““STROKE”STROKE”

Cerebrovascular Cerebrovascular AccidentAccident

Cerebrovascular Accident (CVA)

A stroke, also known as CVA or brain attack, is a sudden impairement of cerebral circulation in one or more blood vessels. A stroke interrupts or lessens O2 supply and commonly causes serious damage or necrosis in the brain tissue. The sooner the circulation returns to normal after a stroke, the better the chances are for a complete recovery. About ½ of the patient’s who survived a stroke, remain permanently disabled and experience a recurrence with in weeks, months or years. It’s the leading cause of admission to long term care.

Stoke is the third most common cause of death in the US and the most common cause of neurologic disability. It strikes more than 500,000 people per year and is fatal in about ½ of this people.

There are two types of stroke the: Ischemic and Hemorrhagic depending on the underlying cause. Ischemic has 3 classifications; Thrombotic, the most common cause of stoke frequently results of artherosclerosis; also associated with hypertension, smoking and diabetes. Embolic, second most common type of stroke and Lacunar, a subtype of thrombotic stroke. Hemorrhagic the third most common type of stroke, typically cause by hypertension or rupture of aneurysm, diminished blood supply to area supplied by ruptured artery and compression by accumulated blood.

Demographic DataPatients Data

Patient E.C. live at Quezon City. She is 66 years old and her birthday is on February 12, 1942. She is married but she’s now living with her sons and daughters house. She is a Roman Catholic. She doesn’t have any work because she is dependent to her siblings. She is a college undergraduate. She admits to the hospital because the patient complains of dizziness and

History of the present illnessOn June 18, 2008 the patient was rash to the hospital because the patient

complains of dizziness and her blood pressure was 180/100 mmHg. According to the family that hospital didn’t admit the patient and the patient went home. After 2 days the patient brought to St. Agnes General Hospital and admitted with a diagnosis of vomiting CVA.

Past Medical IllnessThe patient is already hypertensive and taking maintenance.

Family Health HistoryAccording to the family the patient inherit the disease from her mother side.

Social historyThe patient has a harmonious relationship with other family members. They live

in an apartment. The patient doest have any job because all her siblings are working already.

Gordon’s ApproachGordon’s Approach

When patient E.C. is not yet confined in When patient E.C. is not yet confined in the hospital or when she is in her normal state the hospital or when she is in her normal state of being the patient was oriented and coherent. of being the patient was oriented and coherent. She is kind to everyone. She has a harmonious She is kind to everyone. She has a harmonious relationship to her family as well as to their relationship to her family as well as to their neighbors. The patient can do her own things neighbors. The patient can do her own things and she do her responsibilities as a mother. and she do her responsibilities as a mother. She can eat everything she wants especially She can eat everything she wants especially the “bagoong” which is her favorite. The patient the “bagoong” which is her favorite. The patient do whatever she wants even though she knows do whatever she wants even though she knows that its dangerous to her health.that its dangerous to her health.

Physical AssessmentPhysical AssessmentVital Signs and Physical AssessmentName: ECBirth Date: February 12, 1942Age: 66 years oldVital Signs

Vital Signs Actual Finding Norms and Standards Inferences

Body Temperature 37.60C 36.5 0C-37.50C Normal

Pulse 101bpm 60-100 Slight deviation from normal

Respiration 19cpm 12-20cpm Normal

Blood Pressure 150/90 mmHg 120/80 mmHg Normal

Physical Assessment

Assessment Actual Finding Norms and Standards Inferences

Skin-Color-Uniformity-Moisture-Temperature-Skin turgor

-Brown complexion -Generally uniform except in areas exposed to the sun.-Moisture in the skin folds and the axillae.-Normal range.-Back to the previous state in less than 1 second.

Freckles, some birthmarks, some flat raised nevi; no abrasion or

other lesions. When pinched, skin springs back to previous state

Normal

Hair-Evenness of growth-Thickness or thinness-Hair texture and oiliness-Presence of infections-Amount of body hair

-Evenly distributed hair-Hair is thick, grayish in color.-Hair is soft and oily enough.-No infection or infestation-Variable

Thick hair. Silky, resilient hair. No infection or infestation.

Normal

Nails-Fingernail plate shape-Fingernail and toenail texture-Fingernail and toenail bed color-Blanch test of capillary refill

-Normal curved-Smooth texture-Light pink in color-Return of pink color in less than

4 seconds.

When pressed, prompt return of pink or usual color (generally

less than 4 seconds).

Normal

Skull and Face-Skull size, shape and symmetry-Palpation of the skull for masses

or depression-Facial Features (Symmetry of

structures)-Facial movements

-Rounded, symmetrical, normal size

-No masses or depressions, uniform consistency

-Symmetrical facial features, because both sides are paralyzed.

-Eyebrows elevate together, Eyes close tightly together and the cheeks can puff.

Rounded (normocephalic and symmetrical, with frontal,

parietal and occipital prominences) smooth contour. Absence of nodule or masses.

NormalDeviation from normal

Eye Structure-Eyebrows for hair distribution-Eyelashes for evenness and

direction of curl, color of sclera

-Pupils color, shape and symmetry

-Extraoccular muscle test

-Evenly distributed-Sclera is slight reddish. Iris shape

is somehow distorted, pinkish conjunctiva.

-Color black, round and around 4mm in diameter.

-Both eyes coordinate with parallel alignment movement.

The conjunctiva is shiny, smooth and pink or red. Transparent

capillaries, sometimes evident: sclera appears white. When lids open, no visible sclera

above corneas and upper and lower borders or corneas are slightly covered. Hair is evenly

distributed, skin intact.

-Normal-Normal-Normal

Ears-Auricle for color, symmetry of

size and position-Auricle texture and elasticity

-Same color as facial skin, symmetrical and aligned to the eye.

-Firm and recoils after it is folded.

Color same as facial skin, symmetrical. Firm auricles, the pinna recoils after it is folded

Normal

Nose and Sinuses-External nose shape, size and

color-Palpate fir any masses;

displacement of bone and cartilage.

-Presence of swelling or discharge.

-Straight, uniform in color, medium in size.

-No displacement and lesions.-No discharge.

The external nose is symmetric and straight, no discharge, no

lesions. Air moves freely as the client breathes through the nares of both nasal cavity

Normal

Mouth and Oropharynx-Outer lips are symmetry, color

and texture.-Inner lips for color-Teeth and gums-Tongue movement

-Pink in color but not too moist.-Pale and dry.-Patient has dentures. But is not

worn at the time of assessment.

-Does not move freely.

The outer lips are symmetric of contour. Uniform pink in color.

Soft, moist smooth texture. Intact dentures.

Teeth should be white. Gums and teeth should be intact.

Tongue is pink in color and moves freely.

-Normal-Normal

-Deviation from normal.

Neck-Neck muscles-Head movement-Palpation of neck

-Muscles are equal-Head does not move freely.-No masses, dislocation and

enlargement.

When the head is in movement, it is coordinated, smooth with no discomfort. The lymph nodes are not palpable. The trachea

is in central placement in midline of neck, spaces are

equal on both sides. The thyroid gland is not visible.

Slight deviation from normal.

Thorax and Lungs-Shape and symmetry of the

thorax-Spinal Alignment for deformities

-Chest is symmetric-Spine is aligned.

Chest is symmetric and the spine is aligned. Chest skins are intact

and have uniform temperature, with no

tenderness and no masses.

Normal

Feet No lesions and abrasions No lesions and abrasions Normal

Extremities Upper Extremities Lower extremities

No masses, arms and hands do not move freely and an IV attached to the right metacarpal.

No masses, legs and thighs do not move freely. Legs are not proportion to the rest of the body.

No palpable masses, arms are able to move freely, no contraptions, proportion to the rest of the body.

No palpable masses, legs and thighs are able to move freely, no contraptions, proportion to the rest of the body.

Deviation from normal.Deviation from normal.

Name Definition/Description Indication Nursing Responsibilities

Complete Blood Count (CBC)

A complete blood count (CBC) is a calculation of the cellular makeup of blood. A CBC measures the concentration of white blood cells, red blood cells, and platelets in the blood.

To determine the hemoglobin(Hgb), hematocrit (Hct), and erythrocytes (RBC), count, and assess the bloods ability to carry oxygen; to determine the leukocytes (WBC) count, which signals infection when elevated

Explain procedure to the client/relativeClean the site of extraction of the blood (put cotton and plaster)

Urinalysis Urinalysis is a diagnostic physical, chemical, and microscopic examination of a urine sample (specimen).

To detect urinary tract infections and glucose in the urine.

Explain procedure to the client/relativeAssist in collecting the specimenAdvise the relative on how to clean the genitalia

HBA 1C A1c is a compound created in your body when excess blood sugar sticks to a protein in your red blood cells called hemoglobin (Hb). The higher your blood sugar, the higher your A1c value.

To detect if the patient has Diabetes Mellitus

Tell relative not to give food to the patient 8 hours prior to collecting/getting specimen in the morning

PTT The PTT test is ordered when someone has unexplained bleeding or clotting. Along with the PT (which evaluates the extrinsic and common pathways of the coagulation cascade

), the PTT is often used as a starting place when investigating the cause of a bleeding or thrombotic episode

To determine the clotting factor of the patient

Diagnostic Procedures

Biochemistry Report I June 26, 2008

Test Reference Value Result Findings

Glucose (FBS) 3.6 – 5.8 7.9 umol/L ↑ Increase of glucose indicates diabetes mellitus, Cushing’s syndrome, acute pancreatitis, severe liver disease. Increase of uric acid in the blood indicates alcoholism, gout, high protein weight reduction diet, leukemia, metastatic cancer, renal failure, heart failure.

Triglycerides 0.40 – 1.53 0.69 umol/L

Blood Uric Acid (BUA) 17 – 34 = 149 – 369 283 umol/L ↑

June 29, 2008

Test Reference Value Result Findings

High Density Lipoprotein (HDL)

0.91 – 2.22 1.08 mmol/L Normal

Low Density Lipoprotein (LDL)

3.80 – 4.91 4.15 mmol/L

Total Cholesterol 5.1 – 6.2 5.47 umol/L

Triglyceride 0.40 – 1.53 0.52 umol/L

Laboratory ResultsLaboratory Results

Biochemistry Report II July 3, 2008

Test Reference Value Result Findings

Sodium (Na +) 137 – 145 126 mmol/L Normal

Potassium (K +) 3.6 – 5.0 3.9 mmol/L

July 30 4.5 mmol/L

Urinalysis June 25, 2008

Color Yellow Transparency Haze

Reaction Acidic Spec. Gravity 1.015

Albumin Trace Sugar (-)

Leucocytes 0 – 3 Yeast Cell /

Red Blood Cells 1 – 3 A.Urates few

Mucus Threads few Epithelial Cells +

Bacterial moderate

HBA1C

Date Reference Value Result

June 26 , 2008 4.27 – 6.07 % 4.7 %

Test Reference Value Result Findings

Hgt 80 – 120 95 Normal

Blood Urea Nitrogen (BUN) 2.5 – 6.4 5.6 mmol/L

Creatinine 62 – 106 106

Hematology

Test Reference Value June 25 July 5 Findings

Hemoglobin 12 – 14 12.5 gms % 14. 3 gms % ↑ Increase in hemoglobin indicates chronic obstructive pulmonary disease (COPD), heart failure, hemoconcentration, high altitudes, polycythemia. Increase in hematocrit indicates dehydration, eclampsia, high altitudes, polycythemia, congenital heart disease, burns. Increase in WBC indicates bacterial infections, collagen diseases, Cushing’s syndrome, gout, inflammatory disease, ketoacidosis, myelocytic leukemia, stress, acute infection. Increase in segmenter indicates Cushing’s syndrome, gout, inflammatory disease, ketoacidosis, myelocytic leukemia, stress. Decrease in Lymphocyte indicates chronic infections, hepatitis, lymphocytic leukemia, mononucleosis, multiple myeloma, viral infection.

Hematocrit 36 – 40 37.2 vol % 42 vol % ↑

WBC 5,000 – 10,000 13,000 cumm ↑ 22,700 cumm ↑

Platelet Count 150,000 – 400,000 278,000 cumm 318,000 cumm

Segmenter 36 – 66 % 87% ↑ 84% ↑

Lymphocyte 22 – 40 % 13% ↓ 16% ↓

PTT/APTT Results

Patient 11.9 sec 12 – 14 sec

Control 12.5

INR 1.0

% act 112.4%

Result Reference Value

Patient 29.7 sec 25 – 45 sec

Control 27.9 sec

Anatomy and PhysiologyAnatomy and Physiology

Human Brain

Pathophysiology

Predisposing factor Aggreviating factor Presipitating factor

Food intake with increase Diet Na and increase fat content

Lack of exercise

Sedentary lifestyle

Decrease blood circulation

Decrease contractility of the heart

Decrease C.O.

Hypertension Fatty deposits in the blood Increase BP

That usually embeds in the vessel

Cerebral Infarct

Stroke (CVA)

PrioritizationPrioritizationNURSING DIAGNOSIS RATIONALE RANKING

Impaired physical mobility related to neuromuscular involvement as evidenced by limited range of motion.

Highly prioritized because it needs immediate attention and intervention to help the client and the relatives to cope with the situation.

1

Self-care deficit related to neuromuscular impairment as manifested by impaired ability to perform ADLs.

Moderately prioritized because this involves patient’s self sufficiency. 5th stage of Maslow’s hierarchy of needs.

2

Risk for aspiration due to reduced level of consciousness and contraptions.

Not perceived as a problem by the client and the relatives,

3

ASSESSMENT NURSING DIAGNOSIS

PLANNING NURSING INERVENTION RATIONALE EVALUATION

SUBJECTIVE:“hindi makagalaw yung buong katawan ng nanay ko.” As verbalized by the patient’s son.OBJECTIVE:-BP=150/90-Temp=37.6-RR=19-PR=101-GCS=15-pupils reaction to light=brisk

Impaired physical mobility related to neuromuscular involvement as evidenced by limited range of motion.

After 8 hours of nursing intervention the patient will maintain, increaseStrength & endurance of upper & lower extremities. The relatives of the patient will know how to do ROM exercise.

-maintain the pt. on bed rest and place the pt. in different position (e.g. supine, sidelying)-monitor V/S-promote conducive circulation-encouraged the pt. to assist with movement and exercises using unaffected extremity to support/move weaker side.

-To have a good circulation of blood-For based line purposes-To reduce sympathetic stimulate& promotes relaxation.-May responds as if affected side is no longer part of the body and needs encouragement and active training to “reincorporate” it as a part of own body.

After nursing intervention the patient maintained, increasedStrength & endurance of upper & lower extremities. The relatives of the patient knew how to do ROM exercise.

Nursing Care Plan

ASSESSMENT NURSING DIAGNOSIS

PLANNING NURSING INERVENTION RATIONALE EVALUATION

SUBJECTIVE:“ medyo mahina

pa si nanay at hindi nakakagalaw kaya kami ang nagpapalit at naglilinis ng mga dumi niya.” As verbalized by the patient’s daughter.

OBJECTIVE:-BP=150/90-Temp=37.6-RR=101-PR=19-GCS=11

Self-care deficit related to neuromuscular impairment as manifested by impaired ability to perform ADLs.

After 8 hours of nursing intervention patient and the relatives will be able to:

-identify personal/ community resources that can provide assistance as needed.

-able to demonstrate techniques/ lifestyle changes to meet self care needs.

-perform self-care activities within level of own ability.

-Monitor V/S & neurological status.

-Assess abilities and level of deficit (0-4 scale) for performing ADLs.

-Provide positive feedback for efforts and accomplishments.

-Assist the patient in taking a bath.

-Teach the client as well as the relatives about the different techniques/ lifestyle changes in self-care needs.

-For based line purposes and to identified early neurological changes.

-Aids in anticipating/ planning for meeting individual needs.

-Enhances sense of self-worth, promotes independence, and encourages patient to continue endeavors.

-To promote cleanliness and proliferation of bacteria and microorganism in the body.

-To enhance their knowledge about self-care.

After nursing intervention patient and the relatives

identify personal/ community resources that can provide assistance as needed,

demonstrate techniques/ lifestyle changes to meet self care needs, and

perform self-care activities within level of own ability.

ASSESSMENT NURSING DIAGNOSIS PLANING INTERVENTION EVALUATION

Objective:-cough/ Gag reflex-presence f phlegm-with NGT-with IVF-Lethargic-BP=150/90-Temp=37.6-RR=101-PR=19-GCS=11

Risk for aspiration related to reduce level of consciousness and contraptions.

After an hour of nursing intervention, the presence of gag reflex will lessened and fluids will be able to pass with ease.

Frequent suctioning to remove secretions and clear the airways.Maintain operational suction equipment at bedside.Refrain from using oxygen mask.Auscultate lung sounds frequently to determine presences of secretions/silent aspiration.Ascertain that feeding tube is in correct position.

After an hour of nursing intervention, the presence of gag reflex is lessened. Fluids was able to pass with ease as reported by the relatives.

Medical ManagementDrug Study

Name of Drug Contraindication Side Effect / Adverse Reaction Nursing Responsibility

Ranitidine Hydrochlorite >Zantac

Cirrhosis of the liver, impaired renal or hepatic function

GI – constipation, coma, diarrhea, abdominal painCV – bradycardia or tachycardia

Give antacids for gastric pain although they may interfere with ranitidine absorption

No dilution is required for IM use

Vascor Patients with known hypersensitivity to ACE inhibitors

dry cough, discomfort in the throat, headache and rash should not be given during pregnancy as it may cause fetal/neonatal morbidity or mortality

Clonidine Hydrochloride>Catapress

Epidurally : Presence of an injection site infection, clients on anti coagulant therapy, in bleeding diathesis.

CV – CHF, severe hypotension, postural hypotension, sinus bradycardia

GU – Impotence, urinary retension, loss of libido, nocturia

Don’t use preservatives when given epidurally

If drug is to be discontinued, do so gradually over a period of 2-4 days.

Paracetamol>Aeknil

Nephropathy Skin eruption, hematological toxicity Many OTC and prescription products contain acetaminophen, be aware of this when calculating total daily dose.

Ceftriaxone Sodium>Rocephin

Use cautiously in breastfeeding women and in patient with history of renal insufficiency

CV – PhlebitisGU – CandidiasisSkin – Pain, induration

Obtain specimen for culture and sensitivity test before giving first dose

If large doses are given, therapy is prolonged, or patient is at high risk, monitor patient for signs and symptoms of infections

Exforge Hypersensitivity to amlodipine besylate and valsartan or to any of the excipients

GI - Diarrhea, nausea, abdominal pain, constipation, dry mouth.

Vascular – HypotensionUrinary - polyuria.

Increase fluid intake

Acetaminophen>Paracetamol

Contraindicated to patients with hypersensitivity to drug

Use cautiously in patients with long term alcohol use.

Jaundice, hemolytic anemia, rash, hypoglycemia Many OTC and prescription products contain acetaminophen, be aware of this when calculating total daily dose.

NaCl Contraindicated in patients with conditions in which sodium and chloride administration is detrimental

Abscess, local tenderness, thrombophlebitis Monitor electrolyte levels

Dextromethorphan hydrobromide>Delsym

Persistent or chronic cough or when cough is accompanied by excessive secretions

Dizziness, drowsiness, stomach pain Avoid tasks that require mental alertness until drug effects realized

Atorvastatin calcium>Lipitor

Active liver disease Headache, paresthesia,asthenia,insomnia,muscle pain Give as single dose at any time of the day, w/ or w/o food

Eye Lubricant>Tears natural

Possible adverse effects of carboxymethyl cellulose and other similar lubricants include eye pain, irritation, continued redness, or vision changes

Do not use ocular lubricant if you have a bacterial, viral, or fungal infection in the eye

Senekot Acute surgical abdomen, abdominal pain, nausea, vomiting or symptoms of appendicitis; intestinal hemorrhage or obstruction, persistent diarrhea

Mild abdominal discomfort; diarrhea w/ excessive loss of water & electrolytes

The effectiveness or the toxicity of other drugs may be intensified when stimulant laxatives are overused

Clopidogrel bisulfate>Plavix

Contraindicated in patients hypersensitive to drug or its components and in those with pathologic bleeding

Use cautiously in patients at risk for increased bleeding from trauma, surgery, or other pathologic conditions.

Depression, dizziness, fatigue, edema, epistaxis, UTI,rash

Platelet aggregation won’t return to normal for at least 5 days after drug has been stopped.

dexamethasone>Decadron

Contraindicated in patients hypersensitive to drug or its ingredients.Use with caution in patient with recent MI

Insomnia, vertigo, headache, cataract, glaucoma , edema,

Determine whether patient is sensitive to other corticosteroids

Bisacodyl> Dulcolax

Contraindicated in patients hypersensitive to drug or its components and in those with rectal bleeding.

Dizziness, faintness, electrolyte imbalance, hypokalemia Before giving for constipation, determine whether patient has adequate fluid intake

Stugeron Patients with known hypersensitivity to cinnarizine.

headache, dry mouth, weight gain, perspiration or allergic reactions

Do not give to patient which is allergic to cinnarize

Osmitrol>Mannitol

Contraindicated to patients hypersensitive to drug

Blurred vision, urine retention, edema, headache Monitor VS, including central venous pressure and fluid intake and output hourly.

Clomipramine hydrochloride

>Placil

Use cautiously in patients with history of seizure disorders or with brain damage

Dry mouth, constipation, pharyngitis, nausea Monitor mood and watch for suicidal tendencies.Allow patient to have only minimal amount of drug

Treatment

O2 therapy – to provide constant flow of oxygen into the bodyNo open flame or combustible products should be permitted when oxygen is in use

Nebulizer - device used to administer medication to people in the form of a mist inhaled into the lungsMake sure to measure the right amount of medicine that will be put into the medication cup

NGT - Nasogastric tubes are used for diagnostic, therapeutic, preventative, and feeding purposesDo not insert NGT to patients who have trauma to the jaw, base of skull and neck

CT SCAN - used to image a wide variety of body structures and internal organsAssess for allergic reactions to contrast medium, encourage client to drink fluids if not contraindicated

DietRice,chicken,fish and shrimpLow Fat and Salt Diet

Evaluation

M-Medication- the patient is still presently confined within the hospital therefore no medications to be taken at home and given yet.

E-Exercise – the patient was referred/recommended for therapy. For vascular function patient’s legs should be elevated to promote venous return to the heart. Leg exercise; flexion and extension of the feet. For cardiac function; high fowlers position to decrease ICP (Intra-Cranial Pressure) and reduce pulmonary congestion

T-Treatment – the patient was prescribed to be oxygenated at 2-3L, for nebulization, NGT, CT SCAN and therapy

H-Health Teaching – it is important to discuss that maintaining a normal weight through diet and exercise is essential to lower the risk of hypertension. Cholesterol level should be screened regularly to monitor for a hyperlipidemia

D- Diet – the patient is advised to take low fat low salt diet, no beef and no pork. This is important to maintain or decrease cholesterol level and weight