Download - Cerebrovascular Accident case pres.ppt
““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