medical surgical nursing - neuro
TRANSCRIPT
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PAMANTASAN NG LUNGSOD NG MAYNILA(University of the City of Manila)
Intramuros Manila
College of Nursing
A Case Study of Transient Ischemic Attack
In partial fulfillment for the requirement inMedical-Surgical Nursing I
Submitted By:
ESTEVES, Christian C.BSN III 1
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BSN III 1
I. CASE
INTRODUCTION
Transient Ischemic Attack is the temporary episode of neurologic dysfunction thatmay last a few seconds or minutes but not longer than 24 hours. It occurs when theblood supply to part of the brain is briefly interrupted. It occurs when an area in the brainloses blood supply. As a compensatory mechanism, brain tries to restore blood flow. If blood supply is restored, affected brain cells function may return, permitting the return of function to the affected body part.
It is also called as mini-stroke , hemorrhagic stroke, or ischemic stroke.Generally, Transient Ischemic Attack happens when blood clot is present in the arteries,making blood flow to a part of the brain be reduced or blocked. Within 24 hours, bloodflows again.
Below is a presentation of case on Transient Ischemic Attack.
CASE REPORT
This is a case of a 33 year-old, married, female, Filipino, who is currently residingat Quiapo,Manila, and admitted at Ospital ng Maynila on March 6, 2010 diagnosed withTransient Ischemic Attack , with chief complaint of Syncope.
Upon admission, patient had positive signs and symptoms of sudden onset of dyspnea followed by vomiting and syncope. The sequence of the appearance of signsand symptoms are as follows: During dinner, Mrs. PIE suddenly experienced difficulty of breathing Shortly after her dyspneic episode the patient vomited and experienced left-
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II. SCHEMATIC DIAGRAM OF PATHOPHYSIOLOGY
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III. DIAGNOSTIC PROCEDURES ANDLABORATORY ANALYSIS
NURSING HEALTH HISTORY
Past Health HistoryUpon interview, the patient confirmed that she was confined to
Ospital ng Tondo three years ago (2007) with a medical diagnosis of Gastroenteritis, and was also discharged after four (4) days. Other thanthat, there were no known past illness related to TIA.
Present Health HistoryThe Chief Complaint of the patient is Syncope . Prior to
Admission, Mrs. PIE experienced difficulty of breathing, vomiting and left-sided weakness followed by loss of consciousness.
Family Health - Illness HistoryPatient PIEs mother had a cerebrovascular accident in 2003 and
bedridden for 3 years. Also, one of her first degree relatives, her uncle(fathers brother) and auntie(mothers sister) was diagnosed of Hypertension in the year 2002. On 1999, Her father and auntie also hadTransient Ischemic Attack. Other than these, there were no other reportedillness-related case within her family and relatives.
PHYSICAL ASSESSMENT
On arrival at the emergency department, 2 hours after the onsent of symptoms,she reports vomiting, with no headache. She is a current smoker with a history of 1pack-year. Her blood pressure is 140/80 mm Hg, and her pulse is 97 beats per minute,and is regular. The patient has a capillary refill of 5 seconds on blunch test, the patientski i ld d l t t h d h l ki l l ti Th ti t h
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DIAGNOSTIC AND LABORATORY PROCEDURES
Diagnostic/LaboratoryProcedure
Indications or Purposes
Results Normal Values(Units used inthe hospital)
Analysis and Interpretation of Results
Potassium To determinethe amount of Potassiumpresent in theblood.Potassium isan importantelectrolyte thathelps regulatethe flow of fluids in andout of the cells
3.3 3.6-5.0 mmo/L Decreased levels of potassiumindicate hypokalemia .
Creatinine The creatinine
blood test isusuallyordered alongwith a BUN(blood ureanitrogen) test to assesskidneyfunction
0.64 0.5-1.69 mg/dl Normal
Sodium The amount of Sodiumpresent in theblood
141 137-145 mEq/L Normal-low level of blood sodiummeans you have hyponatremia ,which is usually due to too much
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of energy for most cells.
BUN The BUN testis primarilyused, alongwith thecreatinine test ,to evaluatekidneyfunction under a wide rangeof circumstancesand to monitor patients withacute or chronic kidneydysfunction or failure
7.0 7-21 mg/dl Normal-Increased BUN levels suggestimpaired kidney function. Thismay be due to acute or chronickidney disease , damage, or failure.-Low BUN levels are notcommon and are not usually acause for concern. They may beseen in severe liver disease ,malnutrition, and sometimeswhen a patient is overhydrated(too much fluid volume), but theBUN test is not usually used todiagnose or monitor theseconditions.
Uric Acid The uric acidtest is used tolearn whether the body mightbe breakingdown cells tooquickly or notgetting rid of uric acidquicklyenough. Thetest also isused to
5.07 2.5-7 mg/dl Normal- Higher than normal uric acidlevels mean that the body is nothandling the breakdown of purines well. The doctor willhave to learn whether the causeis the over-production of uricacid, or if the body is unable toclear away the uric acid.- Low levels of uric acid in theblood are seen much lesscommonly than high levels andare seldom considered cause for
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diseasesTriglycerides Blood tests for
triglyceridesare usuallypart of a lipidprofile used toidentify therisk of developingheart disease.
As part of alipid profile, itmay be usedto monitor those whohave riskfactors for heart disease,those who
have had aheart attack ,or those whoare beingtreated for high lipidand/or triglyceridelevels.
115.0 35-135 mg/dl A normal level for fasting
triglycerides is less than 150mg/dL . It is unusual to havehigh triglycerides without alsohaving high cholesterol . Mosttreatments for heart disease riskwill be aimed at lowering LDLcholesterol. However, the type of treatment used to lower LDLcholesterol may differ dependingon whether triglycerides are highor normal.
SGOT/AST Used to detectliver damage.
13 5-35 u/L NormalVery high levels of AST (morethan 10 times the highest normallevel) are usually due to acute
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an importantelectrolyte that
helps regulatethe flow of fluids in andout of the cells
indicate hypokalemia .
Diagnostic/
LaboratoryProcedure
Indications or
Purposes
Results Normal Values Analysis and interpretation
HCT Hematocrit test
measures the
amount of
space
(volume) RBC
take up in the
blood.
36.9 37-47 Decreased hematocrit indicates
anemia , such as that caused by
iron deficiency or other
deficiencies
pH Blood gas
measurements
are used to
evaluate your
oxygenation
and acid/base
343 140-440 Normal
-Abnormal results of any of the
blood gas components may mean
that your body is not getting
eno gh o gen is not getting rid
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is an indicator
of immune
function and
helps to
determine
infection or
inflammation
leukemia , trauma, intense
exercise, or stress.
A decreased WBC count is called
leukopenia. It can result from
many different situations, such as
chemotherapy, radiation therapy,
or diseases of the immune
system.
Granulocytes
(x10/1)
Determines the
level of
granulocytes in
the blood. An
elevated level
means that
there is hgh
bacterial
infection
62
4.7
44.2-80.2
2.0-8.8
The result is within normal range
L h / S ll 38 28 48 Th lt i ithi l g
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HGB Measures the
amount of
hemoglobin in
blood and is a
good measure
of the bloods
ability to carry
oxygenthroughout the
body.
11.2 12-16may lead to anemia that can be
the result of iron deficiency
Diagnostic/LaboratoryProcedure
Indications or Purpose
Results Analysis and Interpretation of Results
Urinalysis To obtainclinicalinformation, todetect renaland metabolicdisease,diagnosis of disease or disorder on
kidneys or urinary tract.
Macroscopic:Color: yellowSpecific Gravity:1.015Sugar: negative
Appearance: slightlyturbidReaction: pH 6.0
Albumin: negative
Microscopic:Pus cells: 1-2Red Cells: 0-1Epithelial cells: few
The greater the concentration of theabnormal substance (such as greatlyincreased amounts of glucose, protein,or red blood cells), the more likely it willbe that there is a problem that needs tobe addressed.
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Intravenous Fluid
MedicalManagement
General description Indications/ purpose
IVF D5NM It is a sterile,nonpyrogenic,
hypertonic solution of balanced
maintenanceelectrolytes and 5%dextrose injection inwater for injection.
The solution isadministered by
intravenous infusionfor parenteral
maintenance of
routine daily fluid andelectrolyterequirements with
minimal carbohydratecalories.
It is indicated for parenteralmaintenance of routine daily
fluid and electrolyterequirements with minimalcarbohydrate calories fromdextrose. Magnesium in theformula may help to prevent
iatrogenic magnesiumdeficiency in patientsreceiving prolongedparenteral therapy.
Drugs
Drugs Action Indication
G i N R l i T h k l i
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Generic Name:Mannitol
Brand Name:Osmitrol
Generic Name:omeprazoleBrand Name:Risek
Generic Name:ClopidogrelbisulfateBrand Name:Plavix
-Increases osmoticpressure of
glomerular filtrate,inhibiting tubular reabsorption of water and electrolytes; drug
elevates plasmaosmolality; increasing
water flow intoextracellular fluid.
inhibits secretion of gastric acid by
irreversibly blockingthe enzyme system
of hydrogen/potassium
adenosine
triphosphate (H+
/K+
ATPase), the protonpump of the gastric
parietal cell.
- Inhibits the bindingof adenosine
diphosphate (ADP) toits platelet receptor,
impeding ADP-mediated activation
and subsequent
To prevent oliguria or acuterenal failure
To prevent gastro-esophageal reflux and peptic
ulcer.
- to reduce thrombotic eventsin patients with
atherosclerosis documentedby recent stroke, MI, or
peripheral arterial disease
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Type of Diet General description Indications /purpose
Low salt and lowfat
To prevent the problems thatresult from the need towithhold food.
AcrivityType of Exercise General description Indications
/purpose
Turning exercise Turning the clientside to side on bedevery 2 hours
To prevent venous stasis,thrombophlebitis, pressureulcer formation andrespiratory complication.
Flexion-extensionexercise
Flexion andextension theunaffectedextremities.
To increase muscle strength.
V. NURSING MANAGEMENT
Encourage early ambulation when possible to enhance venous return Elevate the Head of Bed at night to increase gravitational blood flow Provide information on smoking cessation, low fat and low cholesterol diet, birth
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NURSING CARE PLAN
PATIENT: MRS. PIE AGE: 33 years old GENDER: Female Diagnosis: Transient Ischemic Attack
ASSESSMENT NURSINGDIAGNOSIS
INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Cues:Sumasakit yungpaa ko pagnaglalakad, peronawawala yungsakit pagnapapahinga,asverbalized by thepatient.
Objective Cues:
HR: 97 bpmBP: 140/80 mmHg
> Capillary Refill of 5 seconds> Cold, Clammyskin> Pale skin color on elevation(+) AlteredSensation(+) Homans Sign(+) Claudication
IneffectivePeripheralTissuePerfusionrelated toimpairedtransport of oxygen, asmanifested by:> Capillary Refillof 5 seconds> Cold, clammySkin> Pale skincolor onelevation(+) AlteredSensation(+) HomansSign(+) Claudication
History of Hypertensionand Stroke in
the family(Predisposing
Factor) andPrecipitating
Factors(Stress,
Smoking)
Formation of Lacunar
Infarction
DecreasedBlood Supplyin the Brain
DecreasedOxygen to the
brain
Hypoxia
Ischemia
TemporaryNeurologic
Within 2 daysof nursingintervention,the patient willdemonstrateincreasedperfusion, asmanifested by:- CapillaryRefill of lessthan or equal to3 seconds> Warm skin(-) HomansSign(-) Claudication(-) AlteredSensation
>Monitor vitalsigns q4
>Encourage quietand restfulenvironment
>Caution patient toavoid activities thatincreases cardiacworkload
>Encourage earlyambulation, if possible
>Elevate Head of Bed at night
>Apply anti-thromboembolichose bandages tolower extremitiesbefore arising frombed
>To obtainbaseline data
>To decreseOxygendemand
>To maximizetissueperfusion
>To enhancevenous return
>To increasegravitationalblood flow
> To preventvenous stasis
GOAL MET.Within 2 days of nursingintervention, thepatient willdemonstrateincreasedperfusion, asmanifested by:- Capillary Refillof less than or equal to 3seconds> Warm skin(-) HomansSign(-) Claudication(-) AlteredSensation
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Deficit
Alteredcerebral
metabolism
DecreasedCerebralPerfusion
S/SxCapillary Refillof 5 seconds(+) Homans
Sign
>Encouragesmoking cessation
>Demonstrate useof relaxationactivities,exercises or techniques
>Becausesmokingcausesvasoconstriction and mayfurther compromiseperfusion
>To decreasetension level
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PATIENT: MRS. PIE AGE: 33 years old GENDER: Female Diagnosis: Transient Ischemic Attack
ASSESSMENT NURSINGDIAGNOSIS
INFERENCE OBJECTIVES INTERVENTION RATIONALE EVALUATION
Subjective Cues:
Hindi mahimbingyung tulog ko, lagiakong nagigising-gising, asverbalized by thepatient
Objective Cues:BP: 140/80 mm HgHR: 97 bpm
(+) restlessness(+) fluctuation insleep-wake cycle(+) fluctuation inlevel of consciousness> CognitiveOrientation of 3[moderatelycompromised]
AcuteConfusionrelated todecreasedblood supply inthe brain, asmanifested by:(+) restlessness(+) fluctuation insleep-wakecycle(+) fluctuation inL.O.C.> CognitiveOrientation of 3
History of Hypertensionand Stroke in
the family(Predisposing
Factor) andPrecipitating
Factors(Stress,
Smoking)
Formation of Lacunar
Infarction
DecreasedBlood Supplyin the Brain
DecreasedOxygen to the
brain
Hypoxia
Ischemia
TemporaryNeurologic
Deficit
Within 2 daysof nursingintervention,the patient willdemonstraterestoration of cognitive statusto baseline, asmanifested by:(-) restlessness> Normalsleep-wakecycle> CognitiveOrientation of 5[notcompromised]
> Monitor vitalsigns q4
> Assess diet or nutritional status
> Orient client tosurroundings, staff,and necessaryactivities, asneeded.
> Maintain calmenvironment andeliminateextraneous noise/stimuli
> Discuss situationwith family andinvolve in planning
> To obtainbaseline data
>To identifypossibledeficiencies of essentialnutrients thatcould affectmental status
> For client notto feelendanger withhis safety
> To preventoverstimulation
> To diagnosepresence/severity of lungsdisease.
>To meetidentifiedneeds
GOAL MET.Within 2 days of nursingintervention, thepatient willdemonstraterestoration of cognitive statusto baseline, asmanifested by:(-) restlessness> Normal sleep-wake cycle> CognitiveOrientation of 5[notcompromised
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Alteredcerebral
metabolism
Confusion
>Discuss need for ongoing medicalreview of patientsmedications
>To limitpossibility of misuse or potentialdangerousside effects
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PATIENT: MRS. PIE AGE: 33 years old GENDER: Female Diagnosis: Transient Ischemic Attack
ASSESSMENT NURSINGDIAGNOSIS
INFERENCE OBJECTIVES INTERVENTION RATIONALE EVALUATION
Subjective data:
Nahihirapan akongigalaw tong left armko, parangnanghihina, asverbalized by thepatient.
Objective data:BP: 140/80 mm HgHR: 97 bpm
(+)left extremityweakness(+) fatigue
ActivityIntolerancerelated toneuromuscular impairment asmanifested by:(+) leftextremityweakness(+) fatigue
History of Hypertensionand Stroke in
the family(Predisposing
Factor) andPrecipitating
Factors(Stress,
Smoking)
Formation of Lacunar
Infarction
DecreasedBlood Supplyin the Brain
DecreasedOxygen to the
brain
Hypoxia
Ischemia
TemporaryNeurologic
Deficit
Hypoxia at the
Within 8 hoursof nursingintervention,the patient willparticipatewillingly innecessary/desiredactivities, asmanifested by:(-) leftextremityweakness(-) fatigue
>Encourage client tomaintain positiveattitude
>Provide referral toother disciplines,such as exercisephysiologist,psychologicalcounseling/therapy,etc.
> Provide positiveatmosphere, whileacknowledgingdifficulty of thesituation of thepatient
>Plan care tocarefully balance restperiods
>Assist with activitiesand monitor patientsuse of assistivedevices
>Plan care with restperiods betweenactivities
>To enhancesense of well-being
> To developindividuallyappropriatetherapeuticregimens.
> To helpminimizefrustration andrechannelenergy.
>To reducefatigue
>To protectclient frominjury
>To reducefatigue
GOAL MET.Within 8 hoursof nursingintervention, thepatient willparticipatewillingly innecessary/desiredactivities, asmanifested by:(-) left extremityweakness(-) fatigue
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brain
Left-sidedweakness
>Promote comfortmeasures andprovide relief of pain
>To enhanceability toparticipate inthe activities