Cerebrovascular Accident

Angeles University Foundation Angeles City

College of Nursing

“Cerebrovascular Accident Infarct Right hemisphere” In Partial Fulfillment of the Requirements in NCM RLE 102 OB- Pedia Ward, Balitucan District Hospital

Submitted by: Ano Carl Elexer C. Balilo, Noel Leonicio Dizon, Requelito Estrada, Florence Ancel BSN III-1 Group 1

Submitted To: Fe Pagado R.N., M.N.

February 21, 2009

I. Introduction

Many studies were conducted regarding cerebrovascular accidents tackling different aspects of cerebrovascular accident such as; the cause, precipitating factors, predisposing factor, and its prevalence throughout the world as one of the top ten leading causes of morbidity. Cerebrovascular accident (CVA) is the medical term for what is commonly termed a stroke. It refers to the injury to the brain that occurs when flow of blood to brain tissue is interrupted by a clogged or ruptured artery, causing brain tissue to die because of lack of nutrients and oxygen. The severity associated with cerebrovascular accident can best be demonstrated by the following facts: CVA is the leading cause of adult disability in the world. Two – thirds of strokes appear among 65 year old and above. Stroke affects more men than women and most of the cases are among African American. (Accessed on: http://www.wikidoc.org/index.php/Cerebrovascular_accident) A. Current Trends about the Disease Condition Blunt cerebrovascular injuries can be diagnosed using whole body 16 multidetector CT (MDCT); there's no need for an additional neck MDCT angiography examination according to a recent study conducted by researchers at the University of Maryland Medical Center and R. Adams Cowley Shock Trauma Center, both in Baltimore, MD. The study showed that whole body MDCT is just as accurate as neck MDCTA. Blunt cerebrovascular injuries are uncommon but potentially devastating injuries

that

can

lead

to

stroke

and

death.

These

include

dissections,

pseudoaneurysms, and arteriovenous fistulae. For the study, the researchers identified 108 blunt trauma patients that were examined with either whole-body MDCT or neck MDCTA followed by angiography over a 23-month period. From this group, 77 whole body MDCT and 48 neck MDCTA examinations were compared with the results that were pulled from the reports of correlative angiography.

2

According to the study, angiography confirmed blunt cerebrovascular injuries in 83 patients with 25 of those showing injury to more than one of the four major arteries (carotid or vertebral). In the neck, where injuries were most common, each technique showed low sensitivity for blunt carotid (69% for whole-body MDCT and 64% for MDCTA) and blunt vertebral artery injuries (74% for whole-body MDCT and 68% for MDCTA), but specificities were high for both carotid (82% for whole-body MDCT and 94% for MDCTA) and vertebral artery injuries (91% for whole-body MDCT and 100% for MDCTA). The two techniques diagnosed blunt cerebrovascular injuries with statistically comparable accuracy. Routine use of whole-body MDCT would facilitate diagnosis and treatment of asymptomatic blunt cerebrovascular injuries in patients without typical risk factors for injuries. (Accessed on: http://www.eurekalert.org/pub_releases/2008-03/arrswbm032808.php) B. Reasons for choosing such case for presentation Initially the researchers have difficulty of an appropriate case for presentation since most of the cases present on the institution are common illness such as Acute Gastroenteritis and Bronchopneumonia where in there is a lot of information available regarding these diseases. With that problem in hand, the group decided to ask permission to their clinical instructor to utilize a medical case, and with the approval of their clinical instructor, the group came up into a medical case of a 58 years old widowed female with a diagnosis of Cerebrovascular infarct right hemisphere with accompanying past illnesses of active renal disease, hypertension and Diabetes mellitus. Objectives After the completion of the study, the researchers shall be able to:  Identify and differentiate risks for cerebrovascular accident  Be updated with the latest trends in the treatment of cerebrovascular accident  Perform a comprehensive assessment of Cerebrovascular accident  Enumerate the different signs and symptoms of Cerebrovascular accident

3

 List down the different diagnostic procedures that would help in the diagnosis of

Cerebrovascular accident.  Identify and understand different types of medical treatment necessary for the

treatment of Cerebrovascular accident.  Formulate nursing care plans utilizing the nursing process  Formulate

conclusions

based

on

the

findings

and

enumerated

a

recommendations concerning Cerebrovascular accident. Nurse Centered Objectives: At the end of the study, the researchers: •

Shall have critical thinking skills necessary for providing safe and effective nursing care.

•

Shall have a comprehensive assessment and implement care base on our knowledge and skills of the condition

•

Shall have familiarized us with effective inter-personal skills to emphasized health promotion and illness prevention.

•

Shall have imparted the learning experience from direct patient care.

Patient/Family Centered Objectives: At the end of this study, the patient/family will be able to: 1. Identify measures that could minimize the risk of occurrence of the disease. 2. Identify possible risk factors that may have contributed to the development of

Cerebrovascular accident. 3. Increase awareness on the risk factors of Cerebrovascular accident.

4. Develop the family’s support system and distinguish their respective roles in improving patient’s health status. 5. Involve them in promoting the health care of the patient.

4

II. Nursing Assessment

A. Personal Data 1. Demographic data Mrs. Kitty Sanrio is a 58 year old widow, Filipino who was born on September 18, 1951 in Magalang, Pampanga. She is the second child among the 3 siblings of Disney family and all of them are married. She, together with her youngest daughter Po, currently resides at San Francisco, Magalang, Pampanga. She is religiously affiliated as a Roman Catholic. She is presently unemployed but used to be an eatery vendor. When she was 35 years old she smokes 1 pack of cigarette per day, yielding a pack year history of 23, she was forced to quit smoking due to her present illness. She was admitted at Balitucan District Hospital in Magalang with an admitting diagnosis of cerebrovascular infarct right hemisphere with chief complaints of left sided weakness. 2. Socio-economic and Cultural Factors Mrs. Kitty Sanrio was able to finish her high school education but she was able to pursue a vocational course on dressmaking. She is religiously affiliated to Roman Catholic. As mentioned the family believed on the common practices of the Catholics which her daughter termed as “apis –apis” they also believe in manghihilot. With regards to their sanitary condition of their home it was reported that Mrs. Sanrio always does the housekeeping. In the year 2007, Mrs. Sanrio used to work as an eatery vendor that was specifically year ago before she was been diagnosed of renal disease last 2008, at present her daughters support her daily expenses including household bills.

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B. Pertinent Family Health History Disney Family

Father

Mother

Legend: Renal Heart

Sister

Sister

HPN CVA, HPN, DM, Renal Disease

Mrs.

Mr. Sanrio

Epilepsy Liver Normal

Daughte

Daughte

Daughte

Daughte 6

Upon interview it was reported that Mrs. Sanrio’s father died of renal failure at the age of 82, her mother died of heart attack at the age of 89. Mrs. Sanrio has two sisters, both of them also has hypertension. Mrs. Sanrio’s husband died 8 years ago at the age of 52 due to liver cancer. 3 years after, specifically 2005, Mrs. Sanrio was diagnosed Diabetes Mellitus type 2. At the year 2008, she was diagnosed of renal disease and hypertension by accident. Her four daughters do not have any major illness except for her youngest daughter which has epilepsy which was diagnosed at the age of 15. C. History of Past Illness Upon interview, her daughter told the student nurses that Mrs. Sanrio was diagnosed of Diabetes Mellitus Type II in the year 2004, and she is taking Diamicron as her medication, according to her mother is also fond of eating foods which are rich in fat and cholesterol. She has also mentioned that Kitty cannot eat without putting extra salt on her food. Information relayed by Tinky Winky states that Kitty undergone an incision and drainage surgery due to thumbtacks pricks which became infected and developed a large pus filled lesion in the year 2008. Together with that during her stay on the hospital, it was found out that Kitty has a renal disease; Tinky Winky was not able to specify the exact diagnosis given by the physician, it has also found out that she has a hypertension. In line with this, Kitty managed her renal disease with Bactrim and Eprex. She is also taking Capoten and Neobloc for her Hypertension. Mrs. Sanrio wears a prescribed eyeglass for 3 years now with a grade of 200 as mentioned by Tinky winky. D. History of Present Ilness As narrated by Tinky winky at the district hospital 2-3 days prior to Kitty’s admission she is already complaining of headache, and they regarded it as the usual headache associated with high blood pressure. They have just managed it with her medicines for hypertension. The symptoms persisted for another day and managed it the same way. January 27, 2009 1:30 am, Kitty woke them up with complains of numbness on her body and blurry vision “dudurut ya kanu lawe”, she doesn’t want anybody to touch her as she can feel that her conditions aggravates every time someone will touch her. 7

According also to Tinky winky upon seeing her mother, she have noticed that there is an obvious asymmetry on her mother’s face “balamu mekubit ya lupa, balamu babalag ya lupa” and slurring of speech, she then had an idea that it may be a stroke. They planned to bring Kitty to a private hospital, but Mrs. Sanrio disagreed insisting that she wants to be admitted at the district hospital. So after a few hours of debate, they have decided to bring her to the District Hospital. Upon consult, she was advised to stay at the hospital on January 27, 2009 with admitting diagnosis of CVA infarct right Hemisphere, with accompanying illnesses of renal disease, hypertension and diabetes mellitus. A. Physical Examination January 27, 2009 (lifted from chart)

Patient has chief complaints of left sided body weakness, conscious, alert, (+) facial asymmetry, normal rate and regular rhythm, clear breath sounds, normoactive bowel sounds, GCS= 15, BP= 200/100 mmHg, PR= 85, RR= 16 R 5/5

5/5

L 1/5

1/5

General Appearance - Initial [(January 29, 2009)]

8

Patient is wearing a black with floral design clothing, with unkempt hair, appears weak; patient has halitosis, conscious and coherent. She is lying on bed with an ongoing IVF of #2 D5 0.3 NaCl 500 cc x 20 - 21 µgtts/ min infusing well on the right metacarpal vein currently at 50 cc level, patient has an indwelling Foley catheter attached to urine bag with current urine out put of 2000 ml.

Patient has the following vital signs:

T= 35.8 ° C

R

L

5/5

0/5

5/5

4/5

P= 79 bpm R= 20 cpm BP= 190/90 mmHg Upon the assessment of her head, the researchers noted a normal finding, characterized by symmetrical skull, no presence of nodules and lesions, and with hair properly distributed. Upon the assessment of the client’s face, most of the findings are of normal findings characterized by pupils which are equally round in shape, reactive to light and accommodation, with her right eyebrows evenly distributed and symmetrically aligned. With eyelashes of normal growth, there are no purulent or any discharges seen on the client’s eyes. No periorbital edema noted, cornea is transparent and shiny. Ears are of normal findings. Nose is also of normal findings. Further more upon the assessment of the throat and the mouth, the researchers have noted the following manifestations: lips that are dark and dry, 9

difficulty of swallowing, tongue which deviates towards the right side. Gums are pale. There are no abnormal findings found upon the assessment of the neck. The patient does not have any reports of chest pain upon assessment; there were no presence of murmurs heard upon auscultation of the heart rate. With the gastrointestinal assessment, abdomen is soft and not tender, there were 5 bowel sounds/ min/ quadrant upon auscultation, there were no presence of organomegaly upon palpation. The client was observed with no ROM and sensation on the upper left extremity, there were no presence of edema and with a capillary refill of less than 3 sec, it was also noted that her both lower extremities has scars specifically on the dorsal right lower extremity. It was also noted that the client has weakness on the left lower extremity. January 31, 2009 General Appearance Patient is wearing a dark blue with floral design clothing, with unkempt hair, appears weak, conscious, lethargic. She is lying on bed with an ongoing IVF of #5 D5 0.3 NaCl 500 cc x 20 - 21 µgtts/ min infusing well on the right metacarpal vein currently at 150 cc level, patient has an indwelling Foley catheter attached to urine bag with current urine out put of 100 ml and currently undergoing bladder training. Patient has the following vital signs: T= 36° C P= 63 bpm R= 18 cpm

R 5/5

5/5

L 1/5

4/5

BP= 170/60 mmHg

10

Upon the assessment of her head, the researchers noted a normal finding, characterized by symmetrical skull, no presence of nodules and lesions, and with hair properly distributed. Upon the assessment of the client’s face, most of the findings are of normal findings characterized by pupils which are equally round in shape, reactive to light and accommodation, with her right eyebrows evenly distributed and symmetrically aligned. Patient has eyelashes of normal growth, with dried exudates, with a prescribed eyeglasses “200 ya gradu ing salamin na”. No periorbital edema noted, cornea is transparent and shiny. Ears are of normal findings. Nose is also of normal findings. Further more upon the assessment of the throat and the mouth, the researchers have noted the following manifestations: lips that are dark and dry, with visible cracking of the lips, difficulty of swallowing, tongue which deviates towards the right side. Gums are pale. There are no abnormal findings found upon the assessment of the neck. The patient does not have any reports of chest pain upon assessment; there were no presence of murmurs heard upon auscultation of the heart rate. With the gastrointestinal assessment, abdomen is soft and not tender, there were 5 bowel sounds/ min/ quadrant upon auscultation, there were no presence of organomegaly upon palpation. The client was observed with no ROM and sensation on the upper left extremity, there were no presence of edema and with a capillary refill of less than 3 sec, it was also noted that her both lower extremities has scars specifically on the dorsal right lower extremity. It was also noted that the client has weakness on the left lower extremity.

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F. Diagnostic and Laboratory Procedures DIAGNOSTIC OR LABORATORY PROCEDURES

DATE ORDERED AND DATE RESULTS IN

INDICATIONS OR PURPOSES

RESULTS

NORMAL VALUES

ANALYSIS AND INTERPRETATION

70- 105 mg/dL

A fasting blood sugar level 117mg/ dL which is obviously above the normal limits. This justifies the patients current health condition of Type II Diabetes Mellitus as reflected on the pathophysiolo gy.

CLINICAL CHEMISTRY

Date Ordered: 1/27/09 FBS

Date Results In: 1/28/09

A fasting blood sugar test measures the amount of sugar in your blood after you fast for at least eight hours or 117mg/dL overnight. It is a test that is routinely done in all clients with possible cardiovascula r disorders to determine blood glucose levels.

FBS, Blood:  Pre-test: 1. Inform the patient that the test is used to assist in the evaluation of fasting hypoglycemia 2. Obtain a history of the patient’s complaints, including a list of known allergens such as allergy to latex. 3. Obtain a history of the patient’s endocrine system and results of previously performed laboratory tests, surgical procedures, and other diagnostic procedures. 12

4. Note any procedures that can interfere with the test results. 5. Obtain a list of medications patient is taking, including herbs, and nutritional supplements.  Intra-test; 1. Ensure that the patient has complied with dietary or medication restrictions and other pretesting preparations. 2. Instruct the patient to cooperate fully and to follow directions. Direct patient to breathe normally and to avoid unnecessary movement. 3. If the patient has a history of severe allergic reaction to latex, care should be taken and to avoid the use of equipment containing latex. 4. Observe Standard precautions. 5. After obtaining the specimen, promptly transport to the laboratory for processing and analysis. Post-test: Observe venipuncture site for bleeding or hematoma formation. Instruct the patient to report signs and symptoms of hypoglycemia or hyperglycemia. Emphasize that good glycemic control delays the onset of and slows the progression of diabetic retinopathy, nephropathy, and neuropathy. 4. Reinforce information regarding the test results and address concerns voiced by the family or the patient. It is checked in order to assess Date a known and requested The potassium suspected : 3.6 3.5 – 5.3 electrolyte level disorder 1/27/09 mmoL/L mmoL/L is within normal associated with Potassium range. renal disease, Date glucose results in: metabolism, 1/28/09 trauma or burns. Potassium, blood,  Before  1. 2. 3.

1. Check the doctor’s order 2. Explain the procedure 3. Explain the purpose and what to expect 4. No food or fluid restrictions  During 1. 2. 3. 4. 5.

Do not take the blood sample from hand or arm with receiving IVF The tourniquet should be less on a minute Do not squeeze the punctured site rightly Wipe away the first drop of blood Collect 2ml venous blood in a lavender top tube 13

 After 1. 2. 3. 4. 5.

Observed and record vital signs. Check injection sites for bleeding, infection, tenderness or thrombosis. Report untoward reaction to the physician. Apply warm compress to ease discomfort, as ordered. Encourage relaxation by allowing client to discuss experiences and verbalize feelings. 6. Interpret results and provide counsel appropriately. Provide health teachings regarding proper lifestyle changes and symptoms that may warrant immediate medical attention. The creatinine level is The creatinine Date significantly requested test is used to above the diagnose : normal limits impaired kidney 1/27/09 41mg/dL which is a 0.6 – 1.2 Creatinine function and to result of renal mg/dL determine renal impairment Date (kidney) related to the results in: damage. client’s active 1/28/09 renal disease.

BUA

Date requested : 1/27/09 Date results in: 1/28/09

BUN

Date requested : 1/27/09 Date

The blood uric acid test measures the amount of uric acid in a blood sample. Increased level of uric acid in the blood is brought by too much uric acid is being produced or if the kidneys are not able to remove it from the blood normally. Blood urea nitrogen (BUN) measures the amount of urea nitrogen, a waste product

8.5 mg/ dL

64 mg/dL

2.0 – 6.0 mg/dL

The uric acid level is significantly above the normal limits this also gives justification to the deteriorating function of the renal system.

7-18 mg/ dL

The BUN level is significantly above the normal limits which denotes an impairment 14

results in: 1/28/09

of protein metabolism, in the blood. Urea is formed by the liver and carried by the blood to the kidneys for excretion. Because urea is cleared from the bloodstream by the kidneys, a test measuring how much urea nitrogen remains in the blood can be used as a test of renal function. However, there are many factors besides renal disease that can cause BUN alterations, including protein breakdown, hydration status, and liver failure.

in renal function

Creatinine, BUN, BUA, Blood,  Prior: 1. Select vein for venipuncture (usually antecubital space). 2. Apply tourniquet several inches above intended venipuncture site 3. Clean venipuncture site (with povidone iodine or alcohol, allow area to dry).  During: 1. Perform venipuncture by entering the skin with needle at approximately a 15-degree 15

angle to the skin, needle bevel up. 2. If using a Vacutainer, ease tube forward in holder once in the vein. If using a syringe, pull back on the barrel with slow, even tension as blood fills the syringe. 3. Release tourniquet when the blood begins to flow.  After: 1. After the blood is drawn, place cotton ball over site; withdraw the needle and exert pressure. Apply bandage if needed. 2. Properly dispose contaminated materials. 3. Record the date and time of blood collection. Attach a label to each blood tube. 4. Relay results to the doctor. LIPID PROFILE This is a blood test that measures a kind of fat (lipid) in the Date requested blood. The HDL The LDL level is test helps : within the check your risk 1/27/09 30mg/dL > HDL normal range for heart 87mg/dL disease or Date atherosclerosis, results in: which is a 1/28/09 hardening, narrowing, or blockage of the arteries.

CHOLESTEROL

Date requested : 1/27/09 Date results in: 1/28/09

LDL

Date requested :

Used to estimate risk of developing a disease specifically heart disease. Because high blood cholesterol has been associated with hardening of the arteries, heart disease and a raised risk of death from heart attacks. The LDL test measures how much lowdensity

351 mg/dL

140250mg/dL

219 mg/dL

<178 mg/dL

The client has an increased cholesterol level which is one of the precipitating factor of the client’s Hypertension.

This is also one of the factors that aggravates or 16

1/27/09 Date results in: 1/28/09

Triglycerides

lipoprotein (LDL) you have in your blood. Too much LDL in the blood can clog arteries.

triggers the client’s hypertensive episodes.

A test to determine the cholesterol level circulating in the bloodstream

This is also one of the factors that aggravates or triggers the client’s hypertensive episodes.

209 mg/dL

10190mg/dL

Total Cholesterol Test: (NSG. Implications)  Pretest: 1. Inform the patient that the test is used to assess and monitor risk for coronary artery disease. 2. Obtain history of the patient’s past health history and previously performed laboratory tests, surgical procedures, and other diagnostic procedures. 3. Instruct the patient to withhold drugs and alcohol known to alter cholesterol levels for 12 to 24 hours before specimen collection. 4. Fasting 6 to 12 hours before specimen collection is required if triglyceride measurements are included; it is recommended if cholesterol levels alone are measured for screening.  Intratest: 1. Ensure that the patient has complied with the dietary restrictions and pre testing precautions. 2. If the patient has a history of severe allergic reaction to latex, care should be taken to avoid the use of equipment containing latex. 3. Instruct the client to cooperate fully and to follow directions. 4. Observe Standard Precautions. 5. Remove the needle and apply pressure dressing over the puncture site. 6. Immediately transport the specimen to the laboratory for processing and analysis.  Post-test: 1. Observe venipuncture site for bleeding or hematoma formation. 2. Instruct the patient to reduce intake of foods high in saturated fats and cholesterol and triglyceride levels. (E.g. red meats, eggs, and dairy products are major sources of saturated fats and cholesterol. 3. Consider social and cultural beliefs and practices of the client. 4. Recognize anxiety related to test results. Discuss the implications of abnormal test results on the patient’s lifestyle. 5. Provide teaching and information regarding the clinical indications of the test results. 17

BLOOD HEMATOLOGY

Hemoglobin (Hgb)

Date requested : 1/27/09 Date results in: 1/28/09

Hematocrit (Hct)

Date requested : 1/27/09 Date results in: 1/28/09

WBC

Date requested : 1/27/09 Date results in: 1/28/09

Neutrophils/ Segmenters

Date requested : 1/27/09

- to monitor Hgb value in the RBC - to suggest the presence of body fluid deficit due to elevated Hgb level To aid diagnosis of abnormal states of hydration, polycythemia and anemia.

8.0mg%

27.0 vol%

- It measures the concentration of RBC within the blood volume and is expressed as a percentage. The test is performed to find out how many white blood cells you have. Your body produces more white blood cells when you have an infection or allergic reaction, even when you are under general stress To detect presence of infection in the body

4900/ cu. mm

76%

12-16 mg%

37-47 vol%

5-10 x 103mm

50-70%

The patient having a decreased hemoglobin level with accompanying signs of pallor indicates that the client has anemia.

The hematocrit level is below the normal range, which denotes a decreased concentration of RBC in the blood or hemodilution.

The WBC count is below the normal limits a decrease or increase in the WBC count denotes infection or inflammation.

The Neutrophils is above the normal limits indicating infection. 18

Lymphocytes

Date results in: 1/28/09 Date requested : 1/27/09 Date results in: 1/28/09

Eosinophils

Date requested : 1/27/09

To detect presence of infection within the body.

To detect presence of infection within the body.

24%

1%

25-40%

1-4%

The number of lymphocytes is slightly decreased which indicates infection

The eosinophils count is within the normal range

Date results in: 1/28/09 Nursing Implications for Blood Hematology Test:  Pretest: 1. Inform the patient that the test is used to evaluate numerous conditions inflammation, infection, and response to chemotherapy. 2. Obtain a history of the patient’s complaints (such as allergies and sensitivity to latex. 3. Obtain a history of the patient’s gastrointestinal, hematopoietic, immune, and respiratory systems, as well as results of previously performed laboratory tests, surgical procedures, and other diagnostic procedures. 4. Obtain a list of medications the patient is taking, including herbs, nutritional supplements, and nutraceuticals. 5. Review the procedure with the patient. Explain the duration of the procedure and inform the client that there may be some discomforts during the procedure. 6. Consider the patient’s cultural beliefs and practices and it is important to provide psychological support before, during, and after the procedure.  Intratest: 1. Avoid using equipment containing latex if the patient has allergy to it. 2. Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement. 3. Observe Standard precautions. 4. Remove the needle, and apply a pressure dressing over the puncture site. 5. Promptly transport the specimen to the laboratory for processing and analysis. 19

 Post-test: 1. Observe venipuncture site for bleeding or hematoma formation. Apply paper tape or other adhesive to hold pressure bandage in place. 2. Instruct the patient to limit salt intake, alcohol intake and cut down smoking. 3. Reinforce information regarding the test results and address any concerns voiced by the patient or family. IMAGING

CXR APL

Date requested : 1/27/09 Date results in: 1/30/09

Chest Roentgen ogram reveals minimal hazy infiltrates on both lower lung fields. Heat and great vessels are of normal size and configurat ion.

X-rays a diagnostic test which uses invisible electromagneti c energy beams to produce images of internal tissues, bones, and organs onto film. Chest radiographs may depict segmental or lobar infiltrate but they more Hemidiag phragms, commonly sulci, and reveal a other diffuse, fine, reticulogranular visualized pattern, much including chest like what is structures observed in are RDS. Pleural effusions may unremark able. also be observed. Remarks: Pneumon itis , bilateral

Normal anatomical feature of the lungs. Without signs of effusion, and other abnormal findings.

The chest xray denotes abnormal features of the patient lungs, it shows that her both lung parenchyma are inflamed.

Nursing Implication  BEFORE: 1. Explain the purpose of the CXR to the mother. 2. Inform the mother whether they will be transported to the radiology department or 20

have the x-ray done at bedside (portable CXR). 3. Tell the mother that the test will take only a few minutes and is painless  DURING: 1. Provide a lead apron for any person who must hold the patient during the procedure. 2. Provide extra blankets for patient chilled from exposure during CXR.  AFTER: No aftercare is generally required following a chest x - ray. Immediately following the exam, the technologist will continue to watch the patient for patient’s respiratory pattern. FECALYSIS Color: Brown Consistency:

Soft

FECALYIS

Date requested : 1/27/09 Date results in: 1/30/09

This was done to the patient as a screening for abnormalities within the gastrointestinal tract including bleeding and parasitic infection.

Color: Brown Consiste ncy: Soft Trichiuris: 0-1/hpf

Trichiuris: none Amoeba: None Hookworm: None Pus Cells: None

Fecalysis shows that the patient has a positive parasitic infestation specifically trichiuris

RBC: None Bacteria: None Nursing Implication  1. 2. 3. 4.

Prior: Explain the procedure to the client in order to gain her Inform the client that there is no need for NPO. Educate the patient on the proper way of collecting fecal matter Prepare the container for the stool.

 1. 2. 3.

During: Provide privacy. Assist the patient if unable to get her stool sample on her own. Instruct the patient to prevent contamination of the stool and not to add water to the stool specimen, to prevent alteration of results.

 After: 21

1. Continue taking the medications that were stopped prior to the procedure. URINALYSIS Urinalysis Color: shows that Yellow Color: patient is Yellow manifesting Appearance: pyuria Clear Appearance: This was done indicating Clear to the patient infection as a screening Ph: Acidic Date within the Ph: Acidic for requested urinary tract. Pus abnormalities : She also Cells: Pus Cells: within the 1/27/09 manifests red 4-6/HPF none urinary system URINALYSIS blood cells on as well as for her urine Date Red Red Cells: system indicating a results in: Cells: none problems that problem on 1/29/09 6-8/HPF may manifest the kidney Albumin: through the filtration; this Albumin: negative urinary tract. is supported 4 by Glucose: albuminuria Glucose: negative and rare glucosuria. Nursing Implication Prior: Explain the procedure to the client in order to gain her Inform the client that there is no need for NPO. Educate the patient on the proper way of collecting urine (clean catch midstream specimen). 8. Prepare the container for the urine.  5. 6. 7.

 4. 5. 6.

During: Provide privacy. Assist the patient if unable to get her urine sample on her own. Instruct the patient to prevent contamination of the urine and not to add water to the urine specimen, to prevent alteration of results.

 After: 1. Refrigerate the specimen. 2. Continue taking the medications that were stopped prior to the procedure.

22

III. ANATOMY AND PHYSIOLOGY The Cardiovascular System The heart and circulatory system make up the cardiovascular system. The heart works as a pump that pushes blood to the organs, tissues, and cells of the body. Blood delivers oxygen and nutrients to every cell and removes the carbon dioxide and waste products made by those cells. Blood is carried from the heart to the rest of the body through a complex network of arteries, arterioles, and capillaries. Blood is returned to the heart through venules and veins. The one-way circulatory system carries blood to all parts of the body. This process of blood flow within the body is called circulation. Arteries carry oxygen-rich blood away from the heart, and veins carry oxygen-poor blood back to the heart. In pulmonary circulation, though, the roles are switched. It is the pulmonary artery that brings oxygen-poor blood into the lungs and the pulmonary vein

23

that brings oxygen-rich blood back to the heart. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) Twenty major arteries make a path through the tissues, where they branch into smaller vessels called arterioles. Arterioles further branch into capillaries, the true deliverers of oxygen and nutrients to the cells. Most capillaries are thinner than a hair. In fact, many are so tiny, only one blood cell can move through them at a time. Once the capillaries deliver oxygen and nutrients and pick up carbon dioxide and other waste, they move the blood back through wider vessels called venules. Venules eventually join to form veins, which deliver the blood back to the heart to pick up oxygen. Vasoconstriction or the spasm of smooth muscles around the blood vessels causes and decrease in blood flow but an increase in pressure. In vasodilation, the lumen of the blood vessel increase in diameter thereby allowing increase in blood flow. There is no tension on the walls of the vessels therefore, there is lower pressure. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) Various external factors also cause changes in blood pressure and pulse rate. An elevation or decline may be detrimental to health. Changes may also be caused or aggravated by other disease conditions existing in other parts of the body. The blood is part of the circulatory system. Whole blood contains three types of blood cells, including: red blood cells, white blood cells and platelets. These three types of blood cells are mostly manufactured in the bone marrow of the vertebrae, ribs, pelvis, skull, and sternum. These cells travel through the circulatory system suspended in a yellowish fluid called plasma. Plasma is 90% water and contains nutrients, proteins, hormones, and waste products. Whole blood is a mixture of blood cells and plasma. Red blood cells (also called erythrocytes) are shaped like slightly indented, flattened disks. Red blood cells contain an iron-rich protein called hemoglobin. Blood gets its bright red color when hemoglobin in red blood cells picks up oxygen in the lungs. As the blood travels through the body, the hemoglobin releases oxygen to the tissues. The body contains more red blood cells than any other type of cell, and each 24

red blood cell has a life span of about 4 months. Each day, the body produces new red blood cells to replace those that die or are lost from the body. White blood cells (also called leukocytes) are a key part of the body's system for defending itself against infection. They can move in and out of the bloodstream to reach affected tissues. The blood contains far fewer white blood cells than red cells, although the body can increase production of white blood cells to fight infection. There are several types of white blood cells, and their life spans vary from a few days to months. New cells are constantly being formed in the bone marrow. Several different parts of blood are involved in fighting infection. White blood cells called granulocytes and lymphocytes travel along the walls of blood vessels. They fight bacteria and viruses and may also attempt to destroy cells that have become infected or have changed into cancer cells. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) Certain types of white blood cells produce antibodies, special proteins that recognize foreign materials and help the body destroy or neutralize them. When a person has an infection, his or her white cell count often is higher than when he or she is well because more white blood cells are being produced or are entering the bloodstream to battle the infection. After the body has been challenged by some infections, lymphocytes remember how to make the specific antibodies that will quickly attack the same germ if it enters the body again. Platelets (also called thrombocytes) are tiny oval-shaped cells made in the bone marrow. They help in the clotting process. When a blood vessel breaks, platelets gather in the area and help seal off the leak. Platelets survive only about 9 days in the bloodstream and are constantly being replaced by new cells. Blood also contains important proteins called clotting factors, which are critical to the clotting process. Although platelets alone can plug small blood vessel leaks and temporarily stop or slow bleeding, the action of clotting factors is needed to produce a strong, stable clot. 25

Platelets and clotting factors work together to form solid lumps to seal leaks, wounds, cuts, and scratches and to prevent bleeding inside and on the surfaces of our bodies. The process of clotting is like a puzzle with interlocking parts. When the last part is in place, the clot is formed. When large blood vessels are cut the body may not be able to repair itself through clotting alone. In these cases, dressings or stitches are used to help control bleeding. In addition to the cells and clotting factors, blood contains other important substances, such as nutrients from the food that has been processed by the digestive system. Blood also carries hormones released by the endocrine glands and carries them to the body parts that need them. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) Blood is essential for good health because the body depends on a steady supply of fuel and oxygen to reach its billions of cells. Even the heart couldn't survive without blood flowing through the vessels that bring nourishment to its muscular walls. Blood also carries carbon dioxide and other waste materials to the lungs, kidneys, and digestive system, from where they are removed from the body. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) The Endocrine System The endocrine system is made up of glands that produce and secrete hormones. These hormones regulate the body’s growth, metabolism (the physical and chemical processes

of

the

body),

and

sexual

development and function. The hormones are released into the bloodstream and may affect one or several organs throughout the 26

body. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGrawHill Int. NY 10020 2005) The role of the endocrine system is to maintain the body in balance through the release of hormones which transfer information and instructions from one set of cells to another. Many different hormones move through the bloodstream, but each type of hormone is designed to affect only certain cells. Hormones are chemical messengers created by the body. They transfer information from one set of cells to another to coordinate the functions of different parts of the body. Hormones can act on some specific cells because they themselves do not actually cause an effect. It is only through binding with a receptor (part of the cell specifically designed to recognize the hormone) like a key into a lock - that causes a chain reaction to occur, changing the activity of the cells. If a cell does not have a receptor for a hormone then there will be no effect. Also, there can be different receptors for the same hormone, and so the same hormone can have different effects on different cells. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGrawHill Int. NY 10020 2005) The major glands of the endocrine system are the pituitary, thyroid, parathyroids, adrenals, pineal body, thymus, and the reproductive organs (ovaries and testes). The pancreas is also a part of this system; it has a role in hormone production as well as in digestion. A gland is a group of cells that produces and secretes chemicals. A gland selects and removes materials from the blood, processes them, and secretes the finished chemical product for use somewhere in the body. The endocrine gland cells release a hormone into the blood stream for distribution throughout the entire body. These hormones act as chemical messengers and can alter the activity of many organs at once. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) The hypothalamus controls all the processes undergone by the anterior and posterior pituitary glands. It initiates the production of hormones by the APG. The APG is controlled by releasing hormones which are chemical signals produced by the nerve 27

cells of the hypothalamus, causing either stimulation or inhibition of hormone production. Secretion of hormones by the PPG is controlled by nervous system stimulation of nerve cells in the hypothalamus. Parathyroid glands secrete parathyroid hormone which is essential for the regulation of blood calcium levels. Adrenal glands produce epinephrine and norepinephrine which are fight-or-flight hormones that prepare the body for vigorous physical activity. Testes and ovaries produce hormones that are responsible for secondary sex characteristics, spermatogenesis, and oogenesis. The thymus gland secretes thymosin which aids in the synthesis of WBC for fighting infection. This gland decreases in size in some older adults. The pineal body releases melatonin that is thought to decrease the secretion of LSH & FSH by decreasing the release of hypothalamic-releasing hormones. The thyroid gland, located on either side of the trachea, is controlled by the thyroid stimulating hormone releases by the anterior pituitary gland, which was initially stimulated by the TSH releasing hormone from the hypothalamus. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) The pancreas is also part of the body's hormone-secreting system, even though it is also associated with the digestive system because it produces and secretes digestive enzymes. The pancreas produces two important hormones, insulin and glucagon. They work together to maintain a steady level of glucose, or sugar, in the blood and to keep the body supplied with fuel to produce and maintain stores of energy. The pancreas completes the job of breaking down protein, carbohydrates, and fats using digestive juices of pancreas combined with juices from the intestines, secretes hormones that affect the level of sugar in the blood, and produces chemicals that neutralize stomach acids that pass from the stomach into the small intestine by using substances in pancreatic juice. It contains Islets of Langerhans, which are tiny groups of specialized cells that are scattered throughout the organ. In humans, the pancreas is a 15-25 cm (6-10 inch) elongated organ in the abdomen adjacent to the small intestine and lies toward the back. It has three regions: a head (abuts a part of the duodenum), body (at the level of L2 of the spine) and tail

28

(extends toward the spleen). (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) The pancreatic duct (also called the duct of Wirsung) runs the length of the pancreas and empties into the second part of the duodenum at the ampulla of Vater. The common bile duct usually joins the pancreatic duct at or near this point. Many people also have a small accessory duct, the duct of Santorini, which extends from the main duct more upstream (towards the tail) to the duodenum, joining it more proximal than the ampulla of Vater. The pancreas is supplied arterially by the Pancreaticoduodenal arteries and the splenic artery: the splenic artery supplies the neck, body, and tail of the pancreas; the superior mesenteric artery provides the inferior pancreaticoduodenal artery; and the gastroduodenal artery provides the superior pancreaticoduodenal artery. Venous drainage is via the pancreaticoduodenal veins which end up in the portal vein. The splenic vein passes posterior to the pancreas but is said to not drain the pancreas itself. The portal vein is formed by the union of the superior mesenteric vein and splenic vein posterior to the neck of the pancreas. In some people (some books say 40% of people); the inferior mesenteric vein also joins with the splenic vein behind the pancreas (in others it simply joins with the superior mesenteric vein instead). (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) The pancreas is a compound gland in the sense that it is composed of both exocrine and endocrine tissues. The exocrine function of the pancreas involves the synthesis and secretion of pancreatic juices. The endocrine function resides in the million or so cellular islands (the islets of Langerhans) embedded between the exocrine units of the pancreas. Beta cells of the islands secrete insulin, which helps control carbohydrate metabolism. Alpha cells of the islets secrete glucagon that counters the action of insulin. There are four main types of cells in the islets of Langerhans. They are relatively difficult to distinguish using standard staining techniques, but they can be classified by 29

their secretion: Beta cells secretes Insulin and Amylin lower blood sugar, Alpha Cells secretes Glucagon raise blood sugar, Delta Cells secretes Somastotatin inhibit endocrine pancreas, PP Cells secretes pancreatic polypeptide which inhibits exocrine pancreas The islets are a compact collection of endocrine cells arranged in clusters and cords and are crisscrossed by a dense network of capillaries. The capillaries of the islets are lined by layers of endocrine cells in direct contact with vessels, and most endocrine cells are in direct contact with blood vessels, by either cytoplasmic processes or by direct apposition. There are two main types of exocrine pancreatic cells, responsible for two main classes of secretions: Centroacinar cells secretes bicarbonate ions, Basophilic cells secretes

digestive enzymes

such as pancreatic amylase,

pancreatic lipase. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5 th edition, McGraw-Hill Int. NY 10020 2005) The Nervous System The nervous system is a network of specialized cells that communicate information about an animals surroundings and its self, it processes this information and causes reactions in other parts of the body. It is composed of neurons and other specialized cells called glia, that aid in the function of the neurons. The nervous system is divided broadly into two categories; the peripheral nervous system and the central nervous system. Neurons generate and conduct impulses between and within the two systems. The peripheral nervous system is composed of sensory neurons and the neurons that connect them to the nerve cord, spinal cord and brain, which make up the central nervous system. In response to 30

stimuli, sensory neurons generate and propagate signals to the central nervous system which then process and conduct back signals to the muscles and glands. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) The neurons of the nervous systems of animals are interconnected in complex arrangements and use electrochemical signals and neurotransmitters to transmit impulses from one neuron to the next. The interaction of the different neurons form neural circuits that regulate an organism’s perception of the world and what is going on with its body, thus regulating its behavior. Nervous systems are found in many multicellular animals but differ greatly in complexity between species The central nervous system (CNS) is the largest part of the nervous system, and includes the brain and spinal cord. The spinal cavity holds and protects the spinal cord, while the head contains and protects the brain. The CNS is covered by the meninges, a three layered protective coat. The brain is also protected by the skull, and the spinal cord is also protected by the vertebrae. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) Brain is a part of the Central Nervous System, it plays a central role in the control of most bodily functions, including awareness, movements, sensations, thoughts, speech, and memory. Some reflex movements can occur via spinal cord pathways without the participation of brain structures. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) The cerebrum is the largest part of the brain and controls voluntary actions, speech, senses, thought, and memory. The surface of the cerebral cortex has grooves or infoldings (called sulci), the largest of which are termed fissures. Some fissures separate lobes. The convolutions of the cortex give it a wormy appearance. Each convolution is delimited by two sulci and is also called a gyrus (gyri in plural). The cerebrum is divided into two halves, known as the right and left hemispheres. A mass of fibers called the 31

corpus callosum links the hemispheres. The right hemisphere controls voluntary limb movements on the left side of the body, and the left hemisphere controls voluntary limb movements on the right side of the body. Almost every person has one dominant hemisphere. Each hemisphere is divided into four lobes, or areas, which are interconnected. •

The frontal lobes are located in the front of the brain and are responsible for voluntary movement and, via their connections with other lobes, participate in the execution of sequential tasks; speech output; organizational skills; and certain aspects of behavior, mood, and memory.

•

The parietal lobes are located behind the frontal lobes and in front of the occipital lobes. They process sensory information such as temperature, pain, taste, and touch. In addition, the processing includes information about numbers, attentiveness to the position of one’s body parts, the space around one’s body, and one's relationship to this space.

•

The temporal lobes are located on each side of the brain. They process memory and auditory (hearing) information and speech and language functions.

•

The occipital lobes are located at the back of the brain. They receive and process visual information (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

The

urinary

system

is

system of organs that

produces and excretes urine from the body. Urine is a transparent yellow fluid containing unwanted wastes, mostly excess water, salts, and nitrogen compounds. The major organs of the urinary system are the kidneys, a pair of bean-shaped organs that continuously filter substances 32

from the blood and produce urine. Urine flows from the kidneys through two long, thin tubes called ureters. With the aid of gravity and wavelike contractions, the ureters transport the urine to the bladder, a muscular vessel. The normal adult bladder can store up to about 0.5 liter (1 pt) of urine, which it excretes through the tubelike urethra. An average adult produces about 1.5 liters of urine each day, and the body needs, at a minimum, to excrete about 0.5 liter of urine daily to get rid of its waste products. Excessive or inadequate production of urine may indicate illness and doctors often use urinalysis (examination of a patient’s urine) as part of diagnosing disease. For instance, the presence of glucose, or blood sugar, in the urine is a sign of diabetes mellitus; bacteria in the urine signal an infection of the urinary system; and red blood cells in the urine may indicate cancer of the urinary tract. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) Kidney s

are

paired or

gans w

hose fun

ctions

include

removing waste products from the blood and regulating the amount of fluid in the body. The basic units of the kidneys are microscopically thin structures called nephrons, which filter the blood and cause wastes to be removed in the form of urine. Together with the bladder, two ureters, and the single urethra, the kidneys make up the body’s urinary 33

system. Human beings, as well as members of all other vertebrate species, typically have two kidneys. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) Like kidney beans, the body’s kidneys are dark red in color and have a shape in which one side is convex, or rounded, and the other is concave, or indented. The kidneys of adult humans are about 10 to 13 cm (4 to 5 in) long and about 5 to 7.5 cm (2 to 3 in) wide—about the size of a computer mouse. The kidneys lie against the rear wall of the abdomen, on either side of the spine. They are situated below the middle of the back, beneath the liver on the right and the spleen on the left. Each kidney is encased in a transparent, fibrous membrane called a renal capsule, which helps protect it against trauma and infection. The concave part of the kidney attaches to two of the body’s crucial blood vessels—the renal artery and the renal vein—and the ureter, a tubelike structure that carries urine to the bladder. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) A primary function of kidneys is the removal of poisonous wastes from the blood. Chief among these wastes are the nitrogen-containing compounds urea and uric acid, which result from the breakdown of proteins and nucleic acids. Life-threatening illnesses occur when too many of these waste products accumulate in the bloodstream. Fortunately, a healthy kidney can easily rid the body of these substances. In addition to cleaning the blood, the kidneys perform several other essential functions. One such activity is regulation of the amount of water contained in the blood. This process is influenced by antidiuretic hormone (ADH), also called vasopressin, which is produced in the hypothalamus (a part of the brain that regulates many internal functions) and stored in the nearby pituitary gland. Receptors in the brain monitor the blood’s water concentration. When the amount of salt and other substances in the blood becomes too high, the pituitary gland releases ADH into the bloodstream. When it 34

enters the kidney, ADH makes the walls of the renal tubules and collecting ducts more permeable to water, so that more water is reabsorbed into the bloodstream. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) The hormone aldosterone, produced by the adrenal glands, interacts with the kidneys to regulate the blood’s sodium and potassium content. High amounts of aldosterone cause the nephrons to reabsorb more sodium ions, more water, and fewer potassium ions; low levels of aldosterone have the reverse effect. The kidney’s responses to aldosterone help keep the blood’s salt levels within the narrow range that is best for crucial physiological activities. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) Aldosterone also helps regulate blood pressure. When blood pressure starts to fall, the kidney releases an enzyme (a specialized protein) called renin, which converts a blood protein into the hormone angiotensin. This hormone causes blood vessels to constrict, resulting in a rise in blood pressure. Angiotensin then induces the adrenal glands to release aldosterone, which promotes sodium and water to be reabsorbed, further increasing blood volume and blood pressure. The kidney also adjusts the body's acid-base balance to prevent such blood disorders as acidosis and alkalosis, both of which impair the functioning of the central nervous system. If the blood is too acidic, meaning that there is an excess of hydrogen ions, the kidney moves these ions to the urine through the process of tubular secretion. An additional function of the kidney is the processing of vitamin D; the kidney converts this vitamin to an active form that stimulates bone development. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) Several hormones are produced in the kidney. One of these, erythropoietin, influences the production of red blood cells in the bone marrow. When the kidney detects that the number of red blood cells in the body is declining, it secretes erythropoietin. This hormone travels in the bloodstream to the bone marrow, stimulating the production and release of more red cells. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) 35

The respiratory system generally includes tubes, such as the bronchi, used to carry air to the lungs, where gas exchange takes place. A diaphragm pulls air in and pushes it out. Respiratory systems of various types are found in a wide variety of organisms. Even trees have respiratory systems. In humans, the respiratory system consists of the airways, the lungs, and the respiratory muscles that mediate the movement of air into and out of the body. Within the alveolar system of the lungs, molecules of oxygen and carbon dioxide are passively exchanged, by diffusion, between the gaseous environment and the blood. Thus, the respiratory system facilitates oxygenation of the blood with a concomitant removal of carbon dioxide and other gaseous metabolic wastes from the circulation. The system also helps to maintain the acid-base balance of the body through the efficient removal of carbon dioxide from the blood. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) 1. The SINUSES (frontal, maxillary, and sphenoidal) are hollow spaces in the bones of the head. Small openings connect them to the nose. The functions they serve include helping to regulate the temperature and humidity of air breathed in, as well as to lighten the bone structure of the head and to give resonance to the voice. 36

2. The NOSE (nasal cavity) is the preferred entrance for outside air into the respiratory system. The hairs that line the wall are part of the air-cleaning system. 3. Air also enter through the MOUTH (oral cavity), especially in people who have a mouth-breathing habit or whose nasal passages may be temporarily obstructed, as by a cold or during heavy exercise. 4. The ADENOIDS are lymph tissue at the top of the throat. When they enlarge and interfere with breathing, they may be removed. The lymph system, consisting of nodes (knots of cells) and connecting vessels, carries fluid throughout the body. This system helps to resist body infection by filtering out foreign matter, including germs, and producing cells (lymphocytes) to fight them. 5. The TONSILS are lymph nodes in the wall of the throat (pharynx) that often become infected. They are part of the germ-fighting system of the body. 6. The THROAT (pharynx) collects incoming air from the nose and mouth and passes it downward to the windpipe (trachea). 7. The EPIGLOTTIS is a flap of tissue that guards the entrance to the windpipe (trachea), closing when anything is swallowed that should go into the esophagus and stomach. 8. The VOICE BOX (larynx) contains the vocal chords. It is the place where moving air being breathed in and out creates voice sounds. 9. The ESOPHAGUS is the passage leading from the mouth and throat to the stomach. 10. The WINDPIPE (trachea) is the passage leading from the throat (pharynx) to the lungs. 11. The LYMPH NODES of the lungs are found against the walls of the bronchial tubes and windpipe. 12. The RIBS are bones supporting and protecting the chest cavity. They move to a limited degree, helping the lungs to expand and contract. 37

13. The windpipe divides into the two main BRONCHIAL TUBES, one for each lung, which subdivide into each lobe of the lungs. These, in turn, subdivide further. 14. The right lung is divided into three LOBES, or sections. Each lobe is like a balloon filled with sponge-like tissue. Air moves in and out through one opening -- a branch of the bronchial tube. 15. The left lung is divided into two LOBES. 16. The PLEURA are the two membranes, actually one continuous one folded on itself, that surround each lobe of the lungs and separate the lungs from the chest wall. 17. The bronchial tubes are lines with CILIA (like very small hairs) that have a wave-like motion. This motion carried MUCUS (sticky phlegm or liquid) upward and out into the throat, where it is either coughed up or swallowed. The mucus catches and holds much of the dust, germs, and other unwanted matte that has invaded the lungs. You get rid of this matter when you cough, sneeze, clear your throat or swallow. 18. The DIAPHRAGM is the strong wall of muscle that separates the chest cavity from the abdominal cavity. By moving downward, it creates suction in the chest to draw in air and expand the lungs. 19. The smallest subdivisions of the bronchial tubes are called BRONCHIOLES, at the end of which are the air sacs or alveoli (plural of alveolus). 20. The ALVEOLI are the very small air sacs that are the destination of air breathed in. The CAPILLARIES are blood vessels that are imbedded in the walls of the alveoli. Blood passes through the capillaries, brought to them by the PULMONARY ARTERY and taken away by the PULMONARY VEIN. While in the capillaries the blood gives off carbon dioxide through the capillary wall into the alveoli and takes up oxygen from the air in the alveoli. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5 th edition, McGraw-Hill Int. NY 10020 2005)

38

Mechanics of Breathing To take a breath in, the external intercostal muscles contract, moving the ribcage up and out. The diaphragm moves down at the same time, creating negative pressure within the thorax. The lungs are held to the thoracic wall by the pleural membranes, and so expand outwards as well. This creates negative pressure within the lungs, and so air rushes in through the upper and lower airways. Expiration is mainly due to the natural elasticity of the lungs, which tend to collapse if they are not held against the thoracic wall. This is the mechanism behind lung collapse if there is air in the pleural space (pneumothorax). (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) Physiology of Gas Exchange Each branch of the bronchial tree eventually sub-divides to form very narrow terminal bronchioles, which terminate in the alveoli. There are many millions of alveloi in each lung, and these are the areas responsible for gaseous exchange, presenting a massive surface area for exchange to occur over. Each alveolus is very closely associated with a network of capillaries containing deoxygenated blood from the pulmonary artery. The capillary and alveolar walls are very thin, allowing rapid exchange of gases by passive diffusion along concentration gradients. CO2 moves into the alveolus as the concentration is much lower in the alveolus than in the blood, and O2 moves out of the alveolus as the continuous flow of blood through the capillaries prevents saturation of the blood with O2 and allows maximal transfer across the membrane. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

39

IV. THE PATIENT AND HIS ILLNESS A. PATHOPHYSIOLOGY (BOOK BASED)

Modifiable Factors

Non Modifiable Factors

Smoking, Obesity, Hypertension, High Cholesterol Level, Excessive Alcohol Consumption, Drug Addiction, High Dose of estrogen OC, Diabetes Mellitus, Atrial Fibrillation, Type A personality, Sedentary Life Style

Age, Family History of CVA, Family History of DM, Sex (Men), Race

Weight Loss

Destruction of alpha and beta cells of the pancreas

Polydipsia

Polyuria

Polyphagia

Failure to produce insulin Production of excess glucagon

Inc. osmolarity due to glucose

Inc. serum glucose level

Inc. Ketones

Production of glucose from protein and fat stores

Acidosis

Acetone breath

Glycoprotein cell wall deposits

Wasting of lean body mass

Fatigue Weight loss

40

Impaired immune function (decrease level of morphonuclear leukocytes)

Small vessel disease

Diabetic Nephropathy Neuropath y

Infection

Delayed wound healing

Diabetic Retinopathy

Symmetri cal loss of protective sensation

Accelerated atherosclerosis

Renal Disease Hypertension

Loss of vision Blindness Increase LDL levels

Numbness and tingling in the extremities

Autonomic neuropathy

Dry cracked skin

Wasting of intrinsic muscle Thrombus

Gastro paresis CEREBROVASCULAR ACCIDENT Impotence

Emboli

Charcot changes in joints

Hemiparesis Decreased Tissue perfusion (brain) Neurogenic bladder

Loss of speech Hemisensory loss

Cerebral Hypoxia Syncope/ Vertigo

Source: Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005 Cerebral ischemia

Short term Eschemia (<1015mins)

MID CEREBRAL ARTERY

Long term Eschemia (>1015mins)

Temporary Deficit

Permanent Deficit

No permanent damage

Irreversible damage

ANTERIOR CEREBRAL A.

41

POSTERIOR CEREBRAL A.

VERTEBROBASILAR ARTERY

Hemiparesis/ Hemiplegia

Aphasia

Visual Changes

Dysphagia

Dysarthia

Horner’s Syndrome

Apraxia

Agnosia

Hemisensory loss

Ataxia

Unilarteral Neglect

42

Incontinence

Source: Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005

B. PATHOPHYSIOLOGY (CLIENT BASED)

Non Modifiable Factors

Modifiable Factors

Smoking (23 pack years)

Pneumonitis- radiology report (01-30-09)

Hypertension (BP-200/100 -01/27/09), High Cholesterol Level (Total Chol: 351), Diabetes Mellitus (Diagnosed with since 2004)

Age (58 yrs. Old), Family History of Cardiovascular diseases (Mother of the patient died from heart attack), Family History of DM,

Destruction of alpha and beta cells of the pancreas

Failure to produce insulin

Production of excess glucagon

43

Inc. osmolarity due to glucose

Polyuria

Inc. serum glucose level Production of glucose from protein and fat stores

FBS: 117 mg/dl (01/28/09) 01/29/09 -01/31/09

Glycoprotein cell wall deposits 01/29/09 -01/31/09 Wasting of lean body mass

Impaired immune function (decrease level of morphonuclear leukocytes)

Small vessel disease

Diabetic Nephropathy

Infection

Fatigue

Delayed wound healing

Accelerated atherosclerosis

BP- 200/100 (01/27/09)

Diabetic Retinopathy

Lab results: WBC: 4,900 Normal: (5-10x103) (01/28/09)

Hypertension Blurred Vision Renal Affectation

Pus Cell Urinalysis Albumin: high Sugar: rare Pus cells: 46 /hpf RBC: 68 /hpf (01/29/09)

Glucosuria

01/27/09 -01/31/09 Increase LDL levels

Decreased Production of Erythropoeitin

Lab results: Total Chol: 351 HDL: 87 LDL: 219 Triglycerides: 209 (1/28/09)

Proteinuria

Decreased RBC production in the bone marrow

Anemia

Lab results: Hemoglobin: 8 (F: 12-16) Hematocrit: 27 (F: 3747) (01/28/09)

44

Thrombus

CEREBROVASCULAR ACCIDENT

Emboli 01/27/09 Hemiparesis Decreased Tissue perfusion (brain)

01/27/09 Slurred speech 01/27/09

Hemisensory loss Cerebral Hypoxia Vertigo

01/27/09

Cerebral ischemia

Short term Eschemia (<1015mins)

Temporary Deficit

No permanent damage

MID CEREBRAL ARTERY

ANTERIOR CEREBRAL A.

POSTERIOR CEREBRAL A.

VERTEBROBASILAR ARTERY

45

01/29/09 -01/31/09

Dysphagia Apraxia 01/29/09 -01/31/09 Ataxia

01/29/09 -01/31/09

Dysarthia

01/29/09 -01/31/09

Hemisensory loss Left upper extremities

Hemiparesis (left upper extremities) Hemiplegia (left lower extremities)

01/29/09 -01/31/09

01/29/09 -01/31/09

B. SYNTHESIS OF THE DISEASE

B.1. DEFINITION OF DISEASE Stroke is a term used to describe neurologic changes caused by an interruption in the blood supply to part of the brain. Two major types of stroke are ischemic and hemorrhagic. Ischemic stroke is caused by thrombotic or embolic blockage of blood flow to the brain. Bleeding into the brain tissue or the subarachnoid space causes a hemorrhagic stroke. Ischemic strokes account for about 83% of all strokes. The remaining 17% of strokes are hemorrhagic. 46

Cerebrovascular disorders are the third leading cause of death in United States and account for about 164, 000 mortalities annually. An estimated 550,000 strokes people experience a stroke each year. When second strokes are considered in the estimates, the incidence increases to 700, 000 per year in the united States alone. Stroke is a leading cause of adult disability and leading primary diagnosis for long term care. More than four million stroke survivors are living with varying degrees of disability in the United States. Along with a high mortality rate, strokes produce significant morbidity in people who survive them. (Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005) Vascular Disease which includes C.V.A. is the second leading cause of death in the Philippines with a total of 51,680 according to DOH 2004. Along with this are 37,092 who survived with it. (http://www.doh.gov.ph/kp/statistics/morbidity) New therapies can now prevent or limit the extent can now prevent or limit the extent of damage to brain tissue caused by acute ischemic stroke. Thrombolytic therapy must be administered as soon as possible after onset of the stroke; a treatment window 3 hours from the onset of manifestations has been established. To convey this sense of urgency regarding the evaluation and treatment of stroke, health care professionals now refer to stroke as brain attack. Public education is focused on prevention, recognition of manifestation, and early treatment of brain attack. (Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005) Diabetes Mellitus is a chronic systemic disease characterized by either a deficiency of insulin or a decreased ability of the body to use insulin Diabetes mellitus is sometimes referred to as “high sugars” by both clients and health care providers. The notion of associating sugar with diabetes is appropriate because the passage of large amounts of sugar-laden urine is characteristic of poorly controlled diabetes. However high levels of blood glucose are only one component of the pathologic process and clinical manifestation associated with DM. DM can be associated serious complications, 47

but people with diabetes can take preventive measures to reduce the likelihood of such occurrences. (Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005) B.2. Modifiable and Non Modifiable Factors (Book Based)

1. Modifiable

a. Smoking –nicotine content of cigarettes causes vasoconstriction there by resulting hypertension which may lead to CVA.

b. Hypertension –this is due to plaque deposits on the wall of the arteries which causes narrowing of the blood vessel thereby causing hypertension which may lead to hemorrhagic stroke.

c. Obesity –This is due to increase cholesterol in the body which may contribute plaque formation that will narrow the blood vessel or may cause thrombus formation.

d. Hyperlipidemia –too much lipid in the blood may cause increase plaque formation which may cause thrombus formation.

e. Drug addiction –This may cause vasopasm, hypertension, hypercoagulability and cerebral eschemia which may cause CVA.

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f. Excessive alcohol consumption –heavy alcohol consumption increases one’s risk of a stroke, light or moderate alcohol may protect against ischemic stroke. (Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005) g. High dose Estrogen Oral Contraceptives –increases the risk of stroke in women.

h. Diabetes Mellitus –The mechanism is related to macrovascular changes in people with diabetes mellitus. There is an increase viscousity of blood which may cause formation of thrombus formation.

i. Atrial fibrillation –pulling of blood from poorly emptying atrial which leads to formation of tiny clots in Left atrium which can move on the cerebral circulation.

j. Type A personality –stress causes hypertension thereby increasing chance of having hemorrhagic stroke.

k. Sedentary lifestyle –increase of having DM and Obesity which one of the factors of having CVA (Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005)

2. Non-Modifiable

a. Age –Intracranial hemorrhage is most often secondary to hypertension and is most common after age 50 years. 49

b. Family history of CVA – Family history of stroke increase one’s risk

c. Family history of DM –Family which has history of DM especially type 2 is high risk of having stroke due to accelerated atherosclerosis.

d. Sex (Male) –Incidence of stroke in men is slightly higher than that of women.

e. Race – (more prevalent among African Americans than whites or Hispanics) (Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005)

SIGNS AND SYMPTOMS (Book Based)

DIABETES MELLITUS HYPERGLYCEMIA (INCREASED BLOOD SUGAR LEVEL) Diabetes Mellitus type II may be due to lack of physiologically active insulin that stimulates glucose uptake in the muscles and tissues. Therefore, it leads to an accumulation of glucose in the intravascular space. The glucose is not utilized by the body and it remains in the blood stream. 50

POLYURIA Polyuria is an increased frequency of urination. This may be due to the osmotic diuretic effect of the glucose, wherein it attracts water during urination. When you have diabetes, excess sugar (glucose) builds up in your blood. Your kidneys are forced to work overtime to filter and absorb the excess sugar. If your kidneys can't keep up, the excess sugar is excreted into your urine along with fluids drawn from your tissues. This triggers more frequent urination, which may leave you dehydrated.

POLYDIPSIA Polydipsia is an increased thirst and fluid intake. This may be due to the activation of the thirst center in the hypothalamus resulting from the intracellular dehydration or volume depletion caused by excessive urine production. POLYPHAGIA Increased hunger and food intake. Because glucose cannot enter cells of the satiety center of the brain without insulin, the satiety center in the hypothalamus is stimulated resulting in a “hunger sensation” as if there were very little blood glucose, resulting in an exaggerated appetite.

BODY MALAISE This is due to the decreased glucose uptake by the tissues leading to decreased energy production. (Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005)

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GLYCOSURIA The kidney filters the blood, making it to its normal state. Glucose was filtered out and excreted in the urine. Due to the excess glucose ad compared to the kidney threshold, which results to the excretion of glucose in the urine.

BLURRED VISION Diabetes can affect the lens, vitreous, and retina, causing visual symptoms. Visual blurring may develop acutely as the lens changes shape with marked changes in blood glucose concentrations. This effect, which is caused by osmotic fluxes of water into and out of the lens, usually occurs as hyperglycemia increases.

WEIGHT LOSS Despite eating more than usual to relieve constant hunger by the stimulation of satiety center, weight loss may still exist. Without the glucose supplies, muscle tissues and fat stores may deplete.

SLOW-HEALING SORE AND FREQUENT INFECTION High levels of blood sugar impair your body's natural healing process and your ability to fight infections. For women, bladder and vaginal infections are especially common.

TINGLING SENSATION/ NUMBNESS IN THE HAND AND FEET Excess sugar in your blood can lead to nerve damage. You may notice tingling and loss of sensation in your hands and feet, as well as burning pain in your arms, hands, legs and feet. 52

PROTEINURIA Testing the urine for microalbuminuria shows early nephropathy, long before it would be on routine urinalysis,

ANEMIA If there are renal affectations, this might bring to decrease production of erythropoietin which brings to decrease production of RBC from the bone marrow that may result to anemia.

CEREBROVASCULAR ACCIDENT Clinical Manifestations

1. headache and vomiting – due to an increase ICP which causes cerebral edema, and compressing the medulla oblongata 2. seizures – due to hyper-excitability of neurons because of irritation. 3. changes in mental status – affectation in the RAS 4. fever – affectation in the hypothalamus 5. ECG changes – problem with the medulla oblongata

Warning Signs 1. transient hemiparesis 53

2. loss of speech 3. hemisensory loss 4. vertigo/syncope

Specific Deficits

1. Hemiparesis/Hemiplegia – the former means weakness of one side of the body while the latter means paralysis of one side of the body. 2. Aphasia – defects on using and interpreting symbols of language 3. Apraxia - a condition in which a client can move the affected part but cannot use it for purposeful actions. 4. Homonymous Hemianopsia – a defective vision or vision loss in the same half of the visual field. 5. Agnosia – a problem in interpreting visual, tactile or other sensory information. 6. Dysarthia – imperfect articulation condition. 7. Kinesthesia – alteration in sensation. 8. Incontinence – due to inattention, memory lapses, emotional factors, and inability to communicate. 9. Shoulder pain – severe pain in the affected shoulder after CVA 10. Horner’s syndrome – paralysis of sympathetic nerves to the eye causing sinking of the eyeball, ptosis of the upper eyelid, constriction of pupil, and lack of tearing in the eye. 11. Unilateral neglect – inability to respond to stimulus on the contralateral side. 54

12. Dysphagia (01/29/09 -01/31/09) – difficulty of swallowing 13. Ataxia (01/29/09 -01/31/09) –Problem with motor coordination

B.2. Modifiable and Non Modifiable Factors (Client Based)

1. Modifiable

a. Smoking – (23 pack years) nicotine content of cigarettes causes vasoconstriction there by resulting hypertension which may lead to CVA.

b. Hypertension – (BP-200/100 -01/27/09) this is due to plaque deposits on the wall of the arteries which causes narrowing of the blood vessel thereby causing hypertension which may lead to hemorrhagic stroke.

d. Hyperlipidemia – Total Cholesterol: 351 (01/28/09) too much lipid in the blood may cause increase plaque formation which may cause thrombus formation.

e. Diabetes Mellitus – (She was diagnosed with DM since 2004) The mechanism is related to macrovascular changes in people with diabetes mellitus. There is an increase viscousity of blood which may cause formation of thrombus formation.

2. Non-Modifiable

55

a. Age –Intracranial hemorrhage is most often secondary to hypertension and is most common after age 50 years. (Kitty Sanrio is 58 yrs. Old)

b. Family history of Cardiovascular Diseases – Family history of stroke increases one’s risk. Kitty Sanrio’s mother died from cardiovascular disease specifically heart attack.

c. Family history of DM –Family which has history of DM especially type 2 is high risk of having stroke due to accelerated atherosclerosis.

SIGNS AND SYMPTOMS (Client Based)

DIABETES MELLITUS HYPERGLYCEMIA (INCREASED BLOOD SUGAR LEVEL) (01/28/09) Diabetes Mellitus type II may be due to lack of physiologically active insulin that stimulates glucose uptake in the muscles and tissues. Therefore, it leads to an accumulation of glucose in the intravascular space. The glucose is not utilized by the body and it remains in the blood stream.

POLYURIA (01/29/09 -01/31/09) Polyuria is an increased frequency of urination. This may be due to the osmotic diuretic effect of the glucose, wherein it attracts water during urination. When you have diabetes, excess sugar (glucose) builds up in your blood. Your kidneys are forced to work overtime to filter and absorb the excess sugar. If your kidneys can't

56

keep up, the excess sugar is excreted into your urine along with fluids drawn from your tissues. This triggers more frequent urination, which may leave you dehydrated.

BODY MALAISE (01/29/09 -01/31/09) This is due to the decreased glucose uptake by the tissues leading to decreased energy production.

GLYCOSURIA (01/29/09) The kidney filters the blood, making it to its normal state. Glucose was filtered out and excreted in the urine. Due to the excess glucose ad compared to the kidney threshold, which results to the excretion of glucose in the urine.

BLURRED VISION (01/29/09 -01/31/09) Diabetes can affect the lens, vitreous, and retina, causing visual symptoms. Visual blurring may develop acutely as the lens changes shape with marked changes in blood glucose concentrations. This effect, which is caused by osmotic fluxes of water into and out of the lens, usually occurs as hyperglycemia increases.

ANEMIA [Hemoglobin: 8 (F: 12-16) (01/28/09)] If there are renal affectations, this might bring to decrease production of erythropoietin which brings to decrease production of RBC from the bone marrow that may result to anemia.

57

FREQUENT INFECTION (01/29/09 -01/30/09) High levels of blood sugar impair your body's natural healing process and your ability to fight infections. This is due to low morphonuclear leukocytes which decreases her resistance from infection. For women, bladder and vaginal infections are especially common.

PROTEINURIA (01/29/09) Testing the urine for microalbuminuria shows early nephropathy, long before it would be on routine urinalysis,

PNEUMONITIS – Radiology report (01-30-09). Many factors can cause pneumonitis, including breathing in animal dander, inhaling small food particles "down the wrong pipe" and receiving radiation therapy to your chest and smoking.

CEREBROVASCULAR ACCIDENT Clinical Manifestations 1. headache and vomiting – due to an increase ICP which causes cerebral edema, and compressing the medulla oblongata 2. seizures – due to hyper-excitability of neurons because of irritation. 3. changes in mental status – affectation in the RAS 4. fever – affectation in the hypothalamus 5. ECG changes – problem with the medulla oblongata 58

Warning Signs 1. transient hemiparesis (01/27/09) 2. slurred speech (01/27/09) 3. hemisensory loss(01/27/09) 4. vertigo/syncope (01/27/09) Specific Deficits

1. Hemiparesis/Hemiplegia (01/29/09 -01/31/09) – the former means weakness of one side of the body whiles the latter means paralysis of one side of the body. 2. Apraxia (01/29/09 -01/31/09) –a condition in which a client can move the affected part but cannot use it for purposeful actions. 3. Dysarthia (01/29/09 -01/31/09) – imperfect articulation condition. 4. Dysphagia (01/29/09 -01/31/09) – difficulty of swallowing 5. Ataxia (01/29/09 -01/31/09) –Problem with motor coordination

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V. The Patient and His Care A. Medical Management a. IVF’s, BT, NGT Feedings, Nebulization, TPN, Oxygen Therapy.etc. Medical Management/ Treatment

Date ordered/ Date Performed

D5 LRS (5% 01-27-09 Dextrose Lactated Ringer’s Solution) 1L

D5 0.3 NaCl (5% Dextrose 0.3 Sodium Chloride) 500cc

Jan. 27-31, ‘09

General Description

Indication or purpose

Client’s Response

Hypertonic solution that has higher osmolarity than the serum. It pulls fluid and electrolytes from the intracellular and interstitial compartments into the intravascular compartment. It is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment and caloric supply administered intravenously.

Since the patient was on NPO upon admission, she was given D5 LRS as her IVF administered intravenously to serve as a source of water, electrolytes, and calories. It also serves as a route for medication administration.

The patient was

To

Hypotonic solution that has greater concentration free molecules

of

water that

are found inside the cell.

maintain

rehydration and to replace fluid loss, patient was given this IVF. Also, for medication administration.

able to maintain normal hydration status

and

electrolyte balance

AEB

patient

had

moist skin and good skin turgor.

Patient responded

well

as she did not manifest

any

signs

and

symptoms

of

dehydration such as dry skin 60

and

mucous

membranes.

Nursing Implication:  Before: 1. Check the physician’s order for IV solution and explain to the client the procedure. 2. Check the potency of IV line and needle 3. Check the type of infusion, condition of the vein and medical condition of the patient  During: 1. Maintenance of Aseptic Technique 2. Proper procedure and steps in infusing IV solution 3. Count drops per minute in drip chamber.  After: 1. Monitor IV infusion at least every 2 hour 2. Adjust IV clamp as needed and recount drop per minute. 3. Monitor client for fluid overflow 4. More frequent check maybe prn if a medication(s) are being infused. 5. Inspect site for pain, swelling, coolness or pallor at the site of insertion, which may indicate infiltration of IV 6. Inspect site for redness, swelling, heat and pain which may indicate phlebitis

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b. Drugs

Name of Drugs

Date Ordered/ Date Perform ed/ Date Given

Dosage, Route, Frequenc y of Administr ation

Piracetam

01-27-09

800mg 1 tab PO q6 hrs then BID on 01-28-09

General Action

Indication or Purpose

Client’s Response

Nursing Responsibilities

Piracetam improves the function of the neurotransmit ter acetylcholine via muscarinic cholinergic (ACh) receptors which are implicated in memory processes. It improves brain function and stimulates the central nervous system

Since the patient is diagnosed of CVA, she is given this drug to improve her brain function

The client improved her mentation as she is able to feel deep touch and could raise his right arm and leg as well as comprehend with what the SO is saying. There are no side/adverse effects noted

Prior to: Wash hands thoroughly. Ask the patients name Always observe aseptic technique During: Explain the procedure to the patient/SO. Explain what is the general action of the drug to the body. 62

without any toxicity or addictive properties

After: Record the drug after its administration (charting).

Observe the patients for possible untoward reaction. Instruct to take the medication exactly as directed. Captopril

Jan. 2731, ‘09

25mg SL TID

Captopril lower blood pressure by inhibiting the formation of angiotensin II, thus relaxing the arteries. Relaxing the arteries not only lowers blood pressure, but also improves the pumping efficiency of a

Indicated for the patient since the drug is said to treat hypertension.

Patient did not improve condition since she still had elevated blood pressure of 180/100

Prior to: Wash hands thoroughly. Ask the patients name Always observe aseptic technique During: Explain the procedure to the 63

failing heart and improves cardiac output in patients with heart failure.

patient/SO. Instruct the patient to put the medicine under her tongue or sublingually. After: Record the drug after its administration (charting).

Observe the patients for possible untoward reaction. Instruct to take the medication exactly as directed. Monitor blood pressure Ranitidine

01-27-09

50mg IV q8 then d/c on Jan. 30,’09

It is a competitive, reversible inhibitor of the action of

This is indicated for the patient as she manifested abdominal pain

The patient improved condition as she did not manifest

Prior to: Wash hands thoroughly. Ask the patients 64

histamine at the histamine H2 receptors, including receptors on the gastric cells

abdominal pain.

name. Recheck the order of the doctor Always observe aseptic technique Check the patency of the IV site During: Explain the procedure to the patient/SO. Observe patient closely for at least 30 minutes following administration.

After: Record the drug after its administration (charting). Observe the patients for possible untoward 65

reaction.

Simvastatin

01-28-09

40mg 1tab OD

Simvastatin is a hypolipidemic drug belonging to the class of pharmaceutic als called "statins". It is used to control hypercholeste rolemia (elevated cholesterol levels) and to prevent cardiovascula r disease.

Since the patient had high levels of cholesterol with 351 mg/dl, she was given this drug.

Patient did not improve condition since she still has elevated cholesterol..

Prior to: Wash hands thoroughly. Ask the patients name Always observe aseptic technique During: Explain the procedure to the patient/SO. After: Record the drug after its administration (charting).

Observe the patients for possible untoward reaction. 66

Instruct to take the medication exactly as directed. Metoprolol

01-28-09

50mg 1tab BID then increased frequency of 100mg on Jan. 30,’09

Metoprolol reduces heart rate and cardiac output at rest and upon exercise, reduces systolic blood pressure upon exercise, inhibits isoproterenolinduced tachycardia, and reduces reflex orthostatic tachycardia.

It is also indicated for the patient because the patient has elevated blood pressure.

The client did not improve condition since she still had elevated blood pressure

Prior to: Wash hands thoroughly. Ask the patients name Always observe aseptic technique During: Explain the procedure to the patient/SO. After: Record the drug after its administration (charting). Observe the patients for possible untoward reaction. 67

Instruct to take the medication exactly as directed. Monitor BP

Ketosteril

01-30-09

2 tabs TID

Ketosteril normalizes metabolic processes, Improves nitrogen exchange, reduce ion concentration s of potassium, magnesium and phosphate.

Protein-energy malnutrition, prevention and treatment of conditions caused by modified or insufficient protein metabolism.

Patient improved condition as she did not manifest body weakness because of the energy supplemented.

Prior to: Wash hands thoroughly. Ask the patients name Always observe aseptic technique During: Explain the procedure to the patient/SO. After: Record the drug after its administration (charting). 68

Observe the patients for possible untoward reaction. Instruct to take the medication exactly as directed. Ferrous Sulfate

01-30-09

1 cap OD

Ferrous Sulfate is an essential body mineral. Ferrous sulfate is used to treat iron deficiency anemia

Indicated for the patient as a supplement for iron

Patient did not improve condition as she still has low hemoglobin count.

Prior to: Wash hands thoroughly. Ask the patients name Always observe aseptic technique During: Explain the procedure to the patient/SO. After: Record the drug after its administration (charting). 69

Observe the patients for possible untoward reaction. Instruct to take the medication exactly as directed. Hydralazine

01-29-09

5mg IV q6hrs PRN for BP 130/90

Hydralazine is a direct-acting smooth muscle relaxant used to treat hypertension by acting as a vasodilator primarily in arteries and arterioles. By relaxing vascular smooth muscle, vasodilators act to decrease peripheral resistance, thereby lowering blood pressure.

Indicated for the patient as she has elevated blood pressure

The patient did not improve her condition as she still had elevated blood pressure of 180/100

Prior to: Wash hands thoroughly. Ask the patients name. Recheck the order of the doctor Always observe aseptic technique Check the patency of the IV site During: Explain the procedure to the patient/SO. 70

Observe patient closely for at least 30 minutes following administration.

After: Record the drug after its administration (charting). Observe the patients for possible untoward reaction. Monitor BP

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c. Diet Date ordered Date given Date changed Nothing per 01-27-09 Orem (NPO) Type Of diet

Soft Diet

01-28-09

General description

Indication

Specific Foods Taken

Client’s response

A type of Diet where the patient cannot eat or drink anything

It is for the None purpose of observation precaution

The patient participated with the Doctor’s order

Very similar to regular diet except that the textures of foods have been modified.

This was Boiled Eggs, The client ordered to Sopas, enjoyed provide a Lugaw eating her transitional food and diet between manifested liquids and feeling of regular food fullness after for patients the meal. She who have did not difficult in manifest swallowing or dysphagia. who undergone surgery.

Nursing Responsibilities for NPO ● Check the doctor’s order. ● Educate the patient and significant others why NPO is indicated. ● Discuss to the patient the importance of the diet. ● Assess patient’s level of hydration. Nursing Responsibilities for soft diet ● Check the doctor’s order. ● Educate the patient and significant others on the right foods to be taken. ● Discuss to the patient the importance of nutrition. ● Provide a variety of choices of foods. ● Assess patient’s appetite.

72

d. Activity/ Exercise Date ordered Date given Date changed Back 01-27-09

Type Of exercise High Rest

General description A type of activity or exercise wherein the patient is kept on bed with the head of bed held at at least 45° with limitations to other activities.

Indication To reduce oxygen demand and prevent fatigue. Rest decreases body metabolic rate. Since the patient is old, she is prone to have pressure ulcers and she is more likely to manifest fatigue.

Client’s response Patient shows gradual increase strength.

in

Nursing Responsibilities ● Assist patient if with such privilege in going to the bathroom. ● Change client’s position from time to time, to promote circulation and prevent bed sores.

73

B. Nursing Management NURSING CARE PLAN Problem No:1 Acute Pain ASSESSMENT

NURSING DIAGNOSIS Acute Pain

SCIENTIFIC

PLANNING

EXPLANATION Lots of medicine has the Short Term

INTERVENTIONS Establish rapport

RATIONALE

EXPECTED

To gain pt’s

OUTCOME Short Term

S=” Masakit ku

side effect of gastric Objective:

therapeutic

Objective:

atsan”

upset

relationship

After the nsg int the

causing

abdominal

pain

to

patient after intake of The patient

medication specially PO

manifested the

drugs. It has a side

following:

effect

of

causing

abdominal cramps, and

After 2 hr of nursing intervention the pt

pt shall verbalized a Monitor v/s

8/10 to 4/10

relief of pain.

data

will verbalized rlieve of pain from

To obtain baseline

Assess pt’s

To note for the

general condition

etiology or

pain.

precipitating

O= with facial

factors that can

Long Term

grimace, with

lead to fever.

Objective:

guarding

Long Term

behaviors, pain

Objective:

scale of 8/10, at abdominal area, with quality of dull pain, after intake

After 3 days of NI, pt will demonstrate

After the nsg int the Encourage rest

To overcome pain

pt shall

opportunities

at rest

demonstratetechniq ue to alleviate pain

Ecourage

to divert the pt’s

diversional

attention 74

of meds, left side

technique to

activities such as

paralysis

alleviate pain

talking to S.O. Encourage deep

Helps to lessen

The patient may

breathing

the feeling of

also manifest he

exercises

pain.

Provide comfort

To let pt feel safe

measures and

and comfortable

following:

>discomfort >anxiety >irritable

safety Provide Health

To lessen the pt’s

information

feeling of anxiety

regarding the >Fatigue

occurring problem

>headache Provide

To promote rest

conducive

and pt’s wellness

environment for resting

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Problem No: 2 impaired cerebral tissue perfusion r/t vascular occlusion secondary to disease condition ASSESSMENT

NURSING

SCIENTIFIC

PLANNING

DIAGNOSIS Impaired cerebral

EXPLANATION In cerebral tissue

Short term

tissue perfusion

perfusion, there is a

The patient

r/t vascular

manifested the ff:

INTERVENTIONS

RATIONALE

EXPECTED

> To gain pt’s

OUTCOME Short term

objective:

therapeutic

objective:

decrease in oxygen

After 5hrs. of

relationship

After 5hrs. of

occlusion

supply which results in

Nursing

secondary to

the failure to nourish the

intervention, the

Monitor Vital

> To identify any

intervention, the pt.

disease condition

tissues at the capillary

pt. will

signs

other deviations

shall be able to

O= without signs

level. Blood vessels

demonstrate

from normal.

demonstrate

of IV infiltration, w/

which function is to

increased

contralateral

supply blood to the

perfusion as

Assist pt. in

>To aid with

as individually

hemiparesis,

different parts of the

individually

assuming

proper perfusion

appropriate

sensory loss,

brain are impaired.

appropriate

semifowler’s

or flow of blood

muscle weakness,

Thus, the O2 supply

position w/ head

(circulation or

Long Term

slurred speech,

going to the brain is also

Long Term

midline.

venous drainage).

Objective:

with GCS=15

impaired. Proper

Objective:

perfusion is needed in

After 2-3 days of

Administer

>To probably

Nursing

order to give adequate

Nursing

medications as

decrease cardiac

Intervention, the pt.

The patient may

nourishment to he

Intervention, the

ordered such as

workload and in

shall be able to

also manifest the

different parts of the

pt. will be able o

antihypertensive

maximizing tissue

demonstrate

ff:

brain in order for it to

demonstrate

or diuretics.

perfusion

behaviors which

function well.

behaviors which

S= 0

>Change in

may improve

Establish Rapport

Nursing

increased perfusion

After 2-3 days of

may improve proper >Encourage quiet

circulation such as 76

pupillary reactions

proper circulation

and restful

>To conserve

compliance to

>Change in

such as

atmosphere.

energy which

health management

Mental Status

compliance to

could aid in

& therapies

>Behavioral

health

lowering the O2

provided.

Changes

management &

>Exercise caution

tissue demand.

>Capillary refill

therapies

in using hot or

>The t issues

longer than 3

provided.

cold pads.

may have

secs.

decreased >Encourage use

sensitivity due to

of relaxation

ischemia.

techniques or exercises.

>To decrease the tension level

>Discuss the importance of preventing

>To retain heat or

exposure to cold

warmth efficiently

or extreme cold temp >Discuss to the patient’s SO the importance of

>To promote 77

care of dependent

wellness

limbs, body hygiene, and foot care when circulation is impaired.

Problem No: 3 Impaired Physical Mobility Neuromuscular and Musculoskeletal Impairment ASSESSMENT

NURSING

SCIENTIFIC

PLANNING

INTERVENTIONS

RATIONALE

EXPECTED

DIAGNOSIS Impaired physical

EXPLANATION The nervous system is Short Term

>Establish

> To gain pt’s

OUTCOME Short Term

mobility

made up of nerve cells Objective:

Rapport

therapeutic

Objective:

The patient

neuromuscular

called

neurons

relationship

After 4 hrs. Of

manifested the

and

serve

as

following:

musculoskeletal

communication system Intervention, the

>Monitor Vital

> To identify any

Intervention, the pt.

impairment as

of the body. They carry pt. will be able to

signs

other deviations

shall be able to

O= w/ pale

evidence by

messages in the form of

from normal.

maintain increased

palpebral

limited motor

electrical impulses. The increased

>Assess patient

>To determine

strength and

conjunctiva, w/

skills.

messages move from strength and

condition

any other

function of affected

S= 0

that After 4 hrs. Of the Nursing

Nursing

maintain

pale nail beds, w/

one neuron to another function of

underlying cause

or compensatory

capillary refill

to

of manifestations

part.

time, <3sec. pt. is

functioning.

able to feel deep touch, raise his

keep

the

body affected or >Provide

> To prevent

neurons have, limited part.

adequate rest

further stress &

ability

periods as well as

fatigue

to

Because compensatory repair

Long Term 78

right arm and leg,

themselves unlike other

comfort & safety

Objective:

w/ slurred speech,

body tissues that is why Long Term

measures

After 2-3 days of

w/ left sided

nerve cells cannot be Objective:

weakness, with

repaired

limited ROM on

due to injury or disease.

if

damaged After 2-3 days of nursing

nursing >Turn pt. slowly

> To provide

intervention, the pt.

from side to side

proper circulation

shall be able to

upper and lower

intervention, the

of blood flow on

demonstrate

extremities,

pt. will be able to

both sides

behaviors that

afebrile, (-) DOB,

demonstrate

(-) chest pain.

behaviors that

>Determine pt.

>To assess

enable

level of mobility

functional ability

>Assist pt. in his

>To promote

activities

optimal level of

enable resumption of activities.

resumption of The patient may also manifest he

activities.

following:

function

>Slowed

>Encourage

>Promotes well-

movement,

adequate intake

being and

>Postural

of fluids &

maximizes

instability during

Nutritious foods

energy

performance of

production.

ADLs >Movement

>Involve client’s

>To assist in

induced shortness

SO in care

learning ways of

of breath.

managing 79

problems of immobility.

Problem: 4 Activity Intolerance r/t immobility Assessment

Nursing

Scientific

Objective

Nursing

Expected

Diagnosis Activity

Explanation Infarction on the

Intolerance r/t

right hemisphere

immobility

has a contra

nursing

lateral

intervention the

O>The Patient

manifestation of

patient will use

Manifests:

either left side

identified

paralysis and/or

techniques to

>Assess General

>To note for

techniques to

weakness due to

enhance activity

Condition

signs and

enhance activity

>with Paralysis

left hemisphere

tolerance.

symptoms

tolerance.

of the Left Body

affectation

Side

causing the

>with Left side

immobility

weakness

because of

>with Blurred

stiffness of

Vision

muscle and

>with infraction

unability to

S>O

Short Term:

Intervention >Establish Rapport

Rationale

After 3 hrs of

>To gain patient’s Trust

Outcome Short Term: After the nursing

>Assess V.S.

>To gain

intervention the

baseline data

patient shall use identified

>Adjust Activity

>To prevent overexertion

Long Term: After 3 days of nursing

>Provide positive

>to minimize

atmosphere

frustration

Long term: After the nursing 80

on right

mobilize due to

intervention the

>Promote comfort

>to enhance

intervention the

hemisphere

the

patient will

measure and

ability to

patient shall

>requires

manifestation of

demonstrate

provide for relief of

participate in

demonstrate

assistance and

the disease

increase in

pain

activities

increase in

guidance from

condition.

activity

S.O.

tolerance.

activity >Provide ROM

>to promote

tolerance.

circulation >Give client

>to sustain

The Patient may

information that

motivation

Manifest:

provides evidence/difference

>headache >pain

>Assist client in

>to prevent

>irritable

learning and

injuries

>discomfort

demonstrating

>cold clammy

appropriate safety

skin

measures

>dehydration

Problem No: 5 impaired verbal and/or written communication r/t impaired cerebral circulation 81

ASSESSMENT

NURSING

SCIENTIFIC

PLANNING

DIAGNOSIS impaired verbal

EXPLANATION There is an affectation Short Term

and/or written

of

communication

lobes that caused by After 3 hrs of nsg

The patient

r/t impaired

impaired

manifested the

cerebral

circulation that affects able to verbalize

following:

circulation

its proper functions that or indicate

S= 0

the

leads

certain

delayed

palpebral

ability

conjunctiva, w/

Establish rapport

brain Objective:

RATIONALE

OUTCOME Short Term

therapeutic

Objective:

relationship

After the nrsing intervention the pt

Monitor v/s

To obtain

shall verbalize ir

baseline data

indicate

decreased, understanding of or

understanding of Assess pt’s

To note for the

communication

general condition

etiology or

difficulty and plans

process, transmit and difficulty and

precipitating

for ways of

pale nail beds, w/

use

o plans for ways of

factors that can

handling

capillary refill

symbols

in handling.

lead to fever.

time, <3sec., pt.

communicating

is able to feel

resulting

deep touch, raise

verbal communication.

to a

absent the

EXPECTED

To gain pt’s

cerebral int. the pt will be

to

O= w/ pale

INTERVENTIONS

receive, communication system

in

impaired

Note results of

To assess

Long Term

neurological

causative/contrib

Long Term

his right arm and

Objective:

testing such as

uting factors

Objective:

leg, w/ slurred

After 3 days of

EEG/CTscan and

After the nursing

speech, w/ left

nursing

the likes

intervention the pt

sided weakness,

intervention the

with limited ROM

pt will establish

Assess

To assess

establish methods

on upper and

method of

environment

causative/contrib

of communication

lower extremities,

communication in

factors that may

uting factors

in which can be

which needs can

affect ability to

shall be albe to

expressed. 82

The patient may

be expressed.

communicate

also manifest he following:

Establish

To assist client to

relationship with

establish a

>weakness

the client ,

means of

>headache

listening carefully

communication to

>dyspnea

and attending to

express needs,

>unable to speak

clients

wants, ideas and

>discomfort

verbal/nonverbal

questions

>irritability

expressions

>low self esteem >Difficulty in

Maintain a calm,

Individuals may

expressing needs

unhurried

talk more easily

manner, provide

when they are

sufficient time for

rested and

the client to

relaxed

responds Anticipate needs until effective

To attend pt’s

communication is

needs

reestablished

immediately

Administer due

For pt’s recovery

meds

and to treat 83

underlying conditions

Problem No: 6 Risk for Aspiration ASSESSMENT S= 0 The patient manifested the ff: O= Dysphagia, impaired swallowing The patient may also manifest the ff: >Depressed gag reflex. >Reduced level of consciousness

NURSING DIAGNOSIS Risk for Aspiration

SCIENTIFIC EXPLANATION When there is a blockage of vertebrobasilar artery there will be Cranial nerves affectations. CN V, VII, IX, XII blockage may result to dysphagia or difficulty of swallowing which thereby having high risk for aspiration.

PLANNING Short term objective: After 5hrs. of Nursing intervention, the pt. demonstrate techniques to prevent aspiration. Long Term Objective: After 1-2 days of Nursing Intervention, the pt. will experience no aspiration aeb noiseless respirations, and clear breath sounds.

INTERVENTIONS

RATIONALE

>Established Rapport

>To gain the trust & compliance of the patient & SO

>Monitored Vital signs

> To identify any other deviations from normal.

>Note level of consciousness of surroundings, and cognitive impairment.

>To assess if there is gag reflex or difficulty of swallowing.

>Suction as needed

>To clear secretions

>Auscultate lung sounds

>to determine presence of secretions

>Give semisolid

>To prevent

EXPECTED OUTCOME Short term objective: The patient shall have demonstrated techniques to prevent aspiration. Long Term Objective: The patient shall have experienced no aspiration aeb noiseless respirations, and clear breath sounds.

84

foods; avoid pureed that may increase risk of aspiration.

aspiration and to aide swallowing effort.

>Provide very warm or cold liquids

>This activates temperature receptors in the mouth that help to stimulate swallowing.

>Refer to speech therapist

>To strengthen muscles and techniques to enhance swallowing.

Problem no: 7 Risk for impaired skin integrity 85

ASSESSMENT

S= 0

The patient manifested the following:

O= with dysphagia, with reports of body malaise, increased urine output indwelling Foley catheter, pallor, cold skin, physical immobility.

NURSING DIAGNOSIS

Risk for Impaired skin integrity

SCIENTIFIC EXPLANATION

The skin is the baseline defense of the body against infection. Any break in the skin may harbor microorganisms that may invade the normal processing of the body, which may inflict or aggravate the pt’s disease condition.

PLANNING

Short Term Objective: After 4 hr of nursing intervention the pt will take actions regarding minimizing the risk

Long Term Objective: After 3 days of NI, pt will be free of the risk.

INTERVENTIONS

RATIONALE

EXPECTED OUTCOME

Establish therapeutic relationship

To gain pt’ and SO’s trust and cooperation

The pt shall have

Monitor v/s

To obtain baseline data

minimizing the risk

Assess pt’s general condition

To note for the etiology or precipitating factors that can aggravate the risk. To have a baseline data regarding input and output

Monitor I&O

Encourage increase OFI to al least 2-3 liters per day

To maintain hydration status .

Arrange bed linens

To prevent increase pressure

Encourage and assist client to active and passive ROM

To maintain blood flow

took actions regarding

The pt shall have been free from risk.

86

exercises Encourage rest opportunities

To promote optimum level of functioning

Provided comfort measures and safety

To let pt feel safe and comfortable

Carefully wash and pat dry skin, including skinfold area. Use hydration and moisturization on all at-risk surfaces.

To maintain skin moisture

Assist client in changing positions every two hours

To prevent pressure ulcer

Provided Health information regarding the occurring problem

To lessen the pt’s feeling of anxiety

Provided conducive

To promote rest and pt’s wellness 87

environment for resting Encourage client to have balanced diet especially with increased intake of vitamin C and Protein. Monitor and Regulate IVF as per doctor’s order

To promote adequate nourishment.

For proper replacement of fluid losses.

Problem: 8 Risk for deficient fluid volume 88

Assessment S> O>the patient manifested:  Fatigue  Weakness  Polyuria  Pale to pink palpebral conjunctiva  Change in mental status

 The patient may manifests:  Hemoconcentr ation  Pale skin  Poor skin turgor  Capillary refill time of less than 3 secs.

Nursing Scientific Explanation Diagnosis Risk for Deficient Since the patient had Fluid Volume AEB polyuria, she polyuria experienced frequent urination and with that, she might have lost fluids that could lead to deficient fluid volume. She, then is at risk of fluid volume deficit.

Objectives

Expected Outcome

Interventions

Rationale

Short Term After 4 hours of nursing interventions, patient/SO demonstrate behaviors and techniques to correct deficit

>Evaluate nutritional status, noting current intake, weight changes, and problems with oral intake. Measure subcutaneous fat and muscle mass

> Assess causative factors leading to deficit

Short Term:

Long Term: After 2-3 days of nursing interventions, patient will demonstrate management to prevent fluid volume deficit

>Assess vital signs; note strength of peripheral pulses. Measure blood pressure. Note presence of physical signs. Monitor I/O, color measure amount and specific gravity of the urine.

>Evaluate degree of deficit

Long Term:

>Establish 24-hour replacement needs and routes to be used. >Note client preference

> Prevent peaks and valleys in fluid level

Patient shall have demonstrated behaviors and techniques to correct deficit

Patient shall have demonstrated management to prevent fluid volume deficit.

>Encourage the client to increase 89

concerning fluids and foods with high fluid content

intake of foods high in fluid content

>Provide nutritious diet via appropriate route

>Correct/Replace fluid losses to reverse pathophysiologic mechanism

>Weigh daily

>Assess progress or status of efforts

>Bathe less frequently using mild cleanser/soap and provide optimal skin care

>Maintain skin integrity and prevent excessive dryness

>Provide frequent oral and eye care

>Prevent injury from dryness

>Change position frequently

>Promote comfort and safety

>Discuss factors related to occurrence of the deficit as individually appropriate. Instruct client how

>Promote wellness

90

to measure and record I/O

Problem: 9 Risk for imbalanced nutrition: less than body requirements Assessment S> O> The patient manifested: -muscle weakness - with contralateral hemiparesis - pale to pink palpebral conjunctiva - sensory loss > The patient may manifest: - loss of weight - capillary fragility - decreased in subcutaneous fats and muscle mass

Nursing Diagnosis Risk for imbalanced nutrition: less than body requirements AEB inability to ingest adequate nutrition

Scientific Explanation A paralysis and muscle weakness could lead to impaired mobility, lack of adequate strength to do activities of daily living such as eating. As the patient does not ingest adequate food first because she was ordered to be on NPO, second because she could not ingest the food adequately as she has paralysis, she could be at risk of imbalanced nutrition: less than body requirements.

Objectives SHORT TERM: After 4 hours of NI, the patient will verbalize understanding of causative factors when known and necessary interventions. LONG TERM: After 4 days of NI, the patient will demonstrate behaviors to regain or maintain appropriate weight.

Nursing Interventions >Establish therapeutic relationship

Rationale

Expected Outcome

>To obtain trust and cooperation of the pt.

>Assess and monitor vital signs

>To obtain baseline date

>Identify clients at risk for malnutrition

>To assess causative factors

SHORT TERM: The patient shall have verbalized understanding of causative factors when known and necessary interventions.

>Determine ability to chew, swallow and taste

>Factors that can affect ingestion or digestion of nutrients

>Discuss eating habits, including food preferences, intolerances, aversions

>To appeal to clients likes/desires

>Assess weight, age, body build, strength, activity/rest level

>Provides comparative baseline

LONG TERM: The patient shall have demonstrated behaviors to regain or maintain appropriate weight.

91

>Note total daily intake

>To reveal changes that should be made in client’s dietary intake

>Provide diet modifications indicated for the client’s condition or health status

>To establish a nutritional plan that meets individual needs

>Increase oral fluid intake

>To prevent dehydration and liquefy respiratory secretions

>Encourage client to choose foods that are appealing

>To stimulate appetite

>Limit fiber/bulk if indicated

>May result to early satiety

>Promote pleasant, relaxing environment

>To enhance intake

>Provide oral care before/after meals

>To keep mouth clean

>Emphasize importance of wellbalanced, nutritious

>To promote wellness 92

intake >Give supplemental humidification as needed (oxygen supply)

>To humidify airways and supplement need for oxygen

Problem no: 10 Risk for Infection ASSESSMENT

NURSING DIAGNOSIS

Risk for Infection S= 0

The patient manifested the following:

O= with dysphagia, with reports of body malaise, increased urine output indwelling Foley catheter, pallor, cold skin, cracked and cry lips.

SCIENTIFIC EXPLANATION

An infection is the detrimental colonization of a host organism by a foreign species. In an infection, the infecting organism seeks to utilize the host's resources to multiply. The infecting organism, or pathogen, interferes with the normal functioning of the host and can lead to chronic wounds, gangrene, loss of an infected limb, and even death.

PLANNING

Short Term Objective: After 4 hr of nursing intervention the pt will demonstrate appropriate hygienic measures such as hand washing, oral care, and perineal care

Long Term Objective: After 3 days of NI, pt will maintain

INTERVENTIONS

RATIONALE

EXPECTED OUTCOME

Establish therapeutic relationship

To gain pt’ and SO’s trust and cooperation

The patient shall

Monitor VS

To obtain baseline data

measures such as

Assess pt. general condition

To note for the etiology or precipitating factors that can aggravate the risk.

Observe and report signs of infection such as redness, warmth, discharge, and increased body temperature.

To have a baseline data regarding client’s risk

have demonstrated appropriate hygienic hand washing, oral care, and perineal care

The pt shall have maintained white blood cell (WBC) count and differential within 93

white blood cell (WBC) count and differential within normal limits.

normal limits. Assess skin for color, moisture, texture, and turgor (elasticity). Keep accurate, ongoing documentation of changes. Preventive skin assessment protocol, including documentation, assists in the prevention of skin breakdown. Carefully wash and pat dry skin, including skinfold areas. Use hydration and moisturization on all at-risk surfaces. Encourage a balanced diet, emphasizing proteins, fatty acids, and

To note for degree of deficiency

To promote optimum level of functioning

To prevent skin impariment

To promote pt’s wellness

94

vitamins listed below. Encourage fluid intake. Use appropriate "hand hygiene" (i.e., hand washing or use of alcohol-based hand rubs). Use careful technique when changing and emptying urinary catheter bags. Ensure the client's appropriate hygienic care with hand washing; bathing; and hair, nail, and perineal care performed by either the nurse or the client. Administer antibiotics; use

To maintain hydration status To prevent nosocomial infection

To avoid cross contamination

To prevent good source of bacterial multiplication

To pharmacologically manage the 95

antibiotics sparingly as per doctor’s order

problem.

Problem No: 11 Risk for Injury ASSESSMENT

S= 0 The patient manifested the following: O= with limited range of motion. contralateral hemiparesis, sensory loss, muscle weakness, Blurred vision The patient may also manifest he following: >Fatigue >headache

NURSING DIAGNOSIS Risk for Injury

SCIENTIFIC EXPLANATION Because of limited range of motion and slightly paralyze body the patient is unable to mobilize properly which maybe a risk for injury.

PLANNING

INTERVENTIONS

RATIONALE

Short Term Objective: After 2 hr of nursing intervention the pt will demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury

>Establish rapport

>To gain pt’ and SO’s trust and cooperation

>Monitor v/s

>To obtain baseline data

>Assess pt’s general condition

>To note for the etiology or precipitating factors that can lead to fever.

>Assess mood, coping abilities, personality styles

>that may result in carelessness and increased risk taking without considerations of consequences

>Identify

>To promote safe

Long Term Objective: After 2 days of NI, pt will be free of injury

EXPECTED OUTCOME Short Term Objective: The patient shall have demonstrated behaviors, lifestyle changes to reduce risk factors and protect self from injury

Long Term Objective: The patient shall have been free of injury.

96

>Dizziness

interventions and safety devices

physical environment and individual safety

>Encourage participation in self-help programs, such as assertiveness training, positive self image

>To enhance self esteem. sense of worth

>raise the side rails of the bed

>To promote safe physical environment and individual safety

>Frequent skin inspection

> To assess if there is presence of pressure ulcers.

>Use effective lighting

>To promote safety and easy scanning of the environment.

>Remind client to walk slowly

>To prevent injury due to slipping, and to promote safety. 97

>Keep things into right premises and clear the way going to the restroom

>To prevent injury and promote safety.

Problem No: 12 Self Care Deficit: Bathing/Hygiene ASSESSMENT

NURSING

SCIENTIFIC

PLANNING

INTERVENTION

RATIONALE

EXPECTED

DIAGNOSIS Self Care deficit

EXPLANATION Body movements are Short Term

S >Established

> To gain trust of

OUTCOME Short Term

r/t

possible because of the Objective:

Rapport

the patient and

Objective:

The patient

neuromuscular,

movement of impulses After 4 hrs. Of

SO in order to

After 4 hrs. Of

manifested the

musculoskeletal

elicited by such stimuli Nursing

acquire

Nursing

following:

impairment

which

S= 0

then

passes Intervention, the

compliance with

Intervention,

our

nerves pt. will be able to

appropriate

pt. shall be able to

through O= w/ pale

going to our neurons identify personal

treatments or

identify

palpebral

which

teachings

resources

conjunctiva, w/

interpreted by our brain. can help in

pale nail beds, w/

Nerves

capillary refill

serve as messengers. If assistance.

time, 1-3sec., pt.

these are impaired, the

is able to feel

affectation to the brain

deep touch, raise

function

his right arm and

decreased

leg, w/ slurred

which

are and

then resources which Neurons providing

would may

be Long Term

function Objective: later

on After 2-3 days of

can

the

personal help

>Monitored Vital

> To identify any

providing

signs

other deviations

assistance.

which in

from normal. >Assessed

>To determine

Long Term

patient condition

any other

Objective:

underlying cause

After 2-3 days of 98

speech, w/ left

cause impairment also nursing

of manifestations

nursing

sided weakness,

to other structures of intervention, the

>Provided

> To prevent

intervention,

with limited ROM

the body and this could pt. will be able to

adequate rest

further stress &

pt. shall be able to

on upper and

affect the performance demonstrate

periods as well as

fatigue

demonstrate

lower extremities,

of ADLs. An example of techniques or

comfort & safety

techniques

afebrile, (-) DOB,

that is Impaired ability changes to meet

measures

changes to meet

(-) chest pain.

to

The patient may also manifest he

perform self care needs.

the

self care needs.

bathing/hygiene,

>Turned pt.

> To provide

dressing or grooming.

slowly from side

proper circulation

to side

of blood flow on

following:

both sides of he body

>Inability to get bath supplies

>Determined pt.

>To assess

>Inability to wash

strengths and

degree of

body parts

skills

disability

appropriate

>Assisted pt. in

>To promote

clothing

his activities

optimal level of

>Inability to pick

>Inabiliy to

function

replace articles or clothing on own

>Encouraged

>Promotes well-

>Inability to

adequate intake

being and

maintain

of fluids &

maximizes 99

or

appearance at a

Nutritious foods

satisfactory level

energy production.

>Provided time

>To assist with

for listening to

the patient’s

patient and SO,

current disability

and provided

or condition.

privacy during personal care activities. >Involved client’s

>To assist in

SO in care

learning ways of managing problems of immobility and for providing appropriate nursing care.

> Provided health

>To provide

teachings and

clarification

support o the SO

Reinforcement

for care options

and and periodic Review by client/caregivers.

100

B. Actual Soapies 01-30-09 S =”masakit ku atsan” O =received with patient lying on bed awake and coherent, afebrile with Ivf # 2 of D50.3 NaCl regulated at 20 gtts/min at level of 400cc infusing well on right hand with indwelling folley catheter connected to urine bag draining a dark yellow urine at level of 1000cc, with facial grimace, with guarding behaviors, with dull abdominal pain, with pain scale of 8/10, with pale to pink palpebral conjunctiva, with capillary refill time of 1-3 seconds, with left side paralysis, with VS are as follows: Temp: 36.7c, PR: 71 bpm, RR: 21 bpm, BP: 130/70 mmHG A =Acute Pain P =After 2 hrs of nursing intervention the pt will verbalize relief of pain from 8/10 to 4/10 I = Established rapport = Assessed and Recorded VS = Maintained and Regulated IVF = Assessed General Condition = Encouraged diversional activities such as talking to S.O. = Encouraged rest to overcome pain = Assisted the pt to turn to side q 2hr = Encouraged deep breathing and coughing exercises = Provided comfort and safety measures = Provided back rubbing to alleviate pain = Secured and Documented Lab Result = Seen on round by Dr lumboy with orders made and carried out: -hold hydralazine IV PRN – meds updated

101

-for fecalysis – requested -D/C ranitidine – meds updated -Monitor BD q 4hr -Bladder training q2 = Due meds Given as ordered and indicated by doctors E = Goal met as pt verbalized a relief of pain

01-31-09 S=O O = received with patient on bed conscious and coherent, afebrile with an IVF #2 d5 0.3 NaCl 500cc regulated at 20 gtts/min at level of 50cc infusing well on right hand with indwelling folley catheter connected to a urine bag draining a dark yellow urine, with weak appearance, with moist skin, with good skin turgor, (+) pallor, GCS of 15, with dec. Hgb 8mg, with dec. Hct 27 Vol. right ext. 5/5 and 5/5 and left extremity of 0/5 and 4/5, with left side body paralysis. A = Ineffective tissue perfusion r/t decreased Hgb concentration in the blood P = after 4 hrs of nsg. Int. the pt will demonstrate understanding of health teachings I = Established Rapport = Assessed and Recorded VS = Assessed General Condition = Maintained and Monitored IVF = Instructed pt to increase OFI = Instructed pt to Iron rich foods = Provided assistance in turning pt to side q 2 hr = Provided ROM exercises to promote blood circulation

102

= Instructed pt on strict compliance to medication = Changed IVF with D5o.3 NaCl 500cc regulated at 20 gtts/min = Provided Adequate rest periods = Assessed range of movement = Prescribed all unavailable meds = Provided health teaching regarding problems E = Goal met As evidenced by pt and S.O. adheres with the health teachings VI. CLIENT’S DAILY PROGRESS IN THE HOSPITAL 1. Client’s Daily Progress Chart (From admission to discharge) Days

01-27-09

01-28-09

01-29-09

01-30-09

*

*

01-31-09

(Admission) Nursing Problems: 1.) Acute Pain 2.) Impaired cerebral tissue

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

perfusion 3.) Impaired physical mobility 4.) Activity Intolerance 5.) Impaired verbal and/or written communication 6.) Risk for Aspiration 7.) Risk for impaired skin integrity

103

8.) Risk for

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

36.2c

36.5c

37c

36c

36c

Pulse Rate

84 bpm

88 bpm

76 bpm

71 bpm

69 bpm

Respiratory rate

18 bpm

22 mmHg

19 bpm

17 bpm

18 pbm

Blood Pressure

170/100

140/50

180/90

180/90

170/90

mmHg

mmHg

mmHg

mmHg

mmHG

deficient fluid volume 9.) Risk for imbalanced nutrition: less than body requirements 10.)Risk for Infection 11.)Risk for Injury 12.)Self care Deficit

Vital Signs: Temperature

Diagnostics Procedures:

*

1.) CXR APL

*

2.) Fecalysis 3.) Urinalysis 4.) Potassium K 5.) CBC

*

*

*

104

*

Drugs: 1. Piracetam 2. Captopril 3. Ranitidine

*

*

*

*

*

*

*

D/C

*

*

*

*

*

*

*

*

4. Simvastatin 5. Metoprolol 6. Ketosteril 7. FeSo4

*

*

8. Hydralazine

* *

Hold

*

*

*

*

*

*

*

*

*

*

*

*

Medical managements: 1. D5 LRS 1L 2. D5 0.3 NaCl

*

500cc Diet: 1. NPO

*

2. Soft Diet Activity/Exercises: 1. High Back Rest

*

VII. Conclusion Stroke is a term used to describe the neurologic changes caused by an interruption in the blood supply to a part of the brain. The incidence of stroke and stroke

105

mortalities has gradually declined in many industrialized countries in recent years as a result of increased recognition and treatment of risk factors, which may include modifiable risk factors such as hypertension Public education is focused on prevention, recognition of manifestations and early treatment of brain attack. As they say prevention is better than cure. Therefore it is important for each and every one of us to avoid these modifiable risk factors and change sedentary lifestyles to healthy lifestyles. Cholesterol levels should be brought to a normal level, diabetes should be controlled and reducing heavy alcohol consumption. The best intervention is to stop smoking cigarettes. As nursing students, this study showed us the importance of early detection of diseases such as stroke since it may lead to more serious conditions if it is not properly managed or treated. Knowledge of the risk factors and preventive measures can help in reducing the incidence of stroke. Prompt recognition, which allows for early treatment of stroke is recommended to lessen residual deficits and decreased disability. Through this study, may we be able to help others to understand and know more about stroke and ways to prevent and treat its signs and symptoms. The group was able to assess one patient having a case of Cerebral vascular accident and through the study of case the group was able to identify of the causative factors that predisposes the patient in acquiring such disease condition. Furthermore the group was able to identify how was it occurred and how it would be worse if left untreated, with several condition such as this case a lot of problems has occurred that would might permanently affect the lifestyle of the patient. In this study the group was able to be familiarized to medical managements and its benefits and s side effect to patient during therapy

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VIII. Bibliography Joyce M. Black et al (2005) Medical Surgical Nursing 7th edition Elsevier Suanders Smeltzer, S. et. al. (2008). Brunner and Suddarth’s Textbook of Medical-Surgical Nursing 11th edition. Philadelphia: Lippincott-Williams & Wilkins Spratto, G. and Woods, A. (2008). 2008 Edition PDR® Nurse’s Drug Handbook. New York: Thomson Delmar Learning. Berman, A. et. al. (2008). Kozier & Erb’s Fundamentals of Nursing: Concepts, Process and Practice 8th edition Jurong, Singapore: Pearson Education South Asia Seely, R., Stephens, T., Tate, P. (2007). Essentials of Human Anatomy & Physiology 6th edition. New York: McGraw-Hill. Van Leeuwen, A., Kranpitz, T., Smith, L., (2006) Davis’s Comprehensive Handbook of Laboratory and Diagnostic Test with Nursing Implication 2nd edition, U.S.A, F.A Davis Company Nurse’s Quick Check - Signs and Symptoms (2006) Philadelphia, Lippincott Williams & Wilkins Nurse’s 5- minute Clinical Consult – Diseases, (2007) Philadelphia, Lippincott Williams & Wilkins Hansel, D., Dintzis, R. (2006) Lippincott’s Pocket Pathology, Philadelphia, Lippincott Williams & Wilkins Stewart, Joseph (1989) Clinical Anatomy and Pathophysiology for the Health Professional, Miami, MedMasters Inc. Web information retrieved at: http://en.wikipedia.org/wiki/Nervous_system accessed on January 30, 2009 10:58pm http://www.emedicinehealth.com/anatomy_of_the_endocrine_system/article_em.htm accessed on January 20, 2008 10:00pm http://en.wikipedia.org/wiki/Cardiovascular_system accessed on January 31, 2009 5:00pm http://www.enotes.com/nursing-encyclopedia/cerebrovascular-accident accessed on January 31, 2009, 9:46 pm

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