Cerebrovascular Accident

AMA Computer Learning Center St. Augustine School of Nursing

A Case Study Presented to the faculty of AMA Computer Learning Center Guagua, Pampanga

Cerebrovascular Accident Submitted to: Mr. John Eric T. Salvador B.S.N, R.N

Submitted by:

Almario, Jeanette Cayanan. Gemmalyn Joy Quitaleg, Mary Jane Santos, Cariza Joy M. 3k-PN

October ‘09

Table of Content

Page

Introduction

1

Personal History Lifestyle and Diet

2 3

Complete Physical Assessment

4-9

Neurological Assessment

10-11

Laboratory Procedure

12-13

Diagnostic Procedure

14

Anatomy and Physiology

15-17

Pathophysiology of Cerebrovascular Accident Drug Study Diet and Activity

20-21 23

SOAPIE (actual) SOAPIE (potential)

18-19

24 25

Conclusion

26

Recommendations

27

Bibliography

28

NCP (actual/ potential )

29-33

Introduction

A stroke is damage to part of the brain when its blood supply is suddenly reduced or stopped. A stroke may also be called a cerebral vascular accident, or CVA. The part of the brain deprived of blood dies and can no longer function. Blood is prevented from reaching brain tissue when a blood vessel leading to the brain becomes blocked (ischemic) or bursts (hemorrhagic). The symptoms of a stroke differ, depending on the part of the brain affected and the extent of the damage. Symptoms following a stroke come on suddenly and may include: weakness, numbness, or tingling in the face, arm, or leg, especially on one side of the body trouble walking, dizziness, loss of balance, or coordination inability to speak or difficulty speaking or understanding, trouble seeing with one or both eyes, or double vision, confusion or personality changes, difficulty with muscle movements, such as swallowing, moving arms and legs, loss of bowel and bladder control, severe headache with no known cause, and loss of consciousness. There are following metabolic disorder that may contribute to stroke, excess weight around the waist (waist measurement of more than 40 inches for men and more than 35 inches for women) triglycerides blood level of 150 mg/dL or more, HDL cholesterol levels below 40 mg/dL for men and below 50 mg/dL for women, blood pressure of 130/85 mm HG or higher and prediabetes (a fasting blood sugar between 100 and 125) or diabetes (a fasting blood sugar level over 125 mg/dL).

Latest Trend (Medication for Cerebrovascular Accident) Anti-platelet medicines like aspirin, clopidogrel, extended release dipyridamole and aspirin in combination, and ticlopidine help prevent stroke because they keep the blood from clotting. Like aspirin, these medicines keep your blood from clotting. They are available only prescription. dipyridamole and aspirin combination (Aggrenoxl®), clopidogrel (Plavixl®), ticlopidine (Ticlidl®).Anti-coagulant medicines keep you from getting blood clots. You may hear people call these medicines "blood thinners." Warfarin (Coumadinl®) is often used in patients who have heart problems or artificial heart valves. Tissue plasminogen activator (tPA or thrombolytic therapy) dissolves blood clots, but it may cause bleeding (including bleeding into the brain).This medicine must be given within 3 hours of the start of stroke symptoms. You will not be given t-PA if your blood pressure is too high, if changes on a CT scan show it should not be given, or if the risk of bleeding is too great. Heparin / heparinoid medicines slow the creating of blood clots. But there is little, if any, benefit in treating stroke. The medicines also can cause bleeding.

1.

2.

Personal History

Name: Mr. D

Address:

San Rafael, Guagua

Age: 43 yrs. Old

Work:

Jeepney Driver

Chief Compliant: Impaired Verbal Communication 2.1 Family Health History

2.

2.2 Past

Health History

Mr. D’s wife verbalized that Mr. D was already been confined on the hospital before due to mild stroke last year December 2008 , will he is in their house he experienced sudden headache, dizziness, numbness, blurred vision and that made his wife to bring him into the hospital. Mr. D was confined for 4 days and after a week he was able to work again as jeepney driver though the doctor said he need to take rest from work, avoid stress, smoking, alcohol intake, and high fat/ salt food to avoid the stroke.

2.3 Present Health History Mr. D was been confined again in the hospital of DPMMH last August 27, 2009 and he spent more than 7 days in the hospital. Mr. D’s wife said that while Mr. D is talking with his friend and drinking alcohol he experienced severe headache, sudden dizziness, paralysis in the right part of his body, numbness, blurred vision and loss of consciousness. And made his family to bring him into the hospital.

3. Lifestyle

and Diet

Mrs. D said that his husband was a smoke, he consumed more than 30-40 pieces a day (1 1/2 pack) since 20 years old and he also drink 1 bottle of alcohol since 23 years old. Mrs. D said that her husband likes to eat pork after a long day of handling his jeep.

3.

4. Complete

Physical Assessment

Date assessed: September 4, 2009 Time Assessed: 9:00 A.M Initial Vital Signs: Temperature: 36.3 C Pulse Rate: 77 cpm Respiratory Rate: 21 cpm Blood Pressure: 140/ 100mmHg • • •

General Appearance: The pt. is awake, lying on bed, unconscious with an IVF of PNSS regulated @ 10-15 gtts./min. (KVO) 200ml. level infusing well @ left hand. With Nasogastric Tube inserted. With Foley catheter inserted (2000 ml. urine bag)

Area Assessed

Technique Used

Normal Findings

Actual Findings

SKIN color

Inspection

Tan

Pale

Texture Turgor

Palpation Palpation

Hair Distribution

Inspection

Temperature Moisture

Palpation Palpation

Smooth, soft Skin snaps back immediately When pinched Evenly distributed Warm to touch Dry, skin folds are normally moist

Smooth, soft Skin snaps back immediately When pinched Evenly distributed Warm to touch Dry, skin folds are normally moist

NAILS Color of Nail bed Texture Shape

Inspection Palpation Inspection

Pink and clear Smooth Convex curvature Firm 2-3 seconds

Pink and clear Smooth Convex curvature Firm 4 sec.

Black (varies) Evenly distributed Neither excessively dry

Black (varies) Evenly distributed Neither excessively dry

Nail base Capillary refill time

Inspection Blanch test

HAIR Color Distribution

Inspection Inspection

Moisture

Inspection

Analysis Due to decrease oxygen supply. Normal Normal

Normal Normal Normal

Normal Normal Normal Normal Due to decrease oxygen supply. Normal Normal Normal

Texture HEAD

Inspection

nor oily Silky, resilient

Scalp symmetry

Inspection

Symmetrical

Symmetrical

Normal

Skull size Shape

Normocephalic Round

Normocephalic Round

Normal Normal

Nodules/ masses

Inspection Inspection and Palpation Palpation

Absence of nodules and masses

Absence of nodules and masses

Normal

FACE Symmetry

Inspection

Symmetrical

Symmetrical

Normal

Facial movement

Inspection

Symmetrical

Symmetrical

Normal

Skin color

Inspection

Tan

Pale

EYES Eyebrows

Inspection

Eyelashes

Inspection

Eyelids

Inspection

Ability to blink

Inspection

Symmetrically aligned, equal movement Slightly curved upward Smooth, tan, do not cover pupil as sclera, close symmetrically Blinks involuntarily.

Frequency of blinking Ocular movement

Inspection

Position

Inspection

Size Texture

Inspection Palpation

Symmetrically aligned, equal movement Slightly curved upward Smooth, tan, do not cover pupil as sclera, close symmetrically Blinks voluntarily and bilaterally 20 blinks per min. Eye moves freely Drawn from lateral angel Medium Mobile, firm and non-tender

Due to decrease oxygen supply. Normal

CONJUCTIVA Color

Inspection

Texture

Inspection

Presence of lesions APPARATUS

Inspection

Transparent with light color Shiny and smooth No lesions

Transparent with light color Shiny and smooth No lesions

Inspection

nor oily Silky, resilient

Normal

To speech. Lack of eye movement Drawn from lateral angel Medium Mobile, firm and non-tender

Normal Normal

Due to damage of Broca’s area. Due to damage of Broca’s area. Due to damage of Broca’s area. Normal Normal Normal Normal Normal Normal

Cornea Color Texture

Inspection Inspection

Black Shiny and smooth

Black Shiny and smooth

Normal Normal

PUPILS Color Reaction to light

Inspection Inspection

Inspection Inspection

Symmetry Visual Acuity

Inspection Inspection

Black Pupils Equally Round and React to Light Accommodation (PERRLA) Equal Round and constrict briskly Equal in size Cannot able to real news print.

Normal Normal

Size Shape

Black Pupils Equally Round and React to Light Accommodation (PERRLA) Equal Round and constrict briskly Equal in size Able to real news print

Visual Fields

Inspection

Ocular

Inspection

When looking straight ahead, client can see objects in periphery Eyes move freely

With blurred vision and cannot classify objects in periphery. Eyes move freely

Symmetrical, smooth and tan Reddish to pinkish

Symmetrical, smooth and tan Reddish to pinkish

Normal

Oval, symmetrical No discharge Not tender

Oval, symmetrical No discharge Not tender

Normal

NOSE Symmetry, shape, size and color Mucosa color

Inspection Inspection

Normal Normal Normal Due to damage of the left hemisphere of the brain. Due to damage of the left hemisphere of the brain. Normal

Normal

NASAL SEPTUM Nares Inspection Nasal discharge Sinuses MOUTH Secretion

Inspection Inspection

Normal Normal

Inspection

(neutral in color) without mucus production

without mucus production

Normal

Lips Color

Inspection

Pinkish to slightly brown

Symmetry Texture

Palpation Palpation

Due to decrease oxygen level Normal Normal

Moisture

Palpation

Symmetrical Soft, moist, smooth Soft and moist

Dark and brown and cracking lips Symmetrical Soft, moist, smooth Dry

Due to

decrease oxygen. GUMS Color

Inspection

Pinkish

Pale

Moisture BUCCAL MUCOSA Color

Palpation

Moist

Moist

Inspection

Glistening pink

Slightly pale

Texture Moisture TOUNGE Color

Palpation Palpation

Soft Moist

Soft Moist

Inspection

Pinkish

Slightly pinkish

Size Symmetry Mobility UVULA Location Symmetry TONSILS Color Discharges TEETH Color Number of teeth

Inspection Inspection Inspection

Medium Symmetrical Moves freely

Medium Symmetrical Moves freely

Due to decrease oxygen. Normal Normal Normal

Inspection Inspection

At the midline Symmetrical

At the midline Symmetrical

Normal Normal

Inspection Inspection

Pinkish No discharges

Pinkish No discharges

Normal Normal

Inspection Inspection

Ivory/yellowish 32

Yellowish 28

Normal Due to tooth decay (teeth extraction)

Inspection Inspection Inspection

Head-centered Moves freely Full range

Head-centered Moves freely No ROM

Consistency HEART Heart rate Heart sounds

Inspection

No enlargement

No enlargement

Normal Normal Abnormal due to neuromuscular impairement. Normal

Auscultation Auscultation

77 bpm Clear

Normal Normal

Lung field THORAX & LUNGS POSTERIOR THORAX Symmetry

Auscultation

60-100bpm Clear, without crackles Resonant

Resonant

Normal

Inspection

Symmetrical

Symmetrical

Normal

NECK Position Movement Range of motion

Due to decrease oxygen. Normal Due to decrease oxygen. Normal Normal

Respiratory rate Spinal Alignment

Inspection Inspection

12-20cpm Spine vertically align Skin intact

21 cpm Spine vertically align Skin intact

Normal Normal

Skin integrity ANTERIOR THORAX Breathing pattern

Inspection

Breathing is automatic and effortless, regular and even and produces no noise Bronchiavesicular

Breathing is automatic and effortless, regular and even and produces no noise Bronchiavesicular

Normal

Lung/ breath sounds ABDOMEN Contour Texture Frequency and character

Auscultation Inspection Palpation Auscultation

Flat Smooth Audible; soft gurgling sound occur irregularly and rages from 5-30 mins

Flat Smooth Audible; soft gurgling sound occur irregularly and rages from 5-30 mins

Normal Normal Normal

UPPER EXTREMITY Skin color

Inspection

Tan

Pale

Due to decrease oxygen

Movement

Inspection

With ROM and sensation

With no ROM and sensation

Size (arms) Symmetry Hair distribution

Inspection Inspection Inspection

Equal Symmetrical Evenly distributed

Equal Symmetrical Evenly distributed

Due to neuromuscular impairment Normal Normal Normal

Skin color

Inspection

Tan

Pale

Due to decrease oxygen

Movement

Inspection

With ROM and sensation

With ROM and sensation

Due to neuromuscular impairment and (+) weakness on right lower extremities.

Auscultation

Normal

Normal

LOWER EXTREMITY

Size (legs) Symmetry Hair distribution

Inspection Inspection Inspection

NEUROLOGICAL Level of Interview consciousness

Equal Symmetrical Evenly distributed

Equal Symmetrical Evenly distributed

Can follow instructions and commands Makes eye contact with the examiner

Unconscious

Normal Normal Normal

Due to decrease level of consciousness. Does not make Due to eye contact with decrease level the examiner. of consciousness Expresses Normal feelings which corresponds to the examiner

Behavioral and appearance

Interview

Mood

Interview

Expresses feelings which corresponds to the examiner

MANNERISMS & ACTIONS LANGUAGE Voice inflection

Interview

Clear and strong

Aphasia

Tone

Interview

Fluent and articulated

Aphasia

Manner and speech

Interview

Can give appropriate answer to questions

Cannot give answer or talk.

Interview

Oriented with time

Disoriented with time

Due to decrease level of consciousness

Interview

Recall events readily, immediate recall of remote information Can make logical decisions

Cannot recall events readily, immediate recall of remote information Cannot make logical decisions

Due to aphasia.

MENTAL STATUS Orientation

TIME Recall recent and remote memory

Judgments and thoughts

Interview

Due to damage of Broca’s area in the brain and muscle tone. Due to damage of Broca’s area in the brain and muscle tone. Due to damage of Broca’s area in the brain and muscle tone.

Due to decrease level of consciousness

Neurological Assessment (September 4, 2009) Gloscow Coma Scale Eyes

Verbal

Motor

Normal Values Spontaneous- 4 To speech- 3 To pain- 2 None-1 Oriental- 5 Confused- 4 Inappropriate word- 3 None- 1 Obeys command- 6 Localized pain5 Flexion pain- 4 Abnormal flexion- 3 Abnormal extension- 2 Flaccid- 1

Result To speech- 3

None- 1

Flexion pain- 4

Total GCS Total GCS= 8/15 points.

Interpretation 8/15 pts., good prognosis (15 pts. Pt is alert, can follow simple commands and is completely oriented to time, person and place.) (7 or less= pt is comatose.) (3= indicates deep coma and poor prognosis.z

10.

Cranial Nerve

Normal Result Can smell on both nostrils. With 20/20 vision

Actual Result

Interpretation

Cannot able to extinguish smell Without 20/20 vision.

Occulomotor Nerve Abducens Nerve

PERRLA

PERRLA

Due to decrease LOC. Due to the damage of left hemisphere and decrease LOC. Normal

Lateral movement.

Cannot move eyes in lateral direction.

Trochlear Nerve

Up and down movement.

Pt. cannot move eyes up and down.

Trigeminal Nerve

For touch and pain sensation.

Pt. cannot localize sensation.

Facial Nerve

Can smile, frown, puff the cheek and can feel the cotton. Can hear on both ears.

Cannot follow specific command.

Glossopharengeal

Can swallow.

Vagus Nerve

Check for gag reflex

Inability to swallow due to presence of NGT. With NGT inserted.

Accessory Nerve

With strength on both shoulder.

With no muscle strength.

Hypoglossal Nerve

Sense of taste.

Cannot localize taste.

Olfactory Nerve Optic Nerve

Acoustic Nerve

Date Done September 04. 2009

Cannot follow specific command.

Due to the damage of left hemisphere and decrease LOC. Due to the damage of left hemisphere and decrease LOC. Due to the damage of left hemisphere and decrease LOC. Due to the damage of left hemisphere and decrease LOC. Due to the damage of left hemisphere and decrease LOC. Due to the damage of left hemisphere and decrease LOC. Due to the damage of left hemisphere and decrease LOC. Due to the damage of left hemisphere and decrease LOC. Due to the damage of left hemisphere and decrease LOC.

5.

Laboratory Procedures

Laboratory Procedure Creatine

HDL

Date Done

Normal Values

Result

August 28, 2009

53-115.0

63.6

Nursing Interpretatio n Normal

0.78-2.21

1.30

Normal

Hematocrit 0.37-0.54 g/l

0.44 g/l

Normal

Leucocytes 5-10 x 10 g/l

12.4 x 10 g/l

Platelets 150-450 x 10/l

648 x 10/l

Abnormal due to infection weakened immune response. Abnormal due to blood clot formation.

Nursing Responsibilities Pretest: Explain the procedure to the patient. Instruct the patient to wear easily manipulated clothing to get blood samples easily. Tell the pt. to relax because the procedure is painless. Intra-test: Instruct the patient to look away when the needle is being inserted. Post-test: Put cotton balls on the puncture site to avoid bleeding. Tell the patient to rest after the test.

12.

Laboratory Procedure

Date Done

Normal Values

Result

Nursing Interpretation

Nursing Responsibilities

August 29, 2009

Color Straw/ yellow amber

Yellow

Normal

URINALYSIS

Pre-test: Explain the procedure to the pt. and how he can cooperate.

Transparency Clear Reaction 4.5-8.0

Turbid

Provide privacy.

6.0

Due to infection Normal

Specific Gravity 1.010-1.025 Sugar Negative

1.030

Normal

Negative

Normal

Tell the pt. that the procedure is painless. Post-test: Bring the urine samples in the laboratory.

Albumin Negative

Positive

Due to nearly kidney damage and hypertension.

Intra-test: Instruct the pt. on how to get urine samples (it should be midstream/ sterile technique).

13.

6.

Diagnostic Procedure

Diagnostic Date Done Procedure Electrocardiogram September 1, Report 09

Result Rhythm: Sinus

AL: 120/m PR: 0.20 sec. QRS: 0.40 sec. QT: 0.32 sec. Axis: +250

Interpretation Sinus tachycardia

Nursing Responsibilities Post-test: Explain the procedure to the pt.and how he can cooperate. Tell him to remove all jewelry and coins. Tell him to relax and lie still. Intra-test: Monitor for the result. Post-test: Assist the pt. when he will stand. Remind him about his jewelry and coins or any metal he remove will he is doing the procedure.

14. 7.

Anatomy and Physiology

Cerebellum The cerebellum is involved in the coordination of voluntary motor movement, balance and equilibrium and muscle tone. It is located just above the brain stem and toward the back of the brain. It is relatively well protected from trauma compared to the frontal and temporal lobes and brain stem. Cerebellar injury results in movements that are slow and uncoordinated. Individuals with cerebellar lesions tend to sway and stagger when walking. Damage to the cerebellum can lead to: 1) loss of coordination of motor movement (asynergia), 2) the inability to judge distance and when to stop (dysmetria), 3) the inability to perform rapid alternating movements (adiadochokinesia), 4) movement tremors (intention tremor), 5) staggering, wide based walking (ataxic gait), 6) tendency toward falling, 7) weak muscles (hypotonia), 8) slurred speech (ataxic dysarthria), and 9) abnormal eye movements (nystagmus).

Cerebellum The cerebrum is the part of the brain that occupies the top and front portions of the skull. It is responsible for control of such abilities as movement and sensation, speech, thinking, reasoning, memory, sexual function, and regulation of emotions. The cerebrum is divided into the right and left sides, or hemispheres. Depending on the area and side of the cerebrum affected by the stroke, any, or all, of the following body functions may be impaired: • • • • • • • • • •

movement and sensation speech and language eating and swallowing vision cognitive (thinking, reasoning, judgment and memory) ability perception and orientation to surroundings self-care ability bowel and bladder control emotional control sexual ability

15.

Limbic System The limbic system is a set of evolutionarily primitive brain structures located on top of the brainstem and buried under the cortex. Limbic system structures are involved in many of our emotions and motivations, particularly those that are related to survival. Such emotions include fear, anger, and emotions related to sexual behavior. The limbic system is also involved in feelings of pleasure that are related to our survival, such as those experienced from eating and sex. Broca's Area An area located in the frontal lobe usually of the left cerebral hemisphere and associated with the motor control of speech. Also called Broca's center. Temporal Lobe The temporal lobes are involved in the primary organization of sensory input (Read, 1981). Individuals with temporal lobes lesions have difficulty placing words or pictures into categories. Language can be effected by temporal lobe damage. Left temporal lesions disturb recognition of words. Right temporal damage can cause a loss of inhibition of talking. The temporal lobes are highly associated with memory skills. Left temporal lesions result in impaired memory for verbal material. Right side lesions result in recall of nonverbal material, such as music and drawings. Parietal Lobe Damage to the left parietal lobe can result in what is called "Gerstmann's Syndrome." It includes right-left confusion, difficulty with writing (agraphia) and difficulty with mathematics (acalculia). It can also produce disorders of language (aphasia) and the inability to perceive objects normally (agnosia). Damage to the right parietal lobe can result in neglecting part of the body or space (contralateral neglect), which can impair many self-care skills such as dressing and washing. Right side damage can also cause difficulty in making things (constructional apraxia), denial of deficits (anosagnosia) and drawing ability.

16.

Occipital Lobe The occipital lobes are the center of our visual perception system. They are not particularly vulnerable to injury because of their location at the back of the brain, although any significant trauma to the brain could produce subtle changes to our visual-perceptual system, such as visual field defects and scotomas. The Peristriate region of the occipital lobe is involved in visuospatial processing, discrimination of movement and color discrimination (Westmoreland et al., 1994). Damage to one side of the occipital lobe causes homonomous loss of vision with exactly the same "field cut" in both eyes. Frontal Lobe The frontal lobes are considered our emotional control center and home to our personality. There is no other part of the brain where lesions can cause such a wide variety of symptoms. The frontal lobes are involved in motor function, problem solving, spontaneity, memory, language, initiation, judgement, impulse control, and social and sexual behavior. The frontal lobes are extremely vulnerable to injury due to their location at the front of the cranium, proximity to the sphenoid wing and their large size.

17.

8. Pathophysiology

(Patient Base)

Pathophysiology (Book Base)

9. Drug

Study

Drugs

Classificatio Indication n

Side Effect

Generic Name: Mannitol

Diuretic

Pulmonary congestion, fluid and electrolyte imbalance, electrolyte loss, dryness of mouth, thirst, marked diuresis, urinary retention, edema, headache, blurred vision, convulsions, nausea, vomiting, rhinitis, arm pain, skin necrosis, chills, dizziness, dehydration, hypotension, tachycardia, fever and angina-like chest pains. Difficulty of breathing, swelling of face, lips, tongue or throat, fast pounding heart beats, numbness, joint pain and loss of appetite.

Brand Name: Osmitrol

Generic Name: Hydralazine

Antihypertensive drug

Brand Name: Apresoline

Reduction of intracranial pressure and brain mass.

Severe essential hypertension when the drug cannot be given orally or when there is an urgent need to lower blood pressure.

Nursing Responsibilit ies •

Monitor blood pressure.

•

Check for hypervole mia, urinary tract obstructio n and signs of fluid imbalance .

•

Patient must avoid orthostatic position.

•

Pt. must get up slowly to avoid fall. Monitor Bp.

•

Generic Name: Metropolol

Antihypertensive drug

Metoprolol tartrate tablets are indicated for

Tiredness and dizziness, Shortness of

•

Metoprolol should be used with

Brand Name: Neobloc

Generic Name: Aspirin Brand Name: Zorprin

Anti-thrombosis

the treatment of hypertension. They may be used alone or in combination with other antihypertensive agents.

breath, diarrhea and alopecia.

Treatment of mild to moderate pain; fever; various inflammatory conditions; reduction of risk of death or MI in patients with previous infarction or unstable angina pectoris or recurrent transient ischemia attacks or stroke in men who have had transient brain ischemia caused by platelet emboli.

Nausea, vomiting, tinnitus, dizziness, respiratory alkalosis, metabolic acidosis, hemorrhage, convulsions.

•

•

caution in patients with impaired hepatic function. Should not be given in breast feeding mother. Take Aspirin by mouth with or without food. If stomach upset occurs, take with food to reduce stomach irritation.

•

Swallow Aspirin whole. Do not break, crush, or chew before swallowin g.

•

Take Aspirin with a full glass of water (8 oz/240 mL).

Generic Name: Nicholin Brand Name: Citicoline

Cerebral circulation stimulant

Disturbances of consciousness associated with head and brain injury.

Dropped blood pressure, chest discomfort, dyspnea, nausea, headache and dizziness.

• •

Monitor blood pressure. Check for the correct site for injection. 21.

10.

Diet and Activity

Activity

Date Ordered

Indication

Turn side to side (every 2 hrs.)

August 28, 2009

To prevent bed sores and pneumonia.

Diet

Date Ordered

Osteorize feeding

August 30, 2009

Nursing Responsibilities Accompany the relative whenever mobility is done (q2 hrs.)

Indication

Nursing Responsibilities To prevent Make sure that the aspiration (NGT). NGT is intact whenever feeding is to be made. Check for stomach content to prevent overfeeding.

23.

11.

SOAPIE (actual)

Subjective “Nahihirapan siyang magsalita, kung minsan umuungol din siya, as verbalized by Mr. D’s wife.” Objective Received pt. on lying position on bed, unconscious , with ongoing PNSS 1L regulated @ 10-15 gtts./min. (KVO) 200 ml. level infusing well @ left hand. (+) difficulty in speaking (+) weakness (+) headache (+) dizziness (+) blurred vision (+)Paralysis on right part of the body With NGT inserted With Foley catheter inserted Assessment Impaired verbal communication related to impaired cerebral circulation possibly evidence by impaired articulation. Planning After 4-6 hrs. of N.I the patient will learn techniques on how to communicate with others. Interventions  Established rapport.  Monitored and recorded vital signs.  Maintained good verbal/ non-verbal means of communication.  Thought the patient that loss of ability to talk does not mean loss of intelligence.

 Provided time for the patient to respond.  Conversation should be continue to practical and concrete matter, supplemented with gestures, pictures, and object.  Medications compliance on time (with the doctor’s permission). Evaluation Goal met as evidence by the patient learn techniques on how to communicate nonverbal cues and in which needs are can be expressed. 11.

SOAPIE (potential)

24.

Subjective:

Objective Received pt. on lying position on bed, unconscious , with ongoing PNSS 1L regulated @ 10-15 gtts./min. (KVO) 200 ml. level infusing well @ left hand. (+) difficulty in speaking (+) weakness (+) headache (+) dizziness (+) blurred vision (+)Paralysis on right part of the body With NGT inserted With Foley catheter inserted Assessment Risk for aspiration related to decreased level of consciousness. Planning After 2-4 hrs. of N.I the client/ SO shall be able to identify causative factor that may lead to aspiration. Interventions  Established rapport.  Monitored and recorded vital signs.  Monitored administration of NGT feeding.  Checked for the NGT if intact in the stomach.

 Provided information about the effect of aspiration in the lung.  Always keep the bed elevated whenever feeding.  Keep wire cutter or scissor at bedside all the time. Evaluation Goal partially met as evidence by the pt./SO was able to avoid factors that may cause aspiration. 25. 13.

Conclusion We therefore conclude that CVA or stroke may lead to permanent brain

damage or death to individuals with sedentary lifestyle. People who consumed large amount of food high in cholesterol, alcohol, cigarette smoking, obesity, and high blood pressure can increase the possibility of stroke. This may also lead to heart disease and maybe worsen if we don’t prevent the common factors that cause Stroke. Self discipline is very important for us not to acquire this feared or killing disease.

26. 14.

Recommendations

For the Patient and Family Members Patient and family members should be given proper instruction and knowledge on how to help the patient to cope in his condition. Dealing with emotional stress and changing his sedentary lifestyle can reduce the risk of stroke. Patient way of living should be carefully understand to limit the anxiety and self-pity. Showing emotional and moral support can aid the anxiety and self-pity. If family members adjusted to this kind of treatment to the patient, a fast recovery can be possibly. For Health Care Provider/ Institutions Cerebrovascular accident is one of the most common disease that cause dead in the world. It can happen to anyone, especially to those of people who have sedentary lifestyle and most commonly to people who acquired it through genes. Though we don’t know when it will come, we have to be aware of the main factors that bring our lives into danger. Maintaining good lifestyle and avoiding smoking, alcohol intake, high fat and salty food, exercise, and low sugar food can decrease the possible stroke. Health care provider and Institutions should give the enough knowledge to everyone. Dealing with this kind of condition is one of the healthy processes of fast recovery. It helps the patient and family members to adapt this knowledge and behavior for the sake of the wellness of their love ones.

27.

15.

Bibliography

Website source: http://www.lancastergeneral.org/content/search.htm? inCtx9txtKeyword=CVA&inCtx9cmdKeywordSearch=search&inCtx9txtMode=site http://www.lancastergeneral.org/content/stroke_2008_physician_chronicles.htm http://ww2.allina.com/ac/pharmacy.nsf/ http://www.supportafterstroke.com/whatisahemorrhagicstroke.html http://adam.about.com/reports/Stroke.htm http://www.sciencedaily.com/releases/2008/06/080625123002.htm http://brainmind.com/LeftHemisphere.html http://psychology.wikia.com/wiki/Cerebrovascular_accident http://answers.yahoo.com/question/index?qid=20070902172810AApbHou http://healthlibrary.epnet.com/GetContent.aspx?token=af362d97-4f80-4453-a17502cc6220a387&chunkiid=30616 http://www.neuroskills.com/search/search.php http://dictionary.reference.com/browse/broca%27s+area?qsrc=2446 http://biology.about.com/sitesearch.htm?terms=frontal%20lobe&SUName=biology&TopNode=99

Book Source: NANDA Book

Medical-Surgical Nursing Anatomy and Physiology Mims Annual

28.

The objective of the information in past and future anatomy articles is about generalizations. My intent is not to address specifics. The objective is to provide information and education. The left brain hemisphere, or logic brain, acts as a feature combiner and comprehends spoken language by performing phonetic analysis of the sounds, as opposed to the right brain method of comprehending language by matching acoustic sound patterns. The left brain has the ability to extract isolated details from spoken words or sentences, can generate correct spelling from scratch and can learn from reading by reading for meaning even if the topic is dull. Where the right brain lacks the short-term memory capabilities to be able to follow long sentences and extract their meanings, the left hemisphere can. If a sentence is long and complex grammatically, it falls into the realm of the left hemisphere for comprehension and de-coding for meaning. The left hemisphere is able to work with both slow and rapid speech where the right brain can only deal effectively with slow speech. Complex syntax, semantics, phonics, sight words, new vocabulary (read or heard) are all shuttled to the left brain for comprehension. The left brain is also where re-worded sentences or explanations, even if redundant, are processed. The information processing that one hemisphere isn’t capable of processing is switched to the other via the corpus callosum. The left hemisphere’s speaking and listening vocabulary is almost as large as that for reading and sight and allows it to be able to equally extract meaning from written or spoken words. When we read and hear the words in our head, they’re formed (sub-vocalized) in the left brain because it, and not the right hemisphere, has the ability to de-code written words acoustically. The left brain doesn’t have the ability to handle ambiguity (needs absolutes, clear cut patterns and predictability), doesn’t handle receiving input from changing sources, doesn’t do well if required to make changes in solution strategies or changes in timing of responses. Left is the logical and analytical side and processes information in a sequential manner. It works best with life and projects when they’re presented in a planned and structured manner. It’s the side that works best with multiple choice questions, prefers authority structuring,

controls feelings, is future oriented and time conscious, sees distinct right or wrong according to the prevailing cultural/beliefs system and discerns sharp perceptual and conceptual boundaries. This makes the left brain more involved in seeing differences when dealing with others who are felt to be of lower caste or intelligence. Even though the left brain prefers talking and writing it’s also the hemisphere that’s more likely to suspect everyone and alienate friends. Those who are left brain dominant are more likely to buy, buy, buy, test the limits of credit cards (and their ability to pay) clean everything, buy everything and stock up for suspected or unknown eventualities, reorganize shelves, cupboards, retrace their steps and reorganize shelves, etc. perpetually. They’re also more likely to quit their job before being fired. If we go back and review the information on all aspects of the brain it’s easy to see why we have differences and difficulties. Fortunately, few of us are totally dominated by one hemisphere or the other. If that were the case it would be a world of, “In this corner are the right brainers and in this corner the lefties. Prepare your agendas and come out fighting.” Which, by the way, is how we seem to handle most difficult problems anyway? All of us are endowed with two sides of the brain and a way for the information to travel from one hemisphere to the other. The brain is the area that heredity can be the largest or smallest factor in the way we interpret life around us. If we don’t like our life and our health, the brain gives us the means with which to change. The choices are also up to one of the brain’s functions but the mind and the brain aren’t the same.