kyei full content

7/31/2019 Kyei Full Content

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CHAPTER ONE

ASSESSMENT OF PATIENT/FAMILY

Assessment is the first stage of the nursing process. It involves gathering information about

the clients health. The data is collected systematically through interview, observations, and

investigations. Analysis is then made to help identify clients health problems for

intervention.

Patients particulars

Madam H.A is sixty two (62) years old, born on 1 st January, 1949 to the late Opanin K.D and

Madam A. A. She is the first born among eight siblings; three males and five females.

She comes from Atwima- Koforidua in Atwima Nwabiagya District in the Ashanti Region.

She stays at house number KD 16, Koforidua. She speaks only Twi. She is married to Mr. K.

A and has five children with him.

Madam H.A is 165cm (1.65m) in height, 62kg in weight, and fair in complexion. She is an

Asante by tribe. She is a trader (plantain and yam seller). She is a Christian and attends Christ

Apostolic Church. Her next-of-kin is Miss K, a sister, who lives in the same house with her.

She has given birth to five children, three of them are male and the two are female. Madam

H.A possesses National Health Insurance that assists her in paying some of her hospital bills.


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Familys medical Socio-economic history

Family medical history consists of information about disorders from which the direct blood

relatives of the patient have suffered from. This helps identify a predisposition to develop

certain illnesses.

According to the patients sister, Miss K, the family has no history of Asthma and Sickle Cell

Disease but there is a known member who experienced hypertension and Diabetes Mellitus in

the family. Madam H.A is also known to be a hypertensive patient. There are no chronic

infectious diseases as well as mental illness in the family.

Madam H.A lives with two of her children and her sister. She is a trader and uses her income

to support her family. Her son who is also in USA supports the family with some sum of

money. In addition to these, she receives remittances from her husband who is a farmer. She

does neither smokes nor drinks alcohol or any other narcotic.

Patients developmental history

According to clients sister, client was born spontaneously per vagina. The delivery was

conducted by Traditional Birth Attendant (TBA). There were no complications but she could

not state the month and the date on which client was born. However, she stated that client was

born in 1949. All medical records at the hospital have 1st

January as her birthday.

Development is the quantitative change in an individual where there is an increase in skills or

ability to perform a task.


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Client started schooling when she was seven (7) years at Koforidua Elementary School but

stopped in class three for personal reasons known to her. She helped her family in farming

until where she was engaged in plantain selling with support from her late father when she

was in her teens. She has not suffered any serious illness that might have retarded her

development. She is currently married and has given birth to three male and two female

children.

Patients lifestyle and hobbies

Madam H.A usually sleeps at 10pm and wakes up at 5:00am to begin her household chores.

She has her regular bowel movement twice daily and she maintains her personal hygiene

twice daily. She is not used to making friends. She usually has her siesta between 12:00pm

and 1:00pm when she is less busy. She neither takes alcohol nor smokes. She listens to local

music from radio during hours of leisure.

On Saturdays she visits their farm with her husband to harvest food products for the rest of the

weeks. She also attends church services on Sundays.

Madam H.A takes in normal diet with fufu as her favourite food. She likes koko and koose in

the morning and rice and stew in the afternoon whilst fufu and palm-nut soups in the

evenings.


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Patients past medical history

According to clients sister, she is not a known Sickle Cell Disease patient, neither is she a

diabetic nor asthmatic. The sister confirmed that client was a hypertensive and she (client)

does not take salt. Client has been on admission at Nkawie- Toase Government Hospital on

the basis of hypertension. She has not been operated before. She is not on drug for any

chronic disease but was on hypertensive drugs and she has no allergies. She and her family

also take over the counter drugs for minor ailments like headache, abdominal pains, to

mention but a few.

Patient s present medical history

Client was well until 16 th November, 2011 when in an attempt to take her bath suddenly she

experienced inability to walk and collapsed. She was immediately taken to Kwadaso S.D.A

Hospital where she was given Sublingual Nefidipine 10mg stat and Intravenous infusion to

manage hypertension and to correct fluid and electrolyte imbalance respectively. She was

later referred to the Accident and Emergency unit of Komfo Anokye Teaching Hospital for further

management. At Komfo Anokye Teaching Hospital, she was diagnosed of Cerebrovascular

Accident with Right Sided Hemiplegia secondary to hypertension by Dr. A and was given

Tablet Lisinopril 10mg daily and Nifecard 30mg daily.


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Admission of patient

Client was admitted to ward D5 of Komfo Anokye Teaching Hospital on a trolley through

Medical Emergency Unit at Accident and Emergency Center on 16 th November, 2011 at

8:35am. She presented with a history of sudden collapse and inability to talk. She was

diagnosed of Cerebrovascular Accident with right hemiplegia secondary to hypertension. She

was under the care of team C doctors headed by Dr. A. She was admitted onto already

prepared admission bed. Her vital signs were checked and recorded as follows:

Temperature : 37.3 Degree Celsius

Pulse : 62 beats per minutes

Respiratory : 36 cycle per minutes

Blood Pressure : 180/100 millimeters of mercury

Client was put on Tablet Lisinopril 10mg daily for thirty days. The first dose was served at

the Medical Emergency Unit. Blood sample was taken for the following investigations;

haemoglobin level estimation, White blood cell count, blood urea and nitrogen and creatinine

level estimation.

Client and the relatives were reassured of competent staff. The patient was orientated to the

ward and wards protocols were also explained to the patient. Client and the relatives were

educated on the condition and the importance to register for the National Health Insurance

Scheme. In the presence of the client, her relatives were informed of visiting hours.

Appropriate documentations were done in the admission and discharge book, daily ward state,


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and in the nurses notes. Client and her relatives were educated on Stroke with right

hemiplegia (Cerebrovascular Accident).

Patients concept of her illness

Madam H.A and her family did not know the cause of her illness. They were also anxious of

the outcome of the disease and hospitalization.

LITERATURE REVIEW ON CEREBROVASCULAR ACCIDENT

Cerebrovascular Accident (CVA) also known as Stroke or Apoplexy is a condition that

produces sudden neurological signs and symptoms and paralysis as a result of rapture of a

cerebral blood vessel or occlusion by a blood clot leading to disruption of blood supply to the

brain tissue and death of brain cells.

Incidence

It is considered often as disease of the aged because approximately 60-75% of all CVA cases

occur in persons over 65 years of age. Young people occasionally sustain CVA because of

trauma to cerebral blood vessels, inflammatory disorders of arteries of the brain, or congenital

vascular anomalies. CVA is a major public health problem in terms of mortality and

permanent disability. In United States, it is ranked third among all causes of death.

TYPES OF STROKE

1. Ischaemic stroke: It is a sudden loss of function resulting from disruption of blood

supply to a part of the brain. It is caused by either an embolus or a thrombus.


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A. Embolic: It has sudden onset and sometimes can be transient

B. Thrombolic: It has gradual onset. It is the most common cause and is

usually due to atherosclerosis.

2. Haemorrhagic stroke: It has a sudden onset. It occurs from ruptured secular

aneurysm or as a result of ruptured cerebral blood vessel secondary to hypertension or

subarachnoid haemorrhage.

SPECIFIC CAUSES OF STROKE

1. Cerebral haemorrhage: Rupture of the blood vessel that produces haemorrhage

into the brain tissue. It is common in cases of hypertension.

2. Cerebral thrombosis: It is most common cause of stroke. The cerebral arteries

are affected by arteriosclerosis; in which the lumen of the arteries becomes

thickened and rough. The flow of blood is obstructed and clotting occurs. This

clot blocks the artery and deprives part of the brain of its blood supply.

3. Cerebral embolism: An embolic or detach clot may lodge in one of the cerebral

arteries to cause obstruction and once there is obstruction, there will be no blood

flow and brain cells die.

Predisposing (risk) factors of stro ke

1. Hypertension

2. Diabetes Mellitus

3. Heart Disease

4. Cigarette Smoking


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5. Excessive Alcohol Intake

6. Obesity

7. Family History of Stroke

8. Ageing

9. Emotional Stress

10. Polycythaemia

11. Use of Oral Contraceptive

Pathophysiology of stroke

When the blood vessel supplying an area of the brain is blocked by an embolus, thrombus, or

ruptures, ischaemia of brain tissue occurs. This leads to hypoxia, anoxia, and hypoglycaemia.

The affected part of the brain produces neurological dysfunction and paralysis. If ischaemia

persists, necrosis of the deprived area follows. The infarcted area eventually liquefies and is

absorbed and neurological defects remain. Since the cerebral hemisphere controls the contra

lateral side of the body, damage to the left hemisphere produces paralysis in the right side of

the body and vice versa.

Clinical features

1. Dysphasia

2. Paraesthesia

3. Diplopia

4. Blurred vision

5. Dizziness

6. Visual field cut


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7. Hostility

8. Forgetfulness

9. Difficulty in comprehension

10. Anxiety

11. Depression

Diagnostic investigations

1. Lumbar puncture reveals bloody cerebrospinal fluid in haemorrhagic stroke.

2. Computed tomography scan of the brain shows ischaemic areas of the brain or

reveals evidence of haemorrhage or isolate structural abnormalities.

3. Magnetic Resonance Imaging helps to identify lesion occupying areas.

4. Angiography outlines blood vessels and pinpoints occlusion or ruptured sites.

5. Electroencephalogram may show low-voltage, slow waves in ischaemic

infarction. If haemorrhage, it may show high-voltage but slow waves.

6. Other investigations may include urinalysis, coagulation studies, complete blood

count, and serum osmolarity, and electrolyte, Creatinine and urea nitrogen level.

Medical treatment

Medical treatment includes dietary management, physical rehabilitation, and drug regimen to

help reduce risk factors. Drugs useful in stroke include;

1. Antihypertensive example Nefidipine to reduce hypertension

2. Analgesics example Paracetamol to control headache

3. Anticoagulant example Heparin to prevent further development of thrombosis and

embolism.


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4. Antiplatelet example Aspirin to prevent clotting and reduce risk of recurrent

stroke after treatment has begun.

5. Corticosteroids example Dexamethasone to minimise associated cerebral oedema.

6. Anticonvulsants example Phenytoin to treat seizures.

7. Stool softeners example Sulfocuccinate to avoid straining which increases

intracranial pressure.

8. Haematinics example Folic Acid to help in red blood cell formation to reverse the

effect of antibiotic therapy in decreasing red blood cell production.

9.

Antibiotic example Capsule Amoxicillin to prevent risk of infection.10. Mild sedatives example diazepam to help reduce restlessness.

Specific surgical treatment

One of the following surgical procedures can be carried out depending on the cause of stroke

Craniotomy to help reduce haematoma.

Endoarterectomy to help remove arteriosclerosis plaques from inner arterial wall

Intracranial bypass to circumvent an artery that is blocked or ventricular shunt may be

done to drain cerebrospinal fluid.


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NURSING MANAGEMENT

1. Psychological care

The goal of psychological care is to gain clients cooperation during procedures. Reassure

client and relatives of competent staff and availability of instrument for her care. Explain

every procedure to client and relatives to allay fears and anxiety. Introduce client to other

client who are doing well with similar condition to build their hope of client recovery. Allow

client to express feelings and clear any misconceptions. Permit client spiritual leader to visit

client, pray and share words of encouragement with her.

2. Rest and sleep

Adequate rest and sleep is of importance in client whose physical mobility is impaired. Ensure

rest and sleep by providing comfortable bed free from creases and cramps. Change soiled

linen to clean ones. Minimize noise by turning down the volume of television and radio set

and staff should communicate in low tone. Open nearby windows to improve ventilation

when weather is warm or close windows when weather is cold. Provide dim light and serve

warm drinks to induce sleep. Avoid painful procedures, such as giving of injection at the time

of sleeping. Restrict stress producing visitors.

3. Position

Put client in a position not contraindicated to her condition. Place patient in semi-lateral

position supported with pillows and the head turned to the affected part to allow client use the

unaffected part for minimal activities. Provide foot board to prevent feet from dropping.

Elevate the head of bed to about 30 degrees after patient has gained consciousness to reduce


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intracranial pressure. Turn patient two hourly and treat pressure areas four hourly to prevent

the development of bed sores.

4. Personal hygiene

Give client bed bath twice with warm water. Care for clients mouth twice daily with paste

and brush. Treat clients pressure areas four hourly to prevent bed sores. Keep finger and toe

nails short and clean to prevent them from harbouring microorganisms and prevent patient

from injuring herself. Clean clients hair every other day to prevent lice infestation.

5. Observation

Monitor vital signs (temperature, pulse, respiration, and blood pressure) every four hours

paying particular attention to blood pressure. If client is on intravenous infusion, check the

flow rate and make sure it is at the prescribed flow rate. Check cannular site for swelling,

blockage by a blood clot. Discontinue intravenous line if any occurs and inform the nurse in

charge. Maintain accurate intake and output chart to know the amount of fluid gain or loss.

Check patients level of consciousness and orientation to time, place, and person by

mentioning her name for response, asking her time of day, where she is, and who the

caregiver is. Observe for desired and side effects of drugs. If serious side effect occur, report

to the doctor and nurse in charge and document in the nurses notes.

6. Nutrition

Assess the ability of client to swallow oral food to determine the convenient way to feed. Plan

diet with client and dietician taking into consideration her likes and dislikes. If client is

unconscious, feed per nasogastric tube. Administer prescribed intravenous fluid to maintain


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fluid and electrolyte balance. When condition improves, give normal diet containing right

proportion of carbohydrate for energy, protein for repair of worn out tissue, vitamin to

improve immunity, minerals to maintain electrolyte balance, roughage for free bowel

movement, and low fats and oil. Diet should be low in salt and cholesterol to prevent oedema

and arteriosclerosis. Prior to feeding, remove nauseating substances from clients vicinity.

Avoid painful procedures. Give fluid juice and serve food in bits to stimulate appetite.

7. Exercise

Initiate exercise based on clients tolerance and ability. Begin passive exercise to promote

circulation, prevent joint stiffness and muscle wasting. Encourage and assist client to exercise

the unaffected extremities to prevent impairment in function. Exercise the affected part

supported by the unaffected part. Invite the physiotherapist to take patient through range of

motion exercises.

8. Protection from injury

Nurse client on a low bed with fracture board under the mattress to maintain body alignment.

Provide bed rails to prevent client from falling. Provide pillows to elevate the affected part.

Place items needed by client within her reach. Remove sharp instruments example blade from

within clients reach to prevent it from in juring the client. Keep floor dry to prevent client

from falling when she begins ambulating. Keep client finger and toe nails short and clean to

prevent client from injuring herself.


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9. Elimination

Provide client with bed pan on request or when needed. In case of constipation, encourage the

client to take copious fluids and high roughage diet. Encourage and engage client in passive

exercise to promote free bowel movement. If there is retention of urine, apply warm

compresses to the supra pubic area, open nearby tap, and serve warm beverage drinks to

stimulate client to urinate. If these measures fail, pass urethral catheter to drain urine.

10. Education

Educate client and relatives on the causes, signs and symptoms, and complications of stroke.

Educate client and relatives on drug regimen and the need to take the full course of drugs.

Explain side effects of drugs and coping mechanism to them. Educate and encourage the

intake of low salt and low cholesterol diet. Advice was given to client on the need to avoid

alcohol intake if she is a drunkard. Inform client to report any signs and symptoms to the

doctor for prompt treatment. Document date of follow up for the client and emphasize the

need for follow up.

COMPLICATIONS

1. Paralysis

2. Seizures

3. Hypostatic pneumonia

4. Contractures

5. Neuropathy


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PREVENTION

1. Avoid smoking and alcohol intake.

2. Ensure regular checkups especially the blood pressure and weight.

3. Avoid or minimize stress.

4. Ensure regular exercise.

5. Control weight by reducing fat intake.

6. Avoid excessive intake of oral contraceptive.

7. Reduce intake of sodium and cholesterol diet.

VALIDATION OF DATA

The literature on the condition was compared with the signs and symptoms exhibited by the

client and doctors findings. Laboratory investigations were also compared with standard.

There are no variations in the data from the sources indicating that information gathered for

this study was accurate, valid and free from errors.


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CHAPTER TWO

DATA ANALYSIS

Data analysis is the second stage of the nursing process. It involves the separation of

information to its constituent parts. Data analysis comprises comparison of data to standard,

clients strength, health problem, and nursing diagnosis. This helps to plan care for client.

COMPARISON OF DATA WITH STANDARD

This deals with comparing information gathered from client to standard to help determine any

deviation from normal. This includes comparison of diagnostic investigations, causes, clinical

features, treatment, and complications.


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TABLE ONE: DIAGNOSTIC INVESTIGATIONS/TESTS

DATE SPECIMEN INVESTIGATION RESULTS REFERENCE

RANGE

INTERPRETATION REMARKS

16/11/11 Blood Haemoglobin level

estimation

14.0g/Dl Male:12.0-

18.0g/dL

Female:11.0-

16.0g/dL

Within normal range.

Client was not

anaemic.

No treatment was

given.

16/11/11 Blood White Blood Cell

Count

6.7x10/Ul 2.6-8.5x10u/L Within normal range.

Client had no

infection.

Antibiotics were given

to prevent infection.

16/11/11 Blood Urea and nitrogen

level

5.02mmol/L 2.50-

8.30mmol/L

Within normal range.

There was no renal

dysfunction.

No treatment given.

16/11/11 Blood Creatinine level 50umol/L 44-106umol/L Within normal range.

No renal dysfunction.

No treatment given


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CAUSES OF CLIENTS CONDITION

With reference to the literature review, the cause of Cerebrovascular Accident (stroke)

includes; embolism, thromboembolism, haemorrhage into the brain and others. The risk

factors also include; hypertension, diabetes mellitus, heart diseases etc. In the case of Madam

H.A, her condition was caused by cerebral thrombosis.

TABLE TWO: CLINICAL FEATURES

CLINICAL FEATURES INDICATED

IN THE LITERATURE

CLINICAL FEATURES EXHIBITED

BY CLIENT

1. Dysphasia Client experienced dysphasia

2. Paraesthesia Client experienced paraesthesia

3. Dizziness Client experienced dizziness

4. Blurred vision Client experienced blurred vision

5. Diplopia Client did not experience diplopia

6. Hemiplegia Client experienced right sided hemiplegia

7. Ataxia Client experienced ataxia

8. Dysphagia Client did not experience dysphagia

9. Forgetfulness Client did not exhibit forgetfulness

10. Anxiety Client was anxious

11. Depression Client was not depressed


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TREATMENT

With particular reference to the literature review, the following specific drugs were prescribed

for the client.

1. Tablet Lisinopril 10mg daily x 30

2. Tablet Methyldopa 250mg tds x 30

3. Tablet Amlodipine 10mg daily x30

4. Tablet Bendrofluazide 2.5mg daily x 30

5. Intravenous Metronidazole 500mg tds x 3

6. Intravenous Cefuroxime 1.5g stat, then 750mg tds x 3

7. Tablet Metronidazole 400mg tds x 5

8. Tablet Cefuroxime 500mg tds x 5

9. Artemeter lumefantrine 35mg bd x 3


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TABLE THREE: PHARMACOLOGY OF DRUGS PRESCRIBED FOR CLIENT

DATE DRUG DOSAGE AND

ROUTE OF

ADMINISTRA-

TION

ACCORDING TO

LITERATURE

DOSAGE AND

ROUTE OF

ADMINISTRA-

TION GIVEN TO

CLIENT

CLASSIFICATION DESIRED EFFECT ACTUAL

ACTION

OBSERVED

SIDE

EFFECTS

AND

REMARK

16/11/11 Tablet

Lisinopril

Dose

Adult: 10mg-40mg

Child: 0.07mg-

5mg /day

Route: Oral

10mg daily x 30

days orally

Antihypertensive

(Angiotensin

Converting Enzyme

Inhibitor)

Reduces peripheral

resistance and

decreases blood

pressure

Clients blood

pressure

reduced

gradually.

Headache

Dizziness,

postural

hypotensio

None

observed i

client.

17/11/11 Tablet

Methyldo

pa

Dose

Adult: 0.5-3g/day

Child: 10-

65mg/kg/day

Route: Oral

250mg tds x 30days

orally

Antihypertensive

(Centrally acting

Alpha-agonist)

Stimulates alpha-

adrenergic receptor in

the cardiovascular

centers in the central

nervous system

Clients blood

pressure

reduced

gradually.

Impaired

memory,

Depressio

nasal

congestion


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reducing blood

pressure.

None was

exhibited

client.


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DATE DRUG DOSAGE AND ROUTE

OF

ADMINISTRATION

ACCORDING TO

LITERATURE

DOSAGE AND

ROUTE OF

ADMINISTRA-

TION GIVEN

TO CLIENT

CLASSIFICATION DESIRED

EFFECT

ACTUAL

ACTION

OBSERVED

SIDE

EFFECTS

AND

REMARK

17/11/11 Tablet

Amlodipi

ne

Dose

Adult: 2.5mg,5mg,

10mg/day

Child: 2.5mg-5mg/day

Route: Oral

10mg daily x 30

days orally

Antihypertensive

(Calcium Channel

Blocker)

Dilates coronal

arteries,

peripheral

arteries/arteriole

reducing blood

pressure.

Clients blood

pressure reduced

gradually.

Peripheral

oedema,

Headache

Flushing.

Client did

not

experience

any of the

17/11/11 TabletBendroflu

azide

DoseAdult:

2.5mg,5mg,10mg/day

Child: 50 micrograms -

100 micrograms/kg/day

Route: Oral

2.5mg daily x 30days orally

Thiazides diuretics Reduces bloodpressure with

very little

biochemical

disturbance.

Clients bloodpressure reduced

gradually.

Posturalhypotensio

Hypokalae

mia. N

observed

client.


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OF

ADMINISTRATION

ACCORDING TO

LITERATURE

DOSAGE AND

ROUTE OF

ADMINISTRA-

TION GIVEN

TO CLIENT


EFFECT

ACTUAL

ACTION

OBSERVED

SIDE

EFFECTS

AND

REMARK

18/11/11

and

20/11/11

Metronid

azole

Dose

Adult: 400mg, 500mg

Child: 7.5mg/kg

Route:

Oral, Intravenous (IV)

Intravenous

500mg tds x3

days

Oral

400mg tds x 5

days

Antibiotic Disrupts DNA,

inhibiting

nucleic acid

synthesis by the

bacterial

Client was

infected

throughout

admission.

Anorexia,

nausea, dr

mouth,

metallic

taste,

anaemia.

None was

experience

by client.18/11/11

and

20/11/11

Cefuroxi

me

Dose

Adult: 750mg-2g

Child: 60mg/kg

Route:

Oral, Intravenous.

Intravenous

1.5g stat, then

750mg tds x

3days

Oral

Antibiotic Binds to bacteria

cell membranes,

inhibiting cell

wall synthesis to

prevent

infection.

Client was

infected

throughout

hospitalization.

Nausea

vomiting,

headache,

dizziness.


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Tablet 500mg

tds x3days

None

observed

client


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OF

ADMINISTRATION

ACCORDING TO

LITERATURE

DOSAGE AND

ROUTE OF

ADMINISTRA-

TION GIVEN

TO CLIENT


EFFECT

ACTUAL

ACTION

OBSERVED

SIDE

EFFECTS

AND

REMARK

18/11/11 Tablet

Artemeter

lumefan-

trine

Artemeter 20mg +

Lumefantrine 120mg

Recommended Dosing

Regimen

5-14kg 20/120bd x 3 days

15-24kg 40/240mg bd x 3

days

25-34kg 60/360mg bd x 3

days35 and above 80/480mg

bd x 3 days

600/480mg bd x

3 days

Antimalaria Inhibits nucleic-

acid and protein

synthesis within

the malaria

parasite.

Client did not get

malaria

throughout

hospital.

Anorexia,

headache,

fatigue,

dizziness.

Client

experience

none of

them.


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COMPLICATIONS

Client did not develop any of the complications outlined in the literature. This is due to well

coordinated and executed medical and nursing interventions and clients compliance with

treatment.

PATIENT/FAMILY STRENGTHS

This explains the ability of client and her family members to help in the achievement of goals set

for quick recovery.

Client and the relatives were cooperative with the health team in rendering care to her. They

visited client twice daily; morning and evening as per protocol of the hospital. They do bring

food and other items that might be needed by client. They also pray and share words of

encouragement with her.

Client was a National Health Insurance Scheme (NHIS) beneficiary, so they were able to pay her

hospital bill on discharge.

The son who is in abroad also assisted the care of client by providing financial support which

enables her pay her bills and other necessities.

In addition, client receives support from family members which enables her in the entire stay in

the hospital for treatment.


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HEALTH PROBLEMS

From the data collected from the client, the following health problems were identified.

16/11/2011

1. Client and her relatives were anxious

17/11/2011

2. Client could not perform personal hygiene.

17/11/2011

3. Client could not feed herself.

18/11/2011

4. Client was constipated.

19/11/2011

5. Client was prone to bed sore.

22/11/2011

6. Client could not sleep.

22/11/2011

7. They had little knowledge about stroke.


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NURSING DIAGNOSIS

Nursing diagnosis is actual or potential health problem identified by the nurse which can be

managed by nursing intervention.

1. Anxiety related to unknown outcome of disease condition.

2. Self care deficit related (bathing, grooming, hair care, nail care) related to right sided

hemiplegia.

3. High risk for nutritional deficit related to weakness.

4. Altered bowel movement (constipation) related to change of environment.

5. High risk for impaired skin integrity (bed sore) related to confinement to bed.

6. Sleep pattern disturbances (insomnia) related to change of environment.

7. Knowledge deficit on Cerebrovascular Accident related to lack of information.


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CHAPTER THREE

PLANNING FOR PATIENT/ FAMILY CARE

Planning, the third stage of the nursing process involves objectives and outcome criteria and

outlined nursing strategies that will be instituted to aid speedy recovery of client. It also means

putting in place measures to deal with clients health problem s.

OBJECTIVES / OUTCOME CRITERIA

1. Client and the relatives will be relieved of anxiety within 24 hours as evidenced by client

and the relatives interacting freely with other clients and staff on the ward and verbalizes

that they are no more anxious.

2. Client personal hygiene will be maintained throughout the period of hospitalization as

evidenced by:

a. Client looking neat and well groomed in bed everyday

b. The nurse observing that clients finger and toe nails are kept short and neat.

3. Client will maintain her nutritional status throughout the period of hospitalization as

evidenced by:

a. The nurse observing that client is able to eat.

b. Client maintaining her weight when weighed

4. Client will be able to empty her bowel freely within 24 hours as evidenced by:

a. The nurse observing that client is able to empty her bowel after she was served with

bedpan.


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b. Client verbalizes of her ability to empty her bowels.

5. Client will not develop bedsore throughout the period of hospitalization as evidenced by

client having intact skin on the day of discharge observed by the nurse.

6. Client will be able to sleep at least 5-8 hours within 24 hours as evidenced by:

a. Night nurses report confirming that client slept well without disturbance

b. Client verbalizes that she is able to sleep.

7. Client and her relatives will have insight into Cerebrovascular Accident within 24 hours

as evidenced by client and the relatives being able to give adequate feedback to questionsasked after education.


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and her relatives to

wards

environment.

5. Engage client in

diversional

therapy.

4. Ward staffs were introduced

to client and the relatives.

They were also shown places

of convenience and wards

protocols were explained to

them.

5. Client was made to watch

television and listen to radio to

allay anxiety.


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DATE/

TIME

NURSING

DIAGNOSIS

OBJECTIVE/

OUTCOME

CRITERIA

NURSING

ORDERS

NURSING

INTERVENTIONS

DATE/

TIME

EVALUA

TION

SIGNA

TURE

17/11/11

8:00am

Self care

deficit

(bathing,

grooming, hair

care, nail care)

related to

weakness.

Clients

personal

hygiene will be

maintain

throughout the

period of

hospitalization

as evidenced by

a. Client

looking neat

and well

groomed in bed

everydayb. The nurse

observing that

clients finger

and toe nails are

kept short and

neat.

1. Reassure client.

2. Do skin

assessment.

3. Bath client with

warm water.

4.Care for clients

mouth

1. Client was reassured that

measures would be put in

place to help her maintain her

personal hygiene.

2. Clients skin was assessed to

rule out skin abnormalities and

things needed for the bed bath.

3. Client was bathed twice

daily with warm water

preferred by her. Client was

groomed to enhance neatnessand comfort.

4. Clients mouth was cared

for twice daily with paste and

brush to prevent mouth

abnormalities and other

23/11/11

4:00pm

Goal fully

met as

client

looked

neat each

day on

admission.


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34

5.Keep clients

finger and toe nails

short and clean

6. Wash clients

hair.

infections.

5. Clients finger and toe nails

were kept short and neat to

prevent client from injuring

herself and to prevent

harbouring microorganisms.

6. Client s hair was washed

and covered with a cap to

prevent harbouring

microorganisms.


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DATE/

TIME

NURSING

DIAGNOSIS

OBJECTIVE/

OUTCOME

CRITERIA

NURSING

ORDERS

NURSING INTERVENTIONS DATE/

TIME

EVALUATION SIGNA-

TURE

17/11/11

8:00am

High risk for

nutritional

deficit related

to inability to

feed herself

due to

weakness.

Client will

maintain her

nutritional

status

throughout the

period of

hospitalization

as evidenced

by

a. The nurse

observing that

client is ableto eat.

b. Client

maintaining

her weight

when weighed.

1. Reassure client

and the family

members.

2. Plan diet with

client and the

dietitian

3. Give client

oral care.

4. Give client

fruit juice.

5. Serve food

attractively.

1. Client and the relatives were

reassured that measures will be

instituted to help client maintain

her nutritional status.

2. Diet was planned with client

and dietitian taking her

preferences into consideration.

3. Client was given oral care to

stimulate appetite.

4. Client was given orange juice

prior to feeding to stimulate

appetite.

5. A tray was set a flower vase to

make the food attractive to the

22/11/11

8:00am

Goal fully met as

client maintained

her weight on

discharge.


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36

6. Give food to

client a little at a

time.

client.

6. Client was allowed time for

chewing for easy swallowing and

digestion. Water was given

whenever client desired.


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37

DATE/

TIME

NURSING

DIAGNOSIS

OBJECTIVE/

OUTCOME

CRITERIA

NURSING

ORDERS

NURSING

INTERVENTIONS

DATE/

TIME

EVALUATION SIGNA-

TURE

18/11/11

10:00am

Altered bowel

movement(constipation)

related to

change of

environment.

Client will be

able to empty her

bowel freely

within 24 hours

as evidenced by:

a. the nurse

observing that

client is able to

empty her bowel

after she was

served with bed

panb. Client

verbalizes of her

ability to empty

her bowels.

1. Reassure client.

2. Encourage client

to take copious fluid.

3. Encourage intake

of roughage diet.

4. Encourage and

assist client to


measures would be put in

place to enable her empty her

bowel.

2. Client was encouraged to

take a lot of water, mashed

kenkey, porridge, and orange

juice to help soften the stool.

3. Client was given orange to

eat and was encouraged totake the inner portion for the

stool to form bulky and

facilitate its movement.

4. Client was encouraged and

assisted to perform kegel

18/11/11

6:00pm

Goal fully met as

client was able to

move her bowel

freely when

served with bed

pan.


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38

perform passive

exercises in bed.

5. Serve bed pan on

request.

exercises to enhance

peristaltic movement.

5. A warm bed pan was

served to client on request to

empty her bowel. She was

able to empty her bowels.


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DATE/

TIME

NURSING

DIAGNOSIS

OBJECTIVE/

OUTCOME

CRITERIA

NURSING ORDERS NURSING

INTERVENTIONS

DATE/

TIME

EVALUATION SIGNA

-TUR

19/11/11

9:00am

High risk for

impaired skin

integrity (bed

sore) related to

confinement to

bed.

Client will not

develop bed sore

throughout the

period of

hospitalization as

evidenced by

client having

intact skin on the

day of discharge

observed by the

nurse.

1. Prepare a

comfortable bed.

2. Do skin assessment.

3. Change clients

position two hourly.

4. Treat pressure areas

four hourly.

1. A comfortable bed was

prepared free from creases

and cramps to prevent

pressure on bony

prominences.

2. The skin was assessed to

determine areas which are

prone to bed sore for

immediate intervention.

3. Clients position was

change 2 hourly to maintaincomfort and prevent bony

prominences from pressing on

bed linen for long period.

4. Clients pressure areas

were washed, rinsed, and

23/11/11

4:00pm

Goal fully met as

client had intact

skin without any

sign of bed sore.


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40

5. change bed linen at

regular intervals

6. Massage the

pressure areas.

dried with care and Vaseline

applied to maintain skin

integrity.

5. Bed linens were changed

each morning to enhance

clients comfort.

6. Pressure areas were

massaged to improve blood

circulation to the area in order

to prevent skin breakdown.


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DATE/

TIME

NURSING

DIAGNOSIS

OBJECTIVE/

OUTCOME

CRITERIA


INTERVENTIONS

DATE/

TIME

EVALUATION SIGNA

TUR

19/11/11

10:00pm

Sleep pattern

disturbances

(insomnia)

related to

change of

environment

Client will be

able to sleep for

at least 5-8 hours

within 24 hours

as evidenced by

a. night nurses

report

confirming that

client slept well

without

disturbance

b. Clientverbalizes that

she is able to

sleep.

1. Reassure client.

2. Prepare a

comfortable bed.

3. Give client a warm

bath.

4. Provide a conducive

environment.


she would be able to sleep

with good nursing measures.

2. A comfortable bed was

prepared with clean linen free

from creases and cramps to

ensure her comfort and

promote sleep.

3. Client was bathed with

warm water to induce sleep.

4. Volume of television and

radio sets was turned down

and staff communicated in

low tone to reduce noise.

20/11/11

6:00am

Goal fully met as

client slept for 6

hours indicated by

night nurses

report.


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42

5. Provide client with

a warm beverage.

6. Ensure adequate

ventilation.

5. Warm Milo was given to

client to reduce blood supply

to the brain and induce sleep.

6. Nearby windows were

opened to allow fresh air

inside to induce sleep.


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43

DATE/

TIME

NURSING

DIAGNOSIS

OBJECTIVE/

OUTCOME

CRITERIA


INTERVENTIONS

DATE/

TIME

EVALUATION SIGNA

-TUR

22/11/11

5:30pm

Knowledge

deficit related

to lack of

information on

Cerebrovascula

r Accident.

Client and the

relatives will

have insight into

the literature of

Cerebrovascular

Accident within

24 hours as

evidenced by

client and the

relatives being

able to give

adequatefeedback to

questions asked

after education.

1. Establish good

nurse-client

relationship.

2. Assess client and

the relatives

knowledge.

3. Educate client and

the relatives about

CerebrovascularAccident.

1. Nurse interacted with client

and the relatives to gain their

cooperation.

2. Nurse explored from the

client and the relatives what

they know about

Cerebrovascular accident.

3. The causes, signs and

symptoms, and prevention of

Cerebrovascular Accidentwere explained to client and

the relatives.

23/12/09

4:30pm

Goal fully met as

client and the

relatives were able

to give correct

answers to

questions asked

them after

education.


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44

4. Allow them to ask

questions on areas

they did not get

explanation well.

5. Ask client and the

relatives questions

4. Client and the relatives

asked about the causes of

Cerebrovascular Accident and

they were answered in simple

terms.

5. Series of questions were

asked for feedback to evaluate

their level of understanding.


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45

CHAPTER FOUR

IMPLEMENTING PATIENT/ FAMILY CARE

Implementation, the fourth stage of the nursing process, is the act of carrying out the plan of

care. Nursing care was aimed at relieving client of the condition to prevent complications so that

patient recovers fully.

SUMMARY OF ACTUAL NURSING CARE RENDERED TO PATIENT

DAY OF ADMISSION (16 TH NOVEMBER, 2011).

Madam H. A was admitted to ward D5 of Komfo Anokye Teaching Hospital on 16 th November,

2011, at 8:35am. She was brought in on a trolley accompanied by her sister, Miss K, and two

members of the admission team. She was received onto an already prepared admission bed. After

cross checking information from her folder, admission team members were asked to leave. Her

sister was offered a seat.

Particulars of the client which included her name, age, religion, occupation, marital status, next-

of-kin hometown, and address were taken and cross checked from that of her folder. The

information was recorded in the admission and discharged book and daily ward state.

Her vital signs were taken and recorded as follows;

Temperature : 37.3 degree Celsius

Pulse : 62 beats per minute

Respiration : 36 cycles per minute


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46

Blood Pressure : 180/ 100 millimeters of mercury

Blood sample was taken for full blood count at the Accident and Emergency Unit. Tablet

Lisinopril 10mg daily x 30 was prescribed and the first dose administered at the Accident and

Emergency Unit. Only this drug was prescribed this. All other drugs were prescribed the

subsequent days.

Client and her sister were educated on the disease condition, thus Cerebrovascular Accident.

They were also educated on the importance of registering with the National Health Insurance

Scheme (NHIS).

Client and her sister were informed of visiting hours and the policies and protocols of the ward.

They were reassured of competent staff and appropriate measures to help her recover fully. They

were orientate d to the wards environment. They were informed that the staffs care for them.

The sister of client was asked to go home and come the next day with items client will need for

her stay at the ward. Client was made to sleep in the evening.

SECOND DAY ON ADMISSION (17 TH NOVEMBER, 2011).

According to the night nurses report, client slept well throughout the night. She woke up at

5:30am and was assisted to perform personal hygiene. During visiting hours, her relatives came

with Milo and bread which she was served with. She ate almost everything. Vital signs were

taken and prescribed medication was administered.

During ward rounds, the team of doctors prescribed the following drugs; Tablet Methyldopa

250mg tds x 30; Tablet Amlodipine 10mg daily x 30; Tablet Bendrofluazide 2.5mg daily x 30.


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47

These drugs were taken from the pharmacy and the first doses were administered at 10:00am.

Four hourly vital signs monitoring continued. Client was served with rice and stew in the

afternoon and kenkey with fish in the evening. After she was assisted to perform her personal

hygiene in the evening, she was made to sleep.

THIRD DAY ON ADMISSION (18 TH NOVEMBER, 2011).

Client woke up at 5:30am. She was assisted to perform personal hygiene. She was served with

porridge and bread for breakfast. Vital signs were monitored and prescribed drugs were

administered.

On ward rounds, team of doctors prescribed Intravenous Metronidazole 500mg tds x 3;

Intravenous Cefuroxime 1.5g stat, then 750mg tds x 3; and Tablet Artemeter lumefantrine

600/480mg bd x 3 days. These drugs were given to prevent the occurrence of infection. The

drugs were collected from the pharmacy and the first doses served at 10:30am.

Client was unable to empty her bowels. She was encouraged to drink water. She was given

orange juice and mashed kenkey to help her empty her bowels freely. After two hours, she was

served with bed pan and she was able to pass stool. She was served with banku and okro stew for

lunch.

In the evening, she was served with rice and beans stew. She was assisted to perform personal

hygiene and was made comfortable to sleep.


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48

FOURTH DAY ON ADMISSION (19 TH NOVEMBER, 2011).

Client woke up as usual at 5:30am. She was assisted to perform her personal hygiene. She was

served with tom brown for breakfast. Vital signs were monitored and prescribed medications

were administered.

She was turned in bed every two hours and pressure areas were cared for every four hours to

maintain skin integrity. In the afternoon, she was served with yam and kontomire stew. Four

hourly vital signs monitoring and medications continued.

In the evening, she was given rice and stew. She was assisted to perform her personal hygiene.

During sleep hours client was having difficulty in sleeping as indicated by night nurses report

the previous night. She was given warm beverage, nearby windows were opened to provide

ventilation, and a quiet environment was ensured to enable her to sleep.

FIFTH DAY ON ADMISSION (20 TH NOVEMBER, 2011).

A report on client indicated that she slept well during the night. She woke up as usual. She was

assisted to perform personal hygiene. She ate porridge and bread for breakfast. Vital signs were

monitored and recorded. Prescribed medications were administered.

During ward rounds, she was reviewed by team of doctors and they prescribed the following

drugs; Tablet Metronidazole 400mg tid x 5and Tablet Cefuroxime 500mg bid x 5. The drugs

were collected from the pharmacy and administered as ordered. The doctors also requested for

service of physiotherapist. She ate banku with soup.


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49

In the evening, she was assisted to maintain personal hygiene. She ate rice water after which she

was made to sleep.

SIXTH DAY ON ADMISSION (21 ST NOVEMBER, 2011).

Client woke up at 5:30am as usual. She was assisted to perform her personal hygiene. Vitals

were monitored and recorded. She ate almost all her breakfast thus tom brown and bread.

Prescribed drugs were administered.

Two members from the physiotherapy department of the hospital attended to her and took her

through range of motion exercises. She was served with rice ball with soup during lunch.

In the evening, she was served with fufu with soup prepared from the house. She was assisted to

maintain personal hygiene. Vital signs were monitored and recorded. Prescribed drugs were

administered. She was made comfortable in bed to sleep.

SEVENTH DAY ON ADMISSION (22 ND NOVEMBER, 2011).

Client slept well with no complains based on night nurses report. She woke up at her usual time.

Her personal hygiene was maintained with the help of the nurse. Routine nursing care was

rendered to her. On general ward rounds, clients condition was noticed to be improving. She

was booked for discharge the next day if the condition does not change. The physiotherapists

once again took her through range of motion exercises.


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In the evening, client and her relatives were educated on the causes, common signs and

symptoms, and preventive measures of Cerebrovascular accident. After nursing care had been

rendered to her, she was made comfortable to sleep in bed.

EIGHTH DAY ON ADMISSION (23 RD NOVEMBER, 2011).

Client woke up in the morning looking cheerful with improved condition. Routine nursing care

was rendered to her. The team of doctors discharged her upon improvement in condition. The

relatives were informed on a phone call.

Her hospital bill was assessed and paid for with a receipt issued at the revenue department. The

original copy of the receipt was given to client and her relatives and the duplicate kept at the

ward. She was assisted to pack her belongings.

Client and relatives were educated on disease condition. They were also educated on medication

schedule and the need for client to complete the drug regimen. Adverse effects of drugs and how

to manage minor side effects were explained to them.

Date for review was documented for client and her relatives. They were advised to report to the

hospital for review as stated. They were further informed to report any abnormality in case any

occurs before the review date. They were advised on good personal and environmental hygienic

practices.

Madam H.A and her relatives were educated on dietary modifications; low sodium, low fat but

well balanced diet. They were congratulated for their cooperation throughout the period of

hospitalization. They also expressed their gratitude to the staff at the ward.


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The discharge information was entered in the admission and discharged book, daily ward state,

nurses report book, and the nurses notes. Client and her relatives were seen off at the car park.

After they had left, the bed linens were removed and the mattress decontaminated with parazone

1:10. The linens were sent to the sluice room for washing and subsequent washing and

sterilization at Central Sterilization and Supply Department (CSSD) for reuse.

PREPARATION OF PATIENT AND FAMILY TOWARDS DISCHARGE AND

REHABILITATION

Preparation of client and family towards discharge started on the day of admission. They were

reassured of competency of staff and achievement of the hospital in relation to the condition of

the client. During ward rounds on 23 rd November, 2011, her condition was found to have

improved and she was discharged as such. Her folder was sent to the revenue department for

assessment and subsequent payment of bill.

Client was assisted to pack her belongings. She and her family members were educated on the

causes, common signs and symptoms, complications and preventive measures of

Cerebrovascular Accident. They were also educated on dietary restrictions, thus low sodium, low

fat diet. They were also educated on the need for client to complete the full course of

medications. They were also educated on the importance to register with the National Health

Insurance Scheme to have access to quality health care at a low cost.

Client and relatives were told the date to come for review. The need for review was emphasized.

They were also advised to report abnormality if any occurs before the date of review. They were


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52

congratulated for their cooperation throughout the care of client. They also expressed their

gratitude to the staff of the ward. They were seen off at 5:00pm.

Rehabilitation is a programme that helps a person who is recovering from an injury or sickness to

regain as much function as possible. It can also be termed as a restoration to fullest the physical,

mental, and social capability of an individual.

Client rehabilitation started whiles she was on admission and continued after she was discharged.

She was attending out-patient rehabilitation programme at the physiotherapy department of the

hospital. She was taken through exercise ranging from passive to active to help her gain normal

function as possible. This continued for two weeks after she was discharged.

FOLLOW UP/ HOME VISIT/ CONTINUITY OF CARE

FIRST HOME VISIT

My first follow up visit was embarked on the 22 nd of November, 2011 while client was still on

admission with the family after visiting hours in the evening. She stays at house number KD 16,

Koforidua with her sister, other siblings, and her daughter. They live in a compound house with

other tenants.

They have a single kitchen and a bath which serve all the tenants in the house. They get water

supply from a commercial source, about 300 meters from the house. Toilet facility is also

commercial, a stone throw from the house. They dispose refuse into big bins near the toilet.

Family members were reassured that client would get well soon so they should put in their

maximum support. A second visit was promised after which I was seen off at 6:30pm.


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SECOND HOME VISIT

The second home was undertaken on 28 th November, 2011, after client was discharged home.

Client and her relatives welcomed me and offered a seat. Her condition had improved. Emphasis

was placed on the review date. They were also advised to continue sending client for

rehabilitation. I interacted with other inhabitants of the house. After about an hour of interaction,

I sought permission to leave and was granted. A third visit was promised.

THIRD HOME VISIT

The care was terminated on the third home visit on 9 th December, 2011 after she came for

review. She had responded to treatment and was doing well. Emphasis was placed on already

health education given. The need for good nutrition and dietary restrictions were further

explained. They were also educated on the need for client to complete the full course of

medications. Client and her relatives were encouraged to register with the National Health

Insurance Scheme to have access to quality health care at a low cost. Permission to leave was

granted.


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CHAPTER FIVE

EVALUATION OF CARE RENDERED TO PATIENT/ FAMILY

Evaluation is the stage of the nursing process which measures the effectiveness of care rendered

to client. It also helps to determine the clients progress to meet specific objectives and goals set.

STATEMENT OF EVALUATION

During clients stay at the hospital, many goals were set with their specific outcome criteria.

They were aimed at providing client with a comprehensive holistic nursing care to enhance

speedy recovery

On 16 th November, 2011, client and her relatives were noticed to be anxious. Objective set to

relieve them of anxiety was fully met. Client and relatives said they were no more anxious.

On 17th

November 2011, client could not perform personal hygiene as well as feed herself. Goalsset to help client maintain her personal hygiene and to feed her were fully met.

On 18 th November, 2011, client was constipated. Objective set that client will be able to empty

her bowel freely was fully met. Client was able to empty her bowels.

On 19 th November, 2011, client was noticed to stand the risk of developing bed sore and could

not sleep. Objectives set to help client maintain intact skin and that she will be able to sleep were

fully met as client was relieved of insomnia and was able to sleep.

On 20 th-22 nd November, 2011, routine nursing care was rendered to client.


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On 23 rd November, 2011, client and her relatives were noticed to have less knowledge on

Cerebrovascular Accident. Objective set to educate client and her relatives was fully met. They

were able to answer questions put to them on Right Sided Hemiplegia.

AMENDMENT OF NURSING CARE PLAN FOR PATIALLY MET AND UNMET

OUTCOME CRITERIA

Due to high compliance of client and her relatives, all objectives set were fully met. No

amendment of nursing care plan on objective and outcome criteria was done.

TERMINATION OF CARE

Termination of care was initially difficult since a strong therapeutic relationship was established.

Client and the relatives were made aware that therapeutic interaction would come to an end after

the review.

In order to prepare the client and her family members for termination of care, education was

given on good personal and environmental hygiene, completion of drug regimen, observation of

side effects of drugs and management of minor side effects. The importance of dietary

modification thus low sodium, low fat, adequate vitamin and roughage was emphasized.

Client and her relatives were congratulated for their support and co-operation during the

implementation of the care. The care was terminated on 23 rd November, 2011.


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SUMMARY

Madam H. A, a 62-year old woman was admitted to ward D5 of Komfo Anokye Teaching

Hospital on 16 th November, 2011 at 8:35am. She was diagnosed of Cerebrovascular Accident

with right sided hemiplegia. Her particulars, thus name, age, occupation, religion, marital status,

hometown, address, and next-of-kin were taken and recorded.

Client exhibited the following manifestations aphasia, paraesthesia, dizziness, blurred vision, and

ataxia, to mention but a few. Her problems were identified through thorough assessment and all

objectives/goals set to address her problems were fully met.

Routine nursing cares were rendered to towards her recovery and to avoid complications.

Medications prescribed and administered during the period of hospitalization were;

Apparently, client was well and was discharged on 23 rdNovember, 2011 after spending eight

days on admission. Three separate visits were paid to her and her relatives.


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CONCLUSION

The Patient/ Family Care Study has helped me gain in-depth knowledge into Cerebrovascular

Accident. The study has also helped me to know how to give holistic nursing care to clients

using the nursing process as well to acquire good interpersonal relationship skills with client and

family. The study has once again helped me to put what I have learnt into practice.


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BIBLIOGRAPHY

Barbara B.H., Robert J.K., 2009, Suanders Nursing Drug Handbook , Suander Elsevier,

U.S.A.

Berkow R., Bears M.H., 1997, The Merck Manual of Medical Information, Home edition,

350-355, Merck and co. Inc., New York.

British Medical Association and Royal Pharmaceutical Society of Britain ,, 2004, British National Formulary, 48 th edition, UK.

Ignatavicius D.D., Workman M.L., Mishler M.A., 1999, Medical-Surgical Across the Health

Care Continuum, 3rd edition, 1107-1125, W.B. Saunders Company, Philadelphia.

Phipps W.J., Sands K.J., Marek J.F., 1999, Medical-Surgical Nursing; Concepts and Clinical

Practice, 6th edition, 1737-1757, Mosby Inc., St. Louis.

Suzanne C.S., Brenda G.B., Janice L.H., Kerry H.C., Brunner and Suddarths Textbook of

Medical- Surgical Nursing, 11 th edition, Volume 2, 2206-2231, Lippincott Williams and

Wilkins, Philadelphia.


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APPENDIX

BLOOD PRESSURE CHART

DATE TIME BLOOD PRESSURE

16/11/11 12: 35 pm

4 : 35 pm

8 : 30 pm

170/100 millimeters of mercury



17/11/11 6: 00 am

10: 05 am

2: 10 pm

6: 00 pm





18/11/11 6: 08 am

10: 10 am

2: 00 pm

6: 15 pm





19/11/11 6: 20 am

10: 15 am

2: 20 pm

6: 25 pm




140/80 millimeters of mercury20/11/11 6: 00 am

10: 10 am

2: 15 pm

6: 05 pm





21/11/11 6: 00 am

10: 05 am

2: 15 pm

6: 15 pm





22/11/11 6: 15 am

2: 00 pm

6: 20 pm




23/11/11 6: 00 am 120/70 millimeters of mercury


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SIGNATORIES

Name of Candidate: .................................................

Signature

Date:

Name of Nurse In-Charge: .

Signature:

Date:

Name of Supervisor: ................................................

Signature

Date:

Name of Principal: .

Signature: .

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