/100 -01/27/09) this is due to plaque deposits on the wall of
the arteries which causes narrowing of the blood vessel thereby causing hypertension
which may lead to hemorrhagic stroke.
d. Hyperlipidemia – Total Cholesterol: 351 (01/28/09) too much lipid in the blood may
cause increase plaque formation which may cause thrombus formation.
e. Diabetes Mellitus – (She was diagnosed with DM since 2004) The mechanism is
related to macrovascular changes in people with diabetes mellitus. There is an increase
viscousity of blood which may cause formation of thrombus formation.
2. Non-Modifiable
54
a. Age –Intracranial hemorrhage is most often secondary to hypertension and is most
common after age 50 years. (Kitty Sanrio is 58 yrs. Old)
b. Family history of Cardiovascular Diseases – Family history of stroke increases one’s
risk. Kitty Sanrio’s mother died from cardiovascular disease specifically heart attack.
c. Family history of DM –Family which has history of DM especially type 2 is high risk of
having stroke due to accelerated atherosclerosis.
SIGNS AND SYMPTOMS (Client Based)
DIABETES MELLITUS
HYPERGLYCEMIA (INCREASED BLOOD SUGAR LEVEL) (01/28/09)
Diabetes Mellitus type II may be due to lack of physiologically active insulin that
stimulates glucose uptake in the muscles and tissues. Therefore, it leads to an
accumulation of glucose in the intravascular space. The glucose is not utilized by the
body and it remains in the blood stream.
POLYURIA (01/29/09 -01/31/09)
Polyuria is an increased frequency of urination. This may be due to the osmotic diuretic
effect of the glucose, wherein it attracts water during urination.
When you have diabetes, excess sugar (glucose) builds up in your blood. Your kidneys
are forced to work overtime to filter and absorb the excess sugar. If your kidneys can't
55
keep up, the excess sugar is excreted into your urine along with fluids drawn from your
tissues. This triggers more frequent urination, which may leave you dehydrated.
BODY MALAISE (01/29/09 -01/31/09)
This is due to the decreased glucose uptake by the tissues leading to decreased energy
production.
GLYCOSURIA (01/29/09)
The kidney filters the blood, making it to its normal state. Glucose was filtered out and
excreted in the urine. Due to the excess glucose ad compared to the kidney threshold,
which results to the excretion of glucose in the urine.
BLURRED VISION (01/29/09 -01/31/09)
Diabetes can affect the lens, vitreous, and retina, causing visual symptoms. Visual
blurring may develop acutely as the lens changes shape with marked changes in blood
glucose concentrations. This effect, which is caused by osmotic fluxes of water into and
out of the lens, usually occurs as hyperglycemia increases.
ANEMIA [Hemoglobin: 8 (F: 12-16) (01/28/09)]
If there are renal affectations, this might bring to decrease production of erythropoietin
which brings to decrease production of RBC from the bone marrow that may result to
anemia.
56
FREQUENT INFECTION (01/29/09 -01/30/09)
High levels of blood sugar impair your body's natural healing process and your ability to
fight infections. This is due to low morphonuclear leukocytes which decreases her
resistance from infection. For women, bladder and vaginal infections are especially
common.
PROTEINURIA (01/29/09)
Testing the urine for microalbuminuria shows early nephropathy, long before it would be
on routine urinalysis,
PNEUMONITIS – Radiology report (01-30-09). Many factors can cause pneumonitis,
including breathing in animal dander, inhaling small food particles "down the wrong
pipe" and receiving radiation therapy to your chest and smoking.
CEREBROVASCULAR ACCIDENT
Clinical Manifestations
1. headache and vomiting – due to an increase ICP which causes cerebral
edema, and compressing the medulla oblongata
2. seizures – due to hyper-excitability of neurons because of irritation.
3. changes in mental status – affectation in the RAS
4. fever – affectation in the hypothalamus
5. ECG changes – problem with the medulla oblongata
57
Warning Signs
1. transient hemiparesis (01/27/09)
2. slurred speech (01/27/09)
3. hemisensory loss(01/27/09)
4. vertigo/syncope (01/27/09)
Specific Deficits
1. Hemiparesis/Hemiplegia (01/29/09 -01/31/09) – the former means weakness of one
side of the body whiles the latter means paralysis of one side of the body.
2. Apraxia (01/29/09 -01/31/09) –a condition in which a client can move the affected
part but cannot use it for purposeful actions.
3. Dysarthia (01/29/09 -01/31/09) – imperfect articulation condition.
4. Dysphagia (01/29/09 -01/31/09) – difficulty of swallowing
5. Ataxia (01/29/09 -01/31/09) –Problem with motor coordination
58
V. The Patient and His Care
A. Medical Management
a. IVF’s, BT, NGT Feedings, Nebulization, TPN, Oxygen Therapy.etc.
Medical Management/
Treatment
Date ordered/ Date
Performed
General Description
Indication or purpose
Client’s Response
D5 LRS (5% Dextrose Lactated Ringer’s Solution) 1L
D5 0.3 NaCl
(5% Dextrose 0.3
Sodium Chloride)
500cc
01-27-09
Jan. 27-31, ‘09
Hypertonic solution that has higher osmolarity than the serum. It pulls fluid and electrolytes from the intracellular and interstitial compartments into the intravascular compartment. It is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment and caloric supply administered intravenously.
Hypotonic
solution that has
greater
concentration of
free water
molecules that
are found inside
Since the patient was on NPO upon admission, she was given D5 LRS as her IVF administered intravenously to serve as a source of water, electrolytes, and calories. It also serves as a route for medication administration.
To maintain
rehydration and to
replace fluid loss,
patient was given
this IVF. Also, for
medication
administration.
The patient was
able to maintain
normal hydration
status and
electrolyte
balance AEB
patient had
moist skin and
good skin turgor.
Patient
responded well
as she did not
manifest any
signs and
symptoms of
dehydration
59
the cell. such as dry skin
and mucous
membranes.
Nursing Implication:
Before:1. Check the physician’s order for IV solution and explain to the client the procedure. 2. Check the potency of IV line and needle 3. Check the type of infusion, condition of the vein and medical condition of the patient
During:1. Maintenance of Aseptic Technique 2. Proper procedure and steps in infusing IV solution3. Count drops per minute in drip chamber.
After:1. Monitor IV infusion at least every 2 hour 2. Adjust IV clamp as needed and recount drop per minute.3. Monitor client for fluid overflow 4. More frequent check maybe prn if a medication(s) are being infused.5. Inspect site for pain, swelling, coolness or pallor at the site of insertion, which may
indicate infiltration of IV 6. Inspect site for redness, swelling, heat and pain which may indicate phlebitis
60
b. Drugs
Name of Drugs
Date Ordered/
Date Performed/ Date
Given
Dosage, Route,
Frequency of
Administration
General Action
Indication or Purpose
Client’s Response
Nursing Responsibilities
Piracetam 01-27-09 800mg 1 tab PO q6 hrs then BID on
01-28-09
Piracetam improves the
function of the neurotransmit
ter acetylcholine via muscarinic
cholinergic (ACh)
receptors which are
implicated in memory
processes. It improves
brain function and
stimulates the central
nervous
Since the patient is diagnosed of
CVA, she is given this drug to
improve her brain function
The client improved her
mentation as she is able to feel deep
touch and could raise his right arm and leg as well as comprehend with
what the SO is saying. There are no side/adverse
effects noted
Prior to:
Wash hands
thoroughly.
Ask the patients
name
Always observe
aseptic technique
During:
Explain the
procedure to the
patient/SO.
Explain what is the
general action of the
61
system without any toxicity or addictive properties
drug to the body.
After:
Record the drug after
its administration
(charting).
Observe the patients
for possible untoward
reaction.
Instruct to take the
medication exactly as
directed.
Captopril Jan. 27-31, ‘09
25mg SL TID
Captopril lower blood pressure by inhibiting the formation of
angiotensin II, thus relaxing the arteries. Relaxing the arteries not only lowers
blood
Indicated for the patient since the drug is said to
treat hypertension.
Patient did not improve condition since she still had
elevated blood pressure of
180/100
Prior to:
Wash hands
thoroughly.
Ask the patients
name
Always observe
aseptic technique
During:
62
pressure, but also improves the pumping
efficiency of a failing heart
and improves cardiac output
in patients with heart
failure.
Explain the
procedure to the
patient/SO.
Instruct the patient to
put the medicine
under her tongue or
sublingually.
After:
Record the drug after
its administration
(charting).
Observe the patients
for possible untoward
reaction.
Instruct to take the
medication exactly as
directed.
Monitor blood pressure
Ranitidine 01-27-09 50mg IV It is a This is indicated The patient Prior to:
63
q8 then d/c on Jan.
30,’09
competitive, reversible
inhibitor of the action of
histamine at the histamine H2 receptors,
including receptors on the gastric
cells
for the patient as she manifested abdominal pain
improved condition as she did not
manifest abdominal pain.
Wash hands
thoroughly.
Ask the patients
name.
Recheck the order of
the doctor
Always observe
aseptic technique
Check the patency of
the IV site
During:
Explain the
procedure to the
patient/SO.
Observe patient
closely for at least 30
minutes following
administration.
After:
Record the drug after
64
its administration
(charting).
Observe the patients
for possible untoward
reaction.
Simvastatin 01-28-09 40mg 1tab OD
Simvastatin is a
hypolipidemic drug
belonging to the class of
pharmaceuticals called
"statins". It is used to control
hypercholesterolemia
(elevated cholesterol
levels) and to prevent
cardiovascular disease.
Since the patient had high levels of cholesterol with 351 mg/dl, she was given this
drug.
Patient did not improve condition since she still has
elevated cholesterol..
Prior to:
Wash hands
thoroughly.
Ask the patients
name
Always observe
aseptic technique
During:
Explain the
procedure to the
patient/SO.
After:
Record the drug after
its administration
(charting).
65
Observe the patients
for possible untoward
reaction.
Instruct to take the
medication exactly as
directed.
Metoprolol 01-28-09 50mg 1tab BID then increased frequency of 100mg on Jan. 30,’09
Metoprolol reduces heart
rate and cardiac output
at rest and upon
exercise, reduces
systolic blood pressure
upon exercise, inhibits
isoproterenol-induced
tachycardia, and reduces
reflex orthostatic
It is also indicated for the patient because the patient has
elevated blood pressure.
The client did not improve condition since she still had
elevated blood pressure
Prior to:
Wash hands
thoroughly.
Ask the patients
name
Always observe
aseptic technique
During:
Explain the
procedure to the
patient/SO.
After:
Record the drug after
66
tachycardia. its administration
(charting).
Observe the patients
for possible untoward
reaction.
Instruct to take the medication exactly as
directed.
Monitor BP
Ketosteril 01-30-09 2 tabs TID Ketosteril normalizes metabolic
processes, Improves nitrogen
exchange, reduce ion
concentrations of
potassium, magnesium
and phosphate.
Protein-energy malnutrition,
prevention and treatment of
conditions caused by modified or
insufficient protein metabolism.
Patient improved condition as she did not manifest body weakness because of the
energy supplemented.
Prior to:
Wash hands
thoroughly.
Ask the patients
name
Always observe
aseptic technique
During:
Explain the
procedure to the
patient/SO.
67
After:
Record the drug after
its administration
(charting).
Observe the patients
for possible untoward
reaction.
Instruct to take the
medication exactly as
directed.
Ferrous Sulfate
01-30-09 1 cap OD Ferrous Sulfate is an
essential body mineral.
Ferrous sulfate is
used to treat iron
deficiency anemia
Indicated for the patient as a
supplement for iron
Patient did not improve condition as she still has low hemoglobin count.
Prior to:
Wash hands
thoroughly.
Ask the patients
name
Always observe
aseptic technique
During:
Explain the
procedure to the
68
patient/SO.
After:
Record the drug after
its administration
(charting).
Observe the patients
for possible untoward
reaction.
Instruct to take the
medication exactly as
directed.
Hydralazine 01-29-09 5mg IV q6hrs
PRN for BP 130/90
Hydralazine is a direct-acting
smooth muscle
relaxant used to treat
hypertension by acting as a
vasodilator primarily in arteries and
arterioles. By relaxing vascular
Indicated for the patient as she has
elevated blood pressure
The patient did not improve her
condition as she still had elevated blood pressure of
180/100
Prior to:
Wash hands
thoroughly.
Ask the patients
name.
Recheck the order of
the doctor
Always observe
aseptic technique
69
smooth muscle,
vasodilators act to
decrease peripheral resistance,
thereby lowering
blood pressure.
Check the patency of
the IV site
During:
Explain the
procedure to the
patient/SO.
Observe patient
closely for at least 30
minutes following
administration.
After:
Record the drug after
its administration
(charting).
Observe the patients
for possible untoward
reaction.
Monitor BP
70
c. Diet
TypeOf
diet
Date ordered
Date givenDate
changed
General description
IndicationSpecificFoodsTaken
Client’s response
Nothing per Orem (NPO)
01-27-09 A type of Diet where the patient cannot eat or drink anything
It is for the purpose of observation precaution
None The patient participated with the Doctor’s order
Soft Diet 01-28-09 Very similar to regular diet except that the textures of foods have been modified.
This was ordered to provide a transitional diet between liquids and regular food for patients who have difficult in swallowing or who undergone surgery.
Boiled Eggs, Sopas, Lugaw
The client enjoyed eating her food and manifested feeling of fullness after the meal. She did not manifest dysphagia.
Nursing Responsibilities for NPO
● Check the doctor’s order.● Educate the patient and significant others why NPO is indicated.● Discuss to the patient the importance of the diet.● Assess patient’s level of hydration.
Nursing Responsibilities for soft diet
● Check the doctor’s order.● Educate the patient and significant others on the right foods to be taken.● Discuss to the patient the importance of nutrition.● Provide a variety of choices of foods.● Assess patient’s appetite.
71
d. Activity/ Exercise
TypeOf
exercise
Date orderedDate given
Date changed
General description
IndicationClient’s
response
High Back Rest
01-27-09 A type of activity or exercise wherein the patient is kept on bed with the head of bed held at at least 45° with limitations to other activities.
To reduce oxygen demand and prevent fatigue. Rest decreases body metabolic rate. Since the patient is old, she is prone to have pressure ulcers and she is more likely to manifest fatigue.
Patient shows gradual increase in strength.
Nursing Responsibilities● Assist patient if with such privilege in going to the bathroom.● Change client’s position from time to time, to promote circulation and prevent bed sores.
72
B. Nursing Management
NURSING CARE PLAN
Problem No:1 Acute Pain
ASSESSMENTNURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATIONPLANNING INTERVENTIONS RATIONALE
EXPECTED
OUTCOME
S=” Masakit ku
atsan”
The patient
manifested the
following:
O= with facial
grimace, with
guarding
behaviors, pain
scale of 8/10, at
abdominal area,
with quality of dull
Acute Pain
Lots of medicine has the
side effect of gastric
upset causing
abdominal pain to
patient after intake of
medication specially PO
drugs. It has a side
effect of causing
abdominal cramps, and
pain.
Short Term
Objective:
After 2 hr of
nursing
intervention the pt
will verbalized
rlieve of pain from
8/10 to 4/10
Long Term
Objective:
After 3 days of NI,
pt will
Establish rapport
Monitor v/s
Assess pt’s
general condition
Encourage rest
opportunities
Ecourage
To gain pt’s
therapeutic
relationship
To obtain
baseline data
To note for the
etiology or
precipitating
factors that can
lead to fever.
To overcome pain
at rest
to divert the pt’s
Short Term
Objective:
After the nsg int the
pt shall verbalized a
relief of pain.
Long Term
Objective:
After the nsg int the
pt shall
demonstratetechniq
ue to alleviate pain
73
pain, after intake
of meds, left side
paralysis
The patient may
also manifest he
following:
>discomfort
>anxiety
>irritable
>Fatigue
>headache
demonstrate
technique to
alleviate pain
diversional
activities such as
talking to S.O.
Encourage deep
breathing
exercises
Provide comfort
measures and
safety
Provide Health
information
regarding the
occurring problem
Provide
conducive
environment for
resting
attention
Helps to lessen
the feeling of
pain.
To let pt feel safe
and comfortable
To lessen the pt’s
feeling of anxiety
To promote rest
and pt’s wellness
74
Problem No: 2 impaired cerebral tissue perfusion r/t vascular occlusion secondary to disease condition
ASSESSMENTNURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATIONPLANNING INTERVENTIONS RATIONALE
EXPECTED
OUTCOME
S= 0
The patient
manifested the
ff:
O= without signs
of IV infiltration, w/
contralateral
hemiparesis,
sensory loss,
muscle weakness,
slurred speech,
with GCS=15
The patient may
also manifest the
ff:
Impaired cerebral
tissue perfusion
r/t vascular
occlusion
secondary to
disease condition
In cerebral tissue
perfusion, there is a
decrease in oxygen
supply which results in
the failure to nourish the
tissues at the capillary
level. Blood vessels
which function is to
supply blood to the
different parts of the
brain are impaired.
Thus, the O2 supply
going to the brain is also
impaired. Proper
perfusion is needed in
order to give adequate
nourishment to he
different parts of the
brain in order for it to
Short term
objective:
After 5hrs. of
Nursing
intervention, the
pt. will
demonstrate
increased
perfusion as
individually
appropriate
Long Term
Objective:
After 2-3 days of
Nursing
Intervention, the
pt. will be able o
demonstrate
Establish Rapport
Monitor Vital
signs
Assist pt. in
assuming
semifowler’s
position w/ head
midline.
Administer
medications as
ordered such as
antihypertensive
> To gain pt’s
therapeutic
relationship
> To identify any
other deviations
from normal.
>To aid with
proper perfusion
or flow of blood
(circulation or
venous drainage).
>To probably
decrease cardiac
workload and in
maximizing tissue
Short term
objective:
After 5hrs. of
Nursing
intervention, the pt.
shall be able to
demonstrate
increased perfusion
as individually
appropriate
Long Term
Objective:
After 2-3 days of
Nursing
Intervention, the pt.
shall be able to
demonstrate
behaviors which 75
>Change in
pupillary reactions
>Change in
Mental Status
>Behavioral
Changes
>Capillary refill
longer than 3
secs.
function well. behaviors which
may improve
proper circulation
such as
compliance to
health
management &
therapies
provided.
or diuretics.
>Encourage quiet
and restful
atmosphere.
>Exercise caution
in using hot or
cold pads.
>Encourage use
of relaxation
techniques or
exercises.
>Discuss the
importance of
preventing
exposure to cold
or extreme cold
temp
perfusion
>To conserve
energy which
could aid in
lowering the O2
tissue demand.
>The t issues
may have
decreased
sensitivity due to
ischemia.
>To decrease the
tension level
>To retain heat or
warmth efficiently
may improve proper
circulation such as
compliance to
health management
& therapies
provided.
76
>Discuss to the
patient’s SO the
importance of
care of dependent
limbs, body
hygiene, and foot
care when
circulation is
impaired.
>To promote
wellness
Problem No: 3 Impaired Physical Mobility Neuromuscular and Musculoskeletal Impairment
ASSESSMENTNURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATIONPLANNING INTERVENTIONS RATIONALE
EXPECTED
OUTCOME
S= 0
The patient
manifested the
following:
O= w/ pale
palpebral
conjunctiva, w/
Impaired physical
mobility
neuromuscular
and
musculoskeletal
impairment as
evidence by
limited motor
The nervous system is
made up of nerve cells
called neurons that
serve as the
communication system
of the body. They carry
messages in the form of
electrical impulses. The
messages move from
Short Term
Objective:
After 4 hrs. Of
Nursing
Intervention, the
pt. will be able to
maintain
increased
strength and
>Establish
Rapport
>Monitor Vital
signs
>Assess patient
condition
> To gain pt’s
therapeutic
relationship
> To identify any
other deviations
from normal.
>To determine
any other
Short Term
Objective:
After 4 hrs. Of
Nursing
Intervention, the pt.
shall be able to
maintain increased
strength and
function of affected 77
pale nail beds, w/
capillary refill
time, <3sec. pt. is
able to feel deep
touch, raise his
right arm and leg,
w/ slurred speech,
w/ left sided
weakness, with
limited ROM on
upper and lower
extremities,
afebrile, (-) DOB,
(-) chest pain.
The patient may
also manifest he
following:
>Slowed
movement,
>Postural
instability during
skills. one neuron to another
to keep the body
functioning. Because
neurons have, limited
ability to repair
themselves unlike other
body tissues that is why
nerve cells cannot be
repaired if damaged
due to injury or disease.
function of
affected or
compensatory
part.
Long Term
Objective:
After 2-3 days of
nursing
intervention, the
pt. will be able to
demonstrate
behaviors that
enable
resumption of
activities.
>Provide
adequate rest
periods as well as
comfort & safety
measures
>Turn pt. slowly
from side to side
>Determine pt.
level of mobility
>Assist pt. in his
activities
>Encourage
adequate intake
of fluids &
underlying cause
of manifestations
> To prevent
further stress &
fatigue
> To provide
proper circulation
of blood flow on
both sides
>To assess
functional ability
>To promote
optimal level of
function
>Promotes well-
being and
maximizes
energy
or compensatory
part.
Long Term
Objective:
After 2-3 days of
nursing
intervention, the pt.
shall be able to
demonstrate
behaviors that
enable resumption
of activities.
78
performance of
ADLs
>Movement
induced shortness
of breath.
Nutritious foods
>Involve client’s
SO in care
production.
>To assist in
learning ways of
managing
problems of
immobility.
Problem: 4 Activity Intolerance r/t immobility
AssessmentNursing
Diagnosis
Scientific
ExplanationObjective
Nursing
InterventionRationale
Expected
Outcome
S>O
O>The Patient
Manifests:
>with Paralysis
of the Left Body
Side
>with Left side
Activity
Intolerance r/t
immobility
Infarction on the
right hemisphere
has a contra
lateral
manifestation of
either left side
paralysis and/or
weakness due to
left hemisphere
affectation
causing the
immobility
Short Term:
After 3 hrs of
nursing
intervention the
patient will use
identified
techniques to
enhance activity
tolerance.
>Establish Rapport
>Assess V.S.
>Assess General
Condition
>Adjust Activity
>To gain
patient’s Trust
>To gain
baseline data
>To note for
signs and
symptoms
>To prevent
overexertion
Short Term:
After the
nursing
intervention the
patient shall use
identified
techniques to
enhance activity
tolerance.
79
weakness
>with Blurred
Vision
>with infraction
on right
hemisphere
>requires
assistance and
guidance from
S.O.
The Patient may
Manifest:
>headache
>pain
>irritable
>discomfort
>cold clammy
skin
>dehydration
because of
stiffness of
muscle and
unability to
mobilize due to
the
manifestation of
the disease
condition.
Long Term:
After 3 days
of nursing
intervention the
patient will
demonstrate
increase in
activity
tolerance.
>Provide positive
atmosphere
>Promote comfort
measure and
provide for relief of
pain
>Provide ROM
>Give client
information that
provides
evidence/difference
>Assist client in
learning and
demonstrating
appropriate safety
measures
>to minimize
frustration
>to enhance
ability to
participate in
activities
>to promote
circulation
>to sustain
motivation
>to prevent
injuries
Long term:
After the
nursing
intervention the
patient shall
demonstrate
increase in
activity
tolerance.
80
Problem No: 5 impaired verbal and/or written communication r/t impaired cerebral circulation
ASSESSMENTNURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATIONPLANNING INTERVENTIONS RATIONALE
EXPECTED
OUTCOME
S= 0
The patient
manifested the
following:
O= w/ pale
palpebral
conjunctiva, w/
pale nail beds, w/
capillary refill
time, <3sec., pt.
is able to feel
deep touch, raise
impaired verbal
and/or written
communication
r/t impaired
cerebral
circulation
There is an affectation
of the certain brain
lobes that caused by
impaired cerebral
circulation that affects
its proper functions that
leads to decreased,
delayed or absent
ability to receive,
process, transmit and
use a system o
symbols in
communicating
resulting in impaired
verbal communication.
Short Term
Objective:
After 3 hrs of nsg
int. the pt will be
able to verbalize
or indicate
understanding of
the
communication
difficulty and
plans for ways of
handling.
Long Term
Establish rapport
Monitor v/s
Assess pt’s
general condition
Note results of
neurological
To gain pt’s
therapeutic
relationship
To obtain
baseline data
To note for the
etiology or
precipitating
factors that can
lead to fever.
To assess
causative/contrib
Short Term
Objective:
After the nrsing
intervention the pt
shall verbalize ir
indicate
understanding of
communication
difficulty and plans
for ways of
handling
Long Term
81
his right arm and
leg, w/ slurred
speech, w/ left
sided weakness,
with limited ROM
on upper and
lower extremities,
The patient may
also manifest he
following:
>weakness
>headache
>dyspnea
>unable to speak
>discomfort
>irritability
>low self esteem
>Difficulty in
expressing needs
Objective:
After 3 days of
nursing
intervention the
pt will establish
method of
communication in
which needs can
be expressed.
testing such as
EEG/CTscan and
the likes
Assess
environment
factors that may
affect ability to
communicate
Establish
relationship with
the client ,
listening carefully
and attending to
clients
verbal/nonverbal
expressions
Maintain a calm,
unhurried
manner, provide
sufficient time for
the client to
uting factors
To assess
causative/contrib
uting factors
To assist client to
establish a
means of
communication to
express needs,
wants, ideas and
questions
Individuals may
talk more easily
when they are
rested and
Objective:
After the nursing
intervention the pt
shall be albe to
establish methods
of communication
in which can be
expressed.
82
responds
Anticipate needs
until effective
communication is
reestablished
Administer due
meds
relaxed
To attend pt’s
needs
immediately
For pt’s recovery
and to treat
underlying
conditions
Problem No: 6 Risk for Aspiration
ASSESSMENT NURSING DIAGNOSIS
SCIENTIFIC EXPLANATION
PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME
S= 0
The patient manifested the ff:
O= Dysphagia, impaired swallowing
The patient may
Risk for Aspiration When there is a blockage of vertebrobasilar artery there will be Cranial nerves affectations. CN V, VII, IX, XII blockage may result to dysphagia or difficulty of swallowing which thereby having high risk for aspiration.
Short term objective:After 5hrs. of Nursing intervention, the pt. demonstrate techniques to prevent aspiration.
Long Term
>Established Rapport
>Monitored Vital signs
>Note level of consciousness of surroundings, and
>To gain the trust & compliance of the patient & SO
> To identify any other deviations from normal.
>To assess if there is gag reflex or difficulty of
Short term objective:The patient shall have demonstrated techniques to prevent aspiration.
Long Term Objective:The patient shall have experienced
83
also manifest the ff:
>Depressed gag reflex.>Reduced level of consciousness
Objective:After 1-2 days of Nursing Intervention, the pt. will experience no aspiration aeb noiseless respirations, and clear breath sounds.
cognitive impairment.
>Suction as needed
>Auscultate lung sounds
>Give semisolid foods; avoid pureed that may increase risk of aspiration.
>Provide very warm or cold liquids
>Refer to speech therapist
swallowing.
>To clear secretions
>to determine presence of secretions
>To prevent aspiration and to aide swallowing effort.
>This activates temperature receptors in the mouth that help to stimulate swallowing.
>To strengthen muscles and techniques to enhance swallowing.
no aspiration aeb noiseless respirations, and clear breath sounds.
84
Problem no: 7 Risk for impaired skin integrity
ASSESSMENTNURSING
DIAGNOSISSCIENTIFIC EXPLANATION PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME
S= 0
The patient manifested the following:
O= with dysphagia, with reports of body malaise, increased urine output indwelling Foley catheter,
Risk for Impaired skin integrity
The skin is the baseline defense of the body against infection. Any break in the skin may harbor microorganisms that may invade the normal processing of the body, which may inflict or aggravate the pt’s disease condition.
Short Term Objective:
After 4 hr of nursing intervention the pt will take actions regarding minimizing the risk
Long Term Objective:
Establish therapeutic relationship
Monitor v/s
Assess pt’s general condition
Monitor I&O
To gain pt’ and SO’s trust and cooperation
To obtain baseline data
To note for the etiology or precipitating factors that can aggravate the risk.To have a baseline data regarding input
The pt shall have
took actions
regarding
minimizing the risk
The pt shall have
been free from risk.
85
pallor, cold skin, physical immobility.
After 3 days of NI, pt will be free of the risk. Encourage
increase OFI to al least 2-3 liters per day
Arrange bed linens
Encourage and assist client to active and passive ROM exercises
Encourage rest opportunities
Provided comfort measures and safety
Carefully wash and pat dry skin, including skinfold area. Use hydration and moisturization on
and output
To maintain hydration status.
To prevent increase pressure
To maintain blood flow
To promote optimum level of functioning
To let pt feel safe and comfortable
To maintain skin moisture
86
all at-risk surfaces.
Assist client in changing positions every two hours
Provided Health information regarding the occurring problem
Provided conducive environment for resting
Encourage client to have balanced diet especially with increased intake of vitamin C and Protein.
Monitor and Regulate IVF as per doctor’s order
To prevent pressure ulcer
To lessen the pt’s feeling of anxiety
To promote rest and pt’s wellness
To promote adequate nourishment.
For proper replacement of fluid losses.
87
Problem: 8 Risk for deficient fluid volume
AssessmentNursing
DiagnosisScientific Explanation Objectives Interventions Rationale
Expected Outcome
S>
O>the patient manifested: Fatigue Weakness Polyuria Pale to pink
palpebral conjunctiva
Change in mental status
Risk for Deficient Fluid Volume AEB polyuria
Since the patient had polyuria, she experienced frequent urination and with that, she might have lost fluids that could lead to deficient fluid volume. She, then is at risk of fluid volume deficit.
Short TermAfter 4 hours of nursing interventions, patient/SO demonstrate behaviors and techniques to correct deficit
Long Term:After 2-3 days of nursing
>Evaluate nutritional status, noting current intake, weight changes, and problems with oral intake. Measure subcutaneous fat and muscle mass
>Assess vital signs; note strength of
> Assess causative factors leading to deficit
>Evaluate degree of deficit
Short Term:
Patient shall have demonstrated behaviors and techniques to correct deficit
Long Term:
Patient shall have
88
The patient may manifests:
Hemoconcentration
Pale skin Poor skin turgor Capillary refill
time of less than 3 secs.
interventions, patient will demonstrate management to prevent fluid volume deficit
peripheral pulses. Measure blood pressure. Note presence of physical signs. Monitor I/O, color measure amount and specific gravity of the urine.
>Establish 24-hour replacement needs and routes to be used.>Note client preference concerning fluids and foods with high fluid content
>Provide nutritious diet via appropriate route
>Weigh daily
>Bathe less
> Prevent peaks and valleys in fluid level
>Encourage the client to increase intake of foods high in fluid content
>Correct/Replace fluid losses to reverse pathophysiologic mechanism
>Assess progress or status of efforts
>Maintain skin
demonstrated management to prevent fluid volume deficit.
89
frequently using mild cleanser/soap and provide optimal skin care
>Provide frequent oral and eye care
>Change position frequently
>Discuss factors related to occurrence of the deficit as individually appropriate. Instruct client how to measure and record I/O
integrity and prevent excessive dryness
>Prevent injury from dryness
>Promote comfort and safety
>Promote wellness
Problem: 9 Risk for imbalanced nutrition: less than body requirements
AssessmentNursing
DiagnosisScientific
ExplanationObjectives
Nursing Interventions
Rationale Expected Outcome
S>
O> The patient manifested:-muscle weakness- with contralateral
Risk for imbalanced nutrition: less than body requirementsAEB inability to
A paralysis and muscle weakness could lead to impaired mobility, lack of adequate strength to do activities of daily living such as
SHORT TERM:After 4 hours of NI, the patient will verbalize understanding of causative factors
>Establish therapeutic relationship
>Assess and monitor vital signs
>To obtain trust and cooperation of the pt.
>To obtain baseline date
SHORT TERM:The patient shall have verbalized understanding of causative factors when known and
90
hemiparesis- pale to pink palpebral conjunctiva- sensory loss
> The patient may manifest:- loss of weight- capillary fragility- decreased in subcutaneous fats and muscle mass
ingest adequate nutrition
eating. As the patient does not ingest adequate food first because she was ordered to be on NPO, second because she could not ingest the food adequately as she has paralysis, she could be at risk of imbalanced nutrition: less than body requirements.
when known and necessary interventions.
LONG TERM:After 4 days of NI, the patient will demonstrate behaviors to regain or maintain appropriate weight.
>Identify clients at risk for malnutrition
>Determine ability to chew, swallow and taste
>Discuss eating habits, including food preferences, intolerances, aversions
>Assess weight, age, body build, strength, activity/rest level
>Note total daily intake
>Provide diet modifications indicated for the client’s condition or health status
>Increase oral fluid
>To assess causative factors
>Factors that can affect ingestion or digestion of nutrients
>To appeal to clients likes/desires
>Provides comparative baseline
>To reveal changes that should be made in client’s dietary intake
>To establish a nutritional plan that meets individual needs
>To prevent
necessary interventions.
LONG TERM:The patient shall have demonstrated behaviors to regain or maintain appropriate weight.
91
intake
>Encourage client to choose foods that are appealing
>Limit fiber/bulk if indicated
>Promote pleasant, relaxing environment
>Provide oral care before/after meals
>Emphasize importance of well-balanced, nutritious intake
>Give supplemental humidification as needed (oxygen supply)
dehydration and liquefy respiratory secretions
>To stimulate appetite
>May result to early satiety
>To enhance intake
>To keep mouth clean
>To promote wellness
>To humidify airways and supplement need for oxygen
Problem no: 10 Risk for Infection
ASSESSMENTNURSING
DIAGNOSISSCIENTIFIC EXPLANATION PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME
Risk for Infection An infection is the Short Term Establish To gain pt’ and The patient shall
92
S= 0
The patient manifested the following:
O= with dysphagia, with reports of body malaise, increased urine output indwelling Foley catheter, pallor, cold skin, cracked and cry lips.
detrimental colonization of a host organism by a foreign species. In an infection, the infecting organism seeks to utilize the host's resources to multiply. The infecting organism, or pathogen, interferes with the normal functioning of the host and can lead to chronic wounds, gangrene, loss of an infected limb, and even death.
Objective:
After 4 hr of nursing intervention the pt will demonstrate appropriate hygienic measures such as hand washing, oral care, and perineal care
Long Term Objective:
After 3 days of NI, pt will maintain white blood cell (WBC) count and differential within normal limits.
therapeutic relationship
Monitor VS
Assess pt. general condition
Observe and report signs of infection such as redness, warmth, discharge, and increased body temperature.
Assess skin for color, moisture, texture, and turgor (elasticity). Keep accurate, ongoing documentation of changes.
Preventive skin
SO’s trust and cooperation
To obtain baseline data
To note for the etiology or precipitating factors that can aggravate the risk.
To have a baseline data regarding client’s risk
To note for degree of deficiency
To promote
have demonstrated
appropriate hygienic
measures such as
hand washing, oral
care, and perineal
care
The pt shall have
maintained white
blood cell (WBC)
count and
differential within
normal limits.
93
assessment protocol, including documentation, assists in the prevention of skin breakdown.
Carefully wash and pat dry skin, including skinfold areas. Use hydration and moisturization on all at-risk surfaces.
Encourage a balanced diet, emphasizing proteins, fatty acids, and vitamins listed below.
Encourage fluid intake.
Use appropriate "hand hygiene" (i.e., hand washing or use of
optimum level of functioning
To prevent skin impariment
To promote pt’s wellness
To maintain hydration status
To prevent nosocomial infection
94
alcohol-based hand rubs).
Use careful technique when changing and emptying urinary catheter bags.
Ensure the client's appropriate hygienic care with hand washing; bathing; and hair, nail, and perineal care performed by either the nurse or the client.
Administer antibiotics; use antibiotics sparingly as per doctor’s order
To avoid cross contamination
To prevent good source of bacterial multiplication
To pharmacologically manage the problem.
Problem No: 11 Risk for Injury
ASSESSMENT NURSING DIAGNOSIS
SCIENTIFIC EXPLANATION
PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME
95
S= 0
The patient manifested the following:
O= with limited range of motion. contralateral hemiparesis, sensory loss, muscle weakness, Blurred vision
The patient may also manifest he following:
>Fatigue>headache>Dizziness
Risk for Injury Because of limited range of motion and slightly paralyze body the patient is unable to mobilize properly which maybe a risk for injury.
Short Term Objective: After 2 hr of nursing intervention the pt will demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury
Long Term Objective:After 2 days of NI, pt will be free of injury
>Establish rapport
>Monitor v/s
>Assess pt’s general condition
>Assess mood, coping abilities, personality styles
>Identify interventions and safety devices
>Encourage participation in self-help programs, such as assertiveness training, positive
>To gain pt’ and SO’s trust and cooperation
>To obtain baseline data
>To note for the etiology or precipitating factors that can lead to fever.
>that may result in carelessness and increased risk taking without considerations of consequences
>To promote safe physical environment and individual safety
>To enhance self esteem. sense of worth
Short Term Objective: The patient shall have demonstrated behaviors, lifestyle changes to reduce risk factors and protect self from injury
Long Term Objective:The patient shall have been free of injury.
96
self image
>raise the side rails of the bed
>Frequent skin inspection
>Use effective lighting
>Remind client to walk slowly
>Keep things into right premises and clear the way going to the restroom
>To promote safe physical environment and individual safety
> To assess if there is presence of pressure ulcers.
>To promote safety and easy scanning of the environment.
>To prevent injury due to slipping, and to promote safety.
>To prevent injury and promote safety.
Problem No: 12 Self Care Deficit: Bathing/Hygiene
97
ASSESSMENTNURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATIONPLANNING
INTERVENTION
SRATIONALE
EXPECTED
OUTCOME
S= 0
The patient
manifested the
following:
O= w/ pale
palpebral
conjunctiva, w/
pale nail beds, w/
capillary refill
time, 1-3sec., pt.
is able to feel
deep touch, raise
his right arm and
leg, w/ slurred
speech, w/ left
sided weakness,
with limited ROM
on upper and
lower extremities,
afebrile, (-) DOB,
Self Care deficit
r/t
neuromuscular,
musculoskeletal
impairment
Body movements are
possible because of the
movement of impulses
elicited by such stimuli
which then passes
through our nerves
going to our neurons
which are then
interpreted by our brain.
Nerves and Neurons
serve as messengers. If
these are impaired, the
affectation to the brain
function would be
decreased function
which may later on
cause impairment also
to other structures of
the body and this could
affect the performance
of ADLs. An example of
that is Impaired ability
Short Term
Objective:
After 4 hrs. Of
Nursing
Intervention, the
pt. will be able to
identify personal
resources which
can help in
providing
assistance.
Long Term
Objective:
After 2-3 days of
nursing
intervention, the
pt. will be able to
demonstrate
techniques or
changes to meet
>Established
Rapport
>Monitored Vital
signs
>Assessed
patient condition
>Provided
adequate rest
periods as well as
comfort & safety
> To gain trust of
the patient and
SO in order to
acquire
compliance with
appropriate
treatments or
teachings
> To identify any
other deviations
from normal.
>To determine
any other
underlying cause
of manifestations
> To prevent
further stress &
fatigue
Short Term
Objective:
After 4 hrs. Of
Nursing
Intervention, the
pt. shall be able to
identify personal
resources which
can help in
providing
assistance.
Long Term
Objective:
After 2-3 days of
nursing
intervention, the
pt. shall be able to
demonstrate
techniques or
changes to meet
98
(-) chest pain.
The patient may
also manifest he
following:
>Inability to get
bath supplies
>Inability to wash
body parts
>Inability to pick
appropriate
clothing
>Inabiliy to
replace articles or
clothing on own
>Inability to
maintain
appearance at a
satisfactory level
to perform
bathing/hygiene,
dressing or grooming.
self care needs. measures
>Turned pt.
slowly from side
to side
>Determined pt.
strengths and
skills
>Assisted pt. in
his activities
>Encouraged
adequate intake
of fluids &
Nutritious foods
>Provided time
for listening to
patient and SO,
> To provide
proper circulation
of blood flow on
both sides of he
body
>To assess
degree of
disability
>To promote
optimal level of
function
>Promotes well-
being and
maximizes
energy
production.
>To assist with
the patient’s
current disability
self care needs.
99
and provided
privacy during
personal care
activities.
>Involved client’s
SO in care
> Provided health
teachings and
support o the SO
for care options
or condition.
>To assist in
learning ways of
managing
problems of
immobility and for
providing
appropriate
nursing care.
>To provide
clarification
Reinforcement
and and periodic
Review by
client/caregivers.
100
B. Actual Soapies
01-30-09
S =”masakit ku atsan”
O =received with patient lying on bed awake and coherent, afebrile with Ivf # 2 of D50.3 NaCl
regulated at 20 gtts/min at level of 400cc infusing well on right hand with indwelling folley
catheter connected to urine bag draining a dark yellow urine at level of 1000cc, with facial
grimace, with guarding behaviors, with dull abdominal pain, with pain scale of 8/10, with pale to
pink palpebral conjunctiva, with capillary refill time of 1-3 seconds, with left side paralysis, with
VS are as follows: Temp: 36.7c, PR: 71 bpm, RR: 21 bpm, BP: 130/70 mmHG
A =Acute Pain
P =After 2 hrs of nursing intervention the pt will verbalize relief of pain from 8/10 to 4/10
I = Established rapport
= Assessed and Recorded VS
= Maintained and Regulated IVF
= Assessed General Condition
= Encouraged diversional activities such as talking to S.O.
= Encouraged rest to overcome pain
= Assisted the pt to turn to side q 2hr
= Encouraged deep breathing and coughing exercises
= Provided comfort and safety measures
= Provided back rubbing to alleviate pain
= Secured and Documented Lab Result
= Seen on round by Dr lumboy with orders made and carried out:
-hold hydralazine IV PRN – meds updated
101
-for fecalysis – requested
-D/C ranitidine – meds updated
-Monitor BD q 4hr
-Bladder training q2
= Due meds Given as ordered and indicated by doctors
E = Goal met as pt verbalized a relief of pain
01-31-09
S=O
O = received with patient on bed conscious and coherent, afebrile with an IVF #2 d5 0.3 NaCl
500cc regulated at 20 gtts/min at level of 50cc infusing well on right hand with indwelling folley
catheter connected to a urine bag draining a dark yellow urine, with weak appearance, with
moist skin, with good skin turgor, (+) pallor, GCS of 15, with dec. Hgb 8mg, with dec. Hct 27 Vol.
right ext. 5/5 and 5/5 and left extremity of 0/5 and 4/5, with left side body paralysis.
A = Ineffective tissue perfusion r/t decreased Hgb concentration in the blood
P = after 4 hrs of nsg. Int. the pt will demonstrate understanding of health teachings
I = Established Rapport
= Assessed and Recorded VS
= Assessed General Condition
= Maintained and Monitored IVF
= Instructed pt to increase OFI
= Instructed pt to Iron rich foods
= Provided assistance in turning pt to side q 2 hr
= Provided ROM exercises to promote blood circulation
102
= Instructed pt on strict compliance to medication
= Changed IVF with D5o.3 NaCl 500cc regulated at 20 gtts/min
= Provided Adequate rest periods
= Assessed range of movement
= Prescribed all unavailable meds
= Provided health teaching regarding problems
E = Goal met As evidenced by pt and S.O. adheres with the health teachings
VI. CLIENT’S DAILY PROGRESS IN THE HOSPITAL
1. Client’s Daily Progress Chart (From admission to discharge)
Days 01-27-09
(Admission)
01-28-09 01-29-09 01-30-09 01-31-09
Nursing Problems:
1.) Acute Pain
2.) Impaired
cerebral tissue
perfusion
3.) Impaired
physical
mobility
4.) Activity
Intolerance
5.) Impaired verbal
and/or written
communication
6.) Risk for
Aspiration
7.) Risk for
impaired skin
integrity
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
103
8.) Risk for
deficient fluid
volume
9.) Risk for
imbalanced
nutrition: less
than body
requirements
10.) Risk for
Infection
11.) Risk for
Injury
12.) Self
care Deficit
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
Vital Signs:
Temperature
Pulse Rate
Respiratory rate
Blood Pressure
36.2c
84 bpm
18 bpm
170/100
mmHg
36.5c
88 bpm
22 mmHg
140/50
mmHg
37c
76 bpm
19 bpm
180/90
mmHg
36c
71 bpm
17 bpm
180/90
mmHg
36c
69 bpm
18 pbm
170/90
mmHG
Diagnostics
Procedures:
1.) CXR APL
2.) Fecalysis
3.) Urinalysis
4.) Potassium K
* *
*
*
104
5.) CBC
*
*
Drugs:
1. Piracetam
2. Captopril
3. Ranitidine
4. Simvastatin
5. Metoprolol
6. Ketosteril
7. FeSo4
8. Hydralazine
*
*
*
*
*
*
*
*
*
*
*
*
D/C
*
*
*
*
Hold
*
*
*
Medical
managements:
1. D5 LRS 1L
2. D5 0.3 NaCl
500cc
*
* * * *
Diet:
1. NPO
2. Soft Diet
*
* * * *
Activity/Exercises:
1. High Back Rest * * * * *
VII. Conclusion
105
Stroke is a term used to describe the neurologic changes caused by an
interruption in the blood supply to a part of the brain. The incidence of stroke and stroke
mortalities has gradually declined in many industrialized countries in recent years as a
result of increased recognition and treatment of risk factors, which may include
modifiable risk factors such as hypertension
Public education is focused on prevention, recognition of manifestations and
early treatment of brain attack. As they say prevention is better than cure. Therefore it is
important for each and every one of us to avoid these modifiable risk factors and
change sedentary lifestyles to healthy lifestyles. Cholesterol levels should be brought to
a normal level, diabetes should be controlled and reducing heavy alcohol consumption.
The best intervention is to stop smoking cigarettes.
As nursing students, this study showed us the importance of early detection of
diseases such as stroke since it may lead to more serious conditions if it is not properly
managed or treated. Knowledge of the risk factors and preventive measures can help in
reducing the incidence of stroke. Prompt recognition, which allows for early treatment of
stroke is recommended to lessen residual deficits and decreased disability. Through this
study, may we be able to help others to understand and know more about stroke and
ways to prevent and treat its signs and symptoms.
The group was able to assess one patient having a case of Cerebral vascular
accident and through the study of case the group was able to identify of the causative
factors that predisposes the patient in acquiring such disease condition. Furthermore
the group was able to identify how was it occurred and how it would be worse if left
untreated, with several condition such as this case a lot of problems has occurred that
would might permanently affect the lifestyle of the patient.
In this study the group was able to be familiarized to medical managements and
its benefits and s side effect to patient during therapy
106
VIII. Bibliography
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Smeltzer, S. et. al. (2008). Brunner and Suddarth’s Textbook of Medical-Surgical Nursing 11 th edition . Philadelphia: Lippincott-Williams & Wilkins
Spratto, G. and Woods, A. (2008). 2008 Edition PDR ® Nurse’s Drug Handbook . New York: Thomson Delmar Learning.
Berman, A. et. al. (2008). Kozier & Erb’s Fundamentals of Nursing: Concepts, Process and Practice 8 th edition Jurong, Singapore: Pearson Education South Asia
Seely, R., Stephens, T., Tate, P. (2007). Essentials of Human Anatomy & Physiology 6 th
edition. New York: McGraw-Hill.
Van Leeuwen, A., Kranpitz, T., Smith, L., (2006) Davis’s Comprehensive Handbook of Laboratory and Diagnostic Test with Nursing Implication 2 nd edition , U.S.A, F.A Davis Company
Nurse’s Quick Check - Signs and Symptoms (2006) Philadelphia, Lippincott Williams & Wilkins
Nurse’s 5- minute Clinical Consult – Diseases, (2007) Philadelphia, Lippincott Williams & Wilkins
Hansel, D., Dintzis, R. (2006) Lippincott’s Pocket Pathology, Philadelphia, Lippincott Williams & Wilkins
Stewart, Joseph (1989) Clinical Anatomy and Pathophysiology for the Health Professional, Miami, MedMasters Inc.
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