Liceo De Cagayan University R.n Pelaez Blvd. Carmen, Cagayan De

Liceo de Cagayan University R.N Pelaez Blvd. Carmen, Cagayan de Oro City College of Nursing

Submitted by: Kenneth Joy S. Egona NCM501204

Submitted to: Mr. Leonard U. Solima Clinical Instructor

August 2009

1

TABLE OF CONTENTS I.

Introduction a. Overview of the case b. Objective of the study c. Scope and Limitation of the study

II.

Health History a. Profile of patient b. Family and Personal Health history c. Chief Complaint & History of Present Illness

III.

Developmental Data

IV.

Medical Management a. Medical Orders and Rationale b. Laboratory Results c. Drug Study

V.

Pathophysiology with Anatomy and Physiology

VI.

Nursing Assessment (System Review & Nursing Assessment II)

VII.

Nursing Management a. Ideal Nursing Management (NCP) b. Actual Nursing Management (SOAPIE)

VIII. Referrals and Follow-up IX.

Evaluation and Implications

X.

Bibliography

2

I. INTRODUCTION In our field of study it is very important for us to be exposed to different kinds of situations and cases, which can help us gain more knowledge and is essential for us to be more effective in giving care towards our patients. A. Overview of the Case

B. Objective of the Study The main reason and purpose why, I, as future nurse will conduct a study and exposure in the intensive care unit is for me to be able to identify the problems encountered by my patient. As a health care provider, it is indeed my vocation to adjoined hands with the health care team for the promotion of wellness of our clients. My main goals for this study are the following: •

To establish rapport

•

To identify chief complaints of clients to give its specific interventions

•

To determine the family and personal history of the client that many affect clients present condition

•

To identify the cause and effect the main problem through the correct analysis of the pathophysiology of the case

•

To determine the medical management given through identifying doctor’s order and its rationale

•

To make nursing care plans for the different health problems encountered by the client

•

To evaluate the effectiveness of the actual nursing care plan that was established 3

•

To give referrals and follow-up for the health promotion of the client

C. Scope and Limitation of the Study Specifically this study is more concerned with the care of the patient in Northern Mindanao Medical Center, Intensive Care Unit. I performed physical assessment to the patient to properly identify the nursing problems, which requires necessary and direct interventions and medical regimen. I had 2 days duty or 16 hours care for the patient and some limited informants. The preventive care and the anticipatory guidance are the integral practice to this practice. Thus this care study focuses on the particular case of the patient. The study of the medications and doctor’s order are limited to our chosen patient, a case of Acute Gastroenteritis with severe Dehydration. Any referrals and follow up, so as with the nursing management were fully granted and analyzed for the said case.

II. HEALTH HISTORY A. Profile of the Patient Name:

Mr. Panerio, Alijo Nacilla

Age:

74 years old

Sex:

Male

Birth date: Religion:

July 17, 1935 Roman Catholic

Civil Status:

Married

Nationality:

Filipino

Address:

Zone-6 Baluarte, Tagoloan, Misamis Oriental

Occupation: Date of Admission:

Former Farmer October 19, 2009 4

Time of Admission:

10:00 pm

Admitting Diagnosis:

AGE, with Severe Dehydration

A P:

Dr. Karen G. Gonzales MD

Vital Signs Assessment Temperature:

36.7c

Heart Rate:

68 bpm

Respiratory Rate:

18 cpm

Blood Pressure:

60/40 mmhg

Height:

5 ft. and 4 inches

Weight:

45 kgs.

Allergy:

No known food and drug allergy

B. Family History and Personal Health History The Panerio family resides at Zone-6 Baluarte, Tagoloan, Misamis Oriental. Patient was a former farmer and his spouse is a house wide. Both of their mother and father side had no history of hypotension. C. History of Present Illness A case of Panerio a 73 years old, male, married, a former farmer was admitted for the first time at Northern Mindanao Medical Center. 5 days prior to admission onset of LBM, watery, mucoid, nonblood stealed, amounting 1cup/episode x 10 episode. Associated with vomiting x 5 episode AUD, abdominal pain. 3 days onset of dysuria associated with moderate fever due to LBM thus consult, hence admitted. D. Chief Complaint 5

Patient was admitted to the said hospital last October 19, 2009 at 10:0 pm, his chief complaint prior to admission was LBM associated with moderate fever.

III. DEVELOPMENTAL TASK A. Erik Erikson’s Stages of Psychosocial Development Theory Erikson describes eight developmental stages through which a healthily developing human should pass from infancy to late adulthood. In each stage the person confronts, and hopefully masters, new challenges. Each stage builds on the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future. Each of Erikson's stages of psychosocial development are marked by a conflict, for which successful resolution will result in a favorable outcome and by an important event that this conflict resolves itself around. In the Eriksons 8th stage of psychosocial Development theory which is Senior: Integrity vs. Despair (65 years onwards). Integrity means moral soundness, whole or completeness of a person, Despair means being hopeless. When it comes to my patient he was loosing hope that his illness will be cure, it is because he feels that he was really old and he don’t have the capabilities of living the way it should be. But still, because of the support of the family little by little he was trying to understand his situation tried to think on positive side and for himr to live longer for his family that still need him as a father, as a grandfather and as a husband. B. Sigmund Freud’s Psychosexual Development Theory According to Freud, people enter the world as unbridled pleasure seekers. Specifically, people seek pleasure through from a series of erogenous zones. These erogenous zones are only part of the story, as the 6

social relations learned when focused on each of the zones are also important. Freud's theory of development has 2 primary ideas: One, everything you become is determined by your first few years - indeed, the adult is exclusively determined by the child's experiences, because whatever actions occur in adulthood are based on a blueprint laid down in the earliest years of life (childhood solutions to problems are perpetuated) Two, the story of development is the story of how to handle anti-social impulses in socially acceptable ways. My patient belongs to the genital stage which begins at puberty involves the development of the genitals, and libido begins to be used in its sexual role. However, those feelings for the opposite sex are a source of anxiety, because they are reminders of the feelings for the parents and the trauma that resulted from all that.

C. Robert J. Havighurst’s Developmental Task Theory Havighurst categorized the tasks, in first category are the tasks, which has to be completed in certain period, and the second are the tasks that continue for a long, sometimes for a lifetime. So what happens if the task is not completed in that stage or completed in a later date? Havighurst reply to that it is critical that the tasks should be completed during the appropriate stage, otherwise result will be the failure to achieve success in future tasks. D. Jean Piaget’s Theory of Development According to Piaget, development is driven by the process of equilibration. Equilibration encompasses assimilation (i.e., people transform incoming information so that it fits within their existing schemes or thought patterns) and accommodation (i.e., people adapt their schemes to include incoming information).

7

My patient belongs to the formal operational stage. In this stage, individuals move beyond concrete experiences and begin to think abstractly, reason logically and draw conclusions from the information available, as well as apply all these processes to hypothetical situations. The abstract quality of the adolescent's thought at the formal operational level is evident in the adolescent's verbal problem solving ability. The logical quality of the adolescent's thought is when children are more likely to solve problems in a trial-and-error fashion. Adolescents begin to think more as a scientist thinks, devising plans to solve problems and systematically testing solutions. They use hypothetical-deductive reasoning, which means that they develop hypotheses or best guesses, and systematically deduce, or conclude, which is the best path to follow in solving the problem.

IV. •

MEDICAL MANAGEMENT

Doctor’s Order

DATE October 19, 2009 4:10pm BP: 80/60 HR:86\ RR:20 T:38C

DOCTOR’S ORDER  Please admit to P1F2/A3T2 (ICCU)  Please secure conset to care\  DWI-AGE with severe dehydration  DAT\  V/S Q4 reffer the FF: -BP >140/90 or 90/60mmHg -HR >110 OR < 60BPM -RR >30 OR < 12  Intake and output every shift 

Labs: CBC with creatinine, K,BUN, U/A, Chest xray, 8

RATIONALE

➢ For proper admission and treatment ➢ To closely monitor patients’ vital signs

➢ To know avoid

4:10pm Awake, coherent, BM X 4 BP 70/60 August 20,2009

ECG 12 leads + LII  Start colysis PLR 1L Fd now\  IVF to follow PNSS 1L @ 60gtts/min  MEDICATIONS: -Metronidazole, 500mg IVTT q 8hours -Ciprofloxacin 200mg every 12hours\ -Paracertamol 500mg 1TAB Q4 -Omeprazole 40mg cap OD  Please chart frequency, character, color, volume of stool and please record in separate sheet.  Refer if with sign of SOB, chest pain, change of and unsualities.

 IVF PLR 1L @ 30GTTS/MIN To 80 gtts/min\  Increase IVF



LABS: ○ ○ ○ ○ ○ ○ ○ ○

CBC HGT now attach CT scan (brain) result to chart Na, K, SGPT, creatinine, BUN 12L ECG now

 Meds: 9

complications and to observe any problems ➢ To hydrate the patient and to replace the fluid and electrolyte imbalances ➢ To know any complications and for and for examination purposes

○ coversyl 5mg/80 I tab OD/ngt ○ Dilantin 100g/cap

1:45pm

July 10, 2009 8:00am

 iii caps q8h x 3doses/NGT ○ Omeprazole 40mg IVTT OD  FBC attached to urobag in placed – bloody urine  I&O q shift  Maintain head part @3040 degree  Standby intubation set  Monitor neurovitalsigns q2h  Pls inform AP once admitted  Discussed plan w/ pt. ○ transport to cebu ○ cerebral angiography ○ Possible coiling/ ○ clipping of ○ aneurysm  Pt seen and examined -(+) HPN > 5yrs. w/ good compliance of medication to atenolol - (-DM), (-) BA

10:00am

 Oral care w/ bactidol  IVF TF PNSS rate 20gtts/min  Turn side to side q2h  chest physiotherapy  Nimodipine drip @ 5cc/hr (Nimodipine 4 vials via infusion pump)

10

 For chest x-ray 11:32am  For UA  Paracetamol I amp IVTT now 2:40pm

July 11, 2009 10:00am

 Start nicardipine drip 10mg in 100ml D5W solution in solution set start at 20gtts/min  Give captopril 50mg q6h for SBp ≥ 140mmhg

1:20pm

 Please do chest tapping q after nebulization

5:50 pm

 To consume drip

9:40pm

 Same IVF to follow; PNSS @ 15gtts/min

nicardipine

 May resume nicardipine drip @ 10cc/hr, titrate q 15mins to keep SBp @ 130-140mmhg July 12, 2009 9:10am

 Hold vasalat

 Resume Amlodipine(Vasalat), 10 mg, OD  IVF TF PNSS reg.@15gtts/min  Besacodyl 10mg/supp; 2 rectal suppository now

11

•

Laboratory Results

Date

Diagnostic

Ordered

Exam

7/8/09

WBC

Normal

Values Complete Blood Count 8,100 5,000-

RBC Hemoglobin Hematocrit Platelet

7/8/09

Result

10,000/mm³ 4.20-5.40mil 12.0-16.0 g/dl 37.0-47.0% 174,000 –

4.80 14.4 43.8 233,000

Interpretati on Normal Normal Normal Normal Normal

340,000 Differential Blood Count Neutrophils 44 43.4-76.7% Normal Lymphocytes 43 17.4-46.2% Normal Monocytes 08 4.5-10.5% Normal Eosinophils 05 0-2% % Urinalysis Color: Bloody ph 6.5 Transparency: Hazy Sugar Negative Albumin Negative Pus: +(0-21hpf) RBC To numerous to count 12

Epithelial Cells; Mucous Threads:

•

Rare Rare

Drug study

Generic

Name Dexamethasone

of ordered drug Brand Name Date Ordered Classification

Corticosteroid Glucocorticoid Hormone

Dose/Frequenc y/Route Mechanism Action

of Enters target cells and binds to specific receptors, initiating many complex reactions that are responsible for its anti-inflammatory and immunosuppressive effects.

Specific

Trichinosis with neurologic or myocardial involvement

Indication Contraindicatio

Contraindications and cautions

n

•

•

Side Effects/Toxic

•

Contraindicated with infections, especially tuberculosis, fungal infections, amebiasis, vaccinia and varicella, and antibioticresistant infections, allergy to any component of the preparation used. Use cautiously with renal or hepatic disease; hypothyroidism, ulcerative colitis with impending perforation; diverticulitis; active or latent peptic ulcer; inflammatory bowel disease; CHF, hypertension, thromboembolic disorders; osteoporosis; seizure disorders; diabetes mellitus; lactation. CNS: Seizures, vertigo, headaches, pseudotumor cerebri, euphoria, insomnia, mood swings, depression, psychosis, intracerebral hemorrhage, reversible cerebral atrophy in infants, 13

Effects

• • • • • • • •

cataracts, increased IOP, glaucoma CV: Hypertension, CHF, necrotizing angiitis Endocrine: Growth retardation, decreased carbohydrate tolerance, diabetes mellitus, cushingoid state, secondary adrenocortical and pituitary unresponsiveness GI: Peptic or esophageal ulcer, pancreatitis, abdominal distention GU: Amenorrhea, irregular menses Hematologic: Fluid and electrolyte disturbances, negative nitrogen balance, increased blood sugar, glycosuria, increased serum cholesterol, decreased serum T3 and T4 levels Hypersensitivity: Anaphylactoid or hypersensitivity reactions Musculoskeletal: Muscle weakness, steroid myopathy, loss of muscle mass, osteoporosis, spontaneous fractures Other: Impaired wound healing; petechiae; ecchymoses; increased sweating; thin and fragile skin; acne; immunosuppression and masking of signs of infection; activation of latent infections, including TB, fungal, and viral eye infections; pneumonia; abscess; septic infection; GI and GU infections

Intra-articular

•

Musculoskeletal: Osteonecrosis, tendon rupture, infection

•

CNS: Blindness (when used on face and head—rare)

•

Endocrine: Suppression of HPA function due to systemic absorption Respiratory: Oral, laryngeal, pharyngeal irritation Other: Fungal infections

Intralesional therapy Respiratory inhalant

• • Nursing

•

Precaution

•

•

•

History for systemic administration: Active infections; renal or hepatic disease; hypothyroidism, ulcerative colitis; diverticulitis; active or latent peptic ulcer; inflammatory bowel disease; CHF, hypertension, thromboembolic disorders; osteoporosis; seizure disorders; diabetes mellitus; lactation History for ophthalmic preparations: Acute superficial herpes simplex keratitis, fungal infections of ocular structures; vaccinia, varicella, and other viral diseases of the cornea and conjunctiva; ocular TB Physical for systemic administration: Baseline body weight, T; reflexes, and grip strength, affect, and orientation; P, BP, peripheral perfusion, prominence of superficial veins; R and adventitious sounds; serum electrolytes, blood glucose Physical for topical dermatologic preparations: Affected area for infections, skin injury

14

Generic

Name

of Chlonidine Hydrchloride

ordered drug Brand Name Date Ordered Classification

Catapres Antihypertensive Sympatholytic (centrally acting) Central analgesic

Dose/Frequency/R oute Mechanism Action

of Stimulates CNS alpha2-adrenergic receptors, inhibits sympathetic cardioaccelerator and vasoconstrictor centers, and decreases sympathetic outflow from the CNS.

Specific Indication

• •

Hypertension, used alone or as part of combination therapy Treatment of severe pain in cancer patients in combination with opiates; epidural more effective with neuropathic pain (Duraclon)

Contraindication

•

Contraindicated with hypersensitivity to clonidine or any adhesive layer components of the transdermal system. Use cautiously with severe coronary insufficiency, recent MI, cerebrovascular disease; chronic renal failure; pregnancy, lactation.

•

Side

Effects/Toxic Adverse effects

Effects

Oral therapy

•

•

•

CNS: Drowsiness, sedation, dizziness, headache, fatigue that tend to diminish within 4–6 wk, dreams, nightmares, insomnia, hallucinations, delirium, nervousness, restlessness, anxiety, depression, retinal degeneration CV: CHF, orthostatic hypotension, palpitations, tachycardia, bradycardia, Raynaud's phenomenon, ECG abnormalities manifested as Wenckebach period or ventricular trigeminy Dermatologic: Rash, angioneurotic edema, hives, urticaria, hair thinning and alopecia, pruritus, dryness, itching or burning of the eyes, pallor 15

• • •

GI: Dry mouth, constipation, anorexia, malaise, nausea, vomiting, parotid pain, parotitis, mild transient abnormalities in LFTs GU: Impotence, decreased sexual activity, diminished libido, nocturia, difficulty in micturition, urinary retention Other: Weight gain, transient elevation of blood glucose or serum creatine phosphokinase, gynecomastia, weakness, muscle or joint pain, cramps of the lower limbs, dryness of the nasal mucosa, fever

Nursing Precaution Name confusion has been reported between clonidine and Klonopin (clonazepam); use caution. Assessment

•

•

Generic

Name

History: Hypersensitivity to clonidine or adhesive layer components of the transdermal system; severe coronary insufficiency, recent MI, cerebrovascular disease; chronic renal failure; lactation, pregnancy Physical: Body weight; T; skin color, lesions, T; mucous membranes—color, lesion; breast examination; orientation, affect, reflexes; ophthalmologic examination; P, BP, orthostatic BP, perfusion, edema, auscultation; bowel sounds, normal output, liver evaluation, palpation of salivary glands; normal urinary output, voiding pattern; LFTs, ECG

of amlodipine besylate

ordered drug Brand Name Date Ordered Classification

Norvasc Calcium channel-blocker Antianginal drug Antihypertensive

Dose/Frequency/R oute Mechanism Action

of Inhibits the movement of calcium ions across the membranes of cardiac and arterial muscle cells; inhibits transmembrane calcium flow, which results in the depression of impulse formation in specialized cardiac pacemaker cells, slowing of the velocity of 16

conduction of the cardiac impulse, depression of myocardial contractility, and dilation of coronary arteries and arterioles and peripheral arterioles; these effects lead to decreased cardiac work, decreased cardiac oxygen consumption, and in patients with vasospastic (Prinzmetal's) angina, increased delivery of oxygen to cardiac cells. Specific Indication

• • • •

Contraindication

• Side

Angina pectoris due to coronary artery spasm (Prinzmetal's variant angina) Chronic stable angina, alone or in combination with other drugs Essential hypertension, alone or in combination with other antihypertensives Contraindicated with allergy to amlodipine, impaired hepatic or renal function, sick sinus syndrome, heart block (second or third degree), lactation. Use cautiously with CHF, pregnancy.

Effects/Toxic

Effects Nursing Precaution

Generic

Name

of phenytoin (diphenylhydantoin, phenytoin sodium)

ordered drug

Dilantin

Brand Name Date Ordered Classification

Antiepileptic Antiarrhythmic, group 1b Hydantoin

Dose/Frequency/R oute Mechanism Action

of Has antiepileptic activity without causing general CNS depression; stabilizes neuronal membranes and prevents hyperexcitability caused by excessive stimulation; limits the spread of seizure 17

activity from an active focus; also effective in treating cardiac arrhythmias, especially those induced by digitalis; antiarrhythmic properties are very similar to those of lidocaine; both are class IB antiarrhythmics. Specific Indication

• • • •

Contraindication

•

•

Side

Effects/Toxic

•

Effects

• •

•

•

Control of grand mal (tonic-clonic) and psychomotor seizures Prevention and treatment of seizures occurring during or following neurosurgery Parenteral administration: Control of status epilepticus of the grand mal type Unlabeled uses: Antiarrhythmic, particularly in digitalisinduced arrhythmias (IV preparations); treatment of trigeminal neuralgia (tic douloureux) Contraindicated with hypersensitivity to hydantoins, sinus bradycardia, sinoatrial block, Stokes-Adams syndrome, pregnancy (data suggest an association between antiepileptic use and an elevated incidence of birth defects; however, do not discontinue antiepileptic therapy in pregnant women who are receiving such therapy to prevent major seizures; this is likely to precipitate status epilepticus, with attendant hypoxia and risk to both mother and fetus), lactation. Use cautiously with acute intermittent porphyria, hypotension, severe myocardial insufficiency, diabetes mellitus, hyperglycemia. CNS: Nystagmus, ataxia, dysarthria, slurred speech, mental confusion, dizziness, drowsiness, insomnia, transient nervousness, motor twitchings, fatigue, irritability, depression, numbness, tremor, headache, photophobia, diplopia, conjunctivitis CV: CV collapse, hypotension (when administered rapidly IV; not to exceed 50 mg/min) Dermatologic: Dermatologic reactions, scarlatiniform, morbilliform, maculopapular, urticarial and nonspecific rashes; serious and sometimes fatal dermatologic reactions —bullous, exfoliative, or purpuric dermatitis, lupus erythematosus, and Stevens-Johnson syndrome, toxic epidermal necrolysis, hirsutism, alopecia, coarsening of the facial features, enlargement of the lips, Peyronie's disease GI: Nausea, vomiting, diarrhea, constipation, gingival hyperplasia, toxic hepatitis, liver damage, sometimes fatal; hypersensitivity reactions with hepatic involvement, including hepatocellular degeneration and fatal hepatocellular necrosis GU: Nephrosis 18

•

• • •

Nursing Precaution

•

•

Generic

Name

Hematologic: Hematopoietic complications, sometimes fatal: thrombocytopenia, leukopenia, granulocytopenia, agranulocytosis, pancytopenia; macrocytosis and megaloblastic anemia that usually respond to folic acid therapy; eosinophilia, monocytosis, leukocytosis, simple anemia, hemolytic anemia, aplastic anemia, hyperglycemia IV use complications: Hypotension, transient hyperkinesia, drowsiness, nystagmus, circumoral tingling, vertigo, nausea, CV collapse, CNS depression Respiratory: Pulmonary fibrosis, acute pneumonitis Other: Lymph node hyperplasia, sometimes progressing to frank malignant lymphoma, monoclonal gammopathy and multiple myeloma (prolonged therapy), polyarthropathy, osteomalacia, weight gain, chest pain, periarteritis nodosa, hirsutism, alopecia

History: Hypersensitivity to hydantoins; sinus bradycardia, AV heart block, Stokes-Adams syndrome, acute intermittent porphyria, hypotension, severe myocardial insufficiency, diabetes mellitus, hyperglycemia, pregnancy, lactation Physical: T; skin color, lesions; lymph node palpation; orientation, affect, reflexes, vision examination; P, BP; R, adventitious sounds; bowel sounds, normal output, liver evaluation; periodontal examination; LFTs, urinalysis, CBC and differential, blood proteins, blood and urine glucose, EEG and ECG

of

ordered drug Brand Name Date Ordered Classification Dose/Frequency/R oute Mechanism

of

Action Specific Indication 19

Contraindication Side Effects/Toxic Effects Nursing Precaution

IV.

Anatomy and Physiology

20

The Brain Three cavities, called the primary brain vesicles, form during the early embryonic

development

of

the

brain.

These

are

the

forebrain

(prosencephalon), the midbrain (mesencephalon), and the hindbrain (rhombencephalon). During subsequent development, the three primary brain vesicles develop into five secondary brain vesicles. •

The telencephalon generates the cerebrum (which contains the cerebral cortex, white matter, and basal ganglia).

•

The diencephalon generates the thalamus, hypothalamus, and pineal gland.

•

The mesencephalon generates the midbrain portion of the brain stem.

•

The metencephalon generates the pons portion of the brain stem and the cerebellum.

•

The myelencephalon generates the medulla oblongata portion of the brain stem

21

22

•

The cerebrum consists of two cerebral hemispheres connected by a bundle of nerve fibers, the corpus callosum. The largest and most visible part of the brain, the cerebrum, appears as folded ridges and grooves, called convolutions. The following terms are used to describe the convolutions: •

A

gyrus

(plural,

gyri)

is

an

elevated

ridge

among

the

groove

among

the

convolutions. •

A

sulcus

(plural,

sulci)

is

a

shallow

convolutions. •

A fissure is a deep groove among the convolutions.

The deeper fissures divide the cerebrum into five lobes (most named after bordering skull bones)—the frontal lobe, the parietal love, the temporal lobe, the occipital lobe, and the insula. All but the insula are visible from the outside surface of the brain. A cross section of the cerebrum shows three distinct layers of nervous tissue: •

The cerebral cortex is a thin outer layer of gray matter. Such activities as speech, evaluation of stimuli, conscious thinking, and control of skeletal muscles occur here. These activities are grouped into motor areas, sensory areas, and association areas.

•

The cerebral white matter underlies the cerebral cortex. It contains

mostly

hemispheres

myelinated

(association

axons fibers),

that

connect

connect

gyri

cerebral within

hemispheres (commissural fibers), or connect the cerebrum to the spinal cord (projection fibers). The corpus callosum is a major assemblage of association fibers that forms a nerve tract that connects the two cerebral hemispheres. •

Basal ganglia (basal nuclei) are several pockets of gray matter located deep inside the cerebral white matter. The major 23

regions in the basal ganglia—the caudate nuclei, the putamen, and the globus pallidus—are involved in relaying and modifying nerve impulses passing from the cerebral cortex to the spinal cord. Arm swinging while walking, for example, is controlled here. •

The diencephalon connects the cerebrum to the brain stem. It consists of the following major regions: •

The thalamus is a relay station for sensory nerve impulses traveling from the spinal cord to the cerebrum. Some nerve impulses are sorted and grouped here before being transmitted to the cerebrum. Certain sensations, such as pain, pressure, and temperature, are evaluated here also.

•

The epithalamus contains the pineal gland. The pineal gland secretes

melatonin,

a

hormone

that

helps

regulate

the

biological clock (sleep-wake cycles). •

The

hypothalamus

activities.

It

regulates

controls

the

numerous

autonomic

important

nervous

system

body and

regulates emotion, behavior, hunger, thirst, body temperature, and the biological clock. It also produces two hormones (ADH and oxytocin) and various releasing hormones that control hormone production in the anterior pituitary gland. The following structures are either included or associated with the hypothalamus. •

The mammillary bodies relay sensations of smell.

•

The

infundibulum

connects

the

pituitary

gland

to

the

hypothalamus. •

The optic chiasma passes between the hypothalamus and the pituitary gland. Here, portions of the optic nerve from each eye

24

cross over to the cerebral hemisphere on the opposite side of the brain. •

The brain stem connects the diencephalon to the spinal cord. The brain stem resembles the spinal cord in that both consist of white matter fiber tracts surrounding a core of gray matter. The brain stem consists

of

the

following

four

regions,

all

of

which

provide

connections between various parts of the brain and between the brain and the spinal cord. (Some prominent structures are illustrated in Figure 2 ).

Figur Prominent structures of the 25

e2

brain stem.

•

The midbrain is the uppermost part of the brain stem.

•

The pons is the bulging region in the middle of the brain stem.

•

The medulla oblongata (medulla) is the lower portion of the brain stem that merges with the spinal cord at the foramen magnum.

•

The reticular formation consists of small clusters of gray matter interspersed within the white matter of the brain stem and certain

regions

cerebellum. component

of

The of

the

spinal

reticular

the

cord,

activation

reticular

diencephalon, system

formation,

is

(RAS),

responsible

and one for

maintaining wakefulness and alertness and for filtering out unimportant sensory information. Other components of the reticular formation are responsible for maintaining muscle tone and regulating visceral motor muscles. •

The cerebellum consists of a central region, the vermis, and two winglike

lobes,

the

cerebellar

hemispheres.

Like

that

of

the

cerebrum, the surface of the cerebellum is convoluted, but the gyri, called folia, are parallel and give a pleated appearance. The cerebellum

evaluates

and

coordinates

motor

movements

by

comparing actual skeletal movements to the movement that was intended. The limbic system is a network of neurons that extends over a wide range of areas of the brain. The limbic system imposes an emotional aspect to behaviors, experiences, and memories. Emotions such as pleasure, fear, anger, sorrow, and affection are imparted to events and experiences. The limbic system accomplishes this by a system of fiber tracts (white matter) and gray matter that pervades the diencephalon and

26

encircles the inside border of the cerebrum. The following components are included: •

The hippocampus (located in the cerebral hemisphere)

•

The denate gyrus (located in cerebral hemisphere)

•

The

amygdala

(amygdaloid

body)

(an

almond-shaped

body

associated with the caudate nucleus of the basal ganglia) •

The mammillary bodies (in the hypothalamus)

•

The anterior thalamic nuclei (in the thalamus)

•

The fornix (a bundle of fiber tracts that links components of the limbic system)

Pathophysiology Definition: Cerebrovascular accident or stroke (also called brain attack) results from sudden interruption of blood supply to the brain, which precipitates neurological dysfunction lasting longer than 24 hrs. Hemorrhagic stroke is

27

the leakage of blood vessel causes compression of brain tissue and spasm of adjacent vessels.

Predisposing Factor - Family History

Precipitating Factor - High fat diet Fatty Dispostion in tunica Intimae sp. Low density lipoprotein Macropages will treat them as foreign bodies Will engulf fatty deposits in the tunica Intima Macrophage will become heavier because of fatty deposits

Macrophages will be deposited together with fats (foam cells)

Acumulate, becomes atherosclerotic plaque Hyperperfusion of vital organs specially kidney Juxtaglumerular cells of kidney will secrete renin angiotensin 1 Angiotensin 1 converted to angiotensin 2 by ACE 28

Increase peripheral assistance

Increase Blood Pressure

Hypertension

Blood vessels become weak

Outpouching of brain arteries(aneurysm)

Rupture of Blood vessels

CVA, Hemorrhagic

Accumulation of blood in the brain

Compression of brain organs

Increase Intracranial Pressure

Decreased Brain Perfu -sion

s/sx: - diplopia - nausea - nape pain - dizziness

VI. NURSING ASSESSMENT NURSING SYSTEM REVIEW CHART Name:: Mrs. LML Pulse: 94bpm Height: 5’4

Date: July Temp.: 36.7 c RR: 22 cpm BP: 160/100 mmhg

EENT:

29

Weight:

55

kgs.

× impaired vision □ blind □ Pain □ reddened □ drainage □ gums □ hard of hearing □ deaf □ burning □ edema □ lesion □ teeth Assess eyes, ears, nose Throat for abnormality □ no problem _____________________ RESP: □ Asymmetric □ tachypnea □ apnea □ rales □ cough □ barrel chest 160/100mmhg_____ □ bradypnea □ shallow □ brochi _____________________ □ sputum □ diminished □ dyspnea □ orthopnea □ labored □ wheezing □ pain □ cyanotic Assess resp, rate, rhythm, depth, pattern, _____________________ breath sounds, comfort × no problem

__Diplopia____________ ___Eyepatch __________ _____________________ _____________________ _BP-

_____________________ _Dry skin_____________ _____________________ __IVF

CARDIO VASCULAR □ arrhythmia □ tachycardia □ numbness _____________________ □ diminished pulses □ edema □ fatigue Urobag______ □ irregular □ bradycardia □ murmur □ tingling □ absent pulses □ pain Asses heart sounds, rate rhythm, pulse, blood pressure, clrc., fluid retention, comfort □ no problem GASTRO INTESTINAL TRACT _____________________ □ obese □ distention □ mass □dysphagia □ rigidly □ pain Asses abdomen, bowel habits, swallowing, _____________________ bowel sounds, comfort × no problem GENITO-URINARY and GYNE _____________________ □ pain □ urine color □ vaginal bleeding _____________________ □ hermaturia □ discharge □ noctoria Asses urine freq., color, control, odor, comfort/ _________ Gyn-bleeding, discharge × no problem _____________________ NEURO □ paralysis □ stuporous □ unsteady □ seizures _____________________ □ lethartic □ comatose □ vertigo □ tremors □ confused □ vision □ grip Asses motor function, sensation, LOC, strength, Grip, gait, coordination, orientation, speech, turgor________ × no problem MUSCULOSKELETAL and SKIN □ appliance □ stiffness □itching □ petechiae hot □ drainage □ prosthesis □ swelling _____________________ □ lesion × poor turgor □ cool □ deformity _____________________

_site____________

_____________________ ___FBC

to

_____________________ _____________________ _____________________ _____________________ _____________________ _____________________ ____mild headache_____ _____________________

_____________________ nape pain_

_____________________

_____________________ _____________________ Poor Skin _____________________ _____________________ _____________________

30

□ wound □ rash □ skin color □ flushed □ atrophy □ pain □ ecchymosis _____________________ □ diaphoretic □ moist Asses mobility, motion. Galt, alignment, joint function _____________________ /skin color, texture, turgor, integrity □ no problem _____________________

_____________________ _____________________

_____________________ _____________________

NURSING ASSESSMENT II

31

SUBJECTIVE

OBJECTIVE

COMMUNICATION:  Hearing Loss × Visual Changes Denied

comment: “duha man ang ako pananaw mao gani gi butangan ko ani tanon sa ako mata. ”

 Glasses  Contact Lens

OXYGENATION:  Dyspnea  Smoking History × Cough  Sputum  Denied

COMMENT: _”maayo raman pud akong pag-ginhawa, wala man pud ko naglisod, usahay lang kay mutukar ako ubo”

Resp. × Regular Irregular Describe: Breathing pattern is regular.

CIRCULATION:  Chest Pain  Leg Pain  Numbness Extremities ×Denied

COMMENT: “,wala man nuon sakit sa ako tiil ug dughan, kani raman ako liog”

of

NUTRITION: Diet: Low salt, low fat Diet  N □V COMMENT: “katong Character: miaging adlaw ga ×Recent change in suka ko, pero karon wala naman, pero weight, appetite wala lng ko gana  Swallowing Diff. mukaon.” Denied ELIMINATION: Usual bowel pattern: 1-2x daily_________  Constipation remedies: ___ Date of last BM: July 6, 2009 Diarrhea Character: None_____________

Urinary Frequency:     × 

Dysuria Hematuria Incontinence Polyuria Foley in place Denied

MGT. OF HEALTH AND ILLNESS:  Alcohol × Denied (Amount, Frequency): SBE: Last Pap Smear:__N/A____ LMP: ____N/A ________

 Languages  Hearing Loss  Speech Difficulties

Pupils size: 3 mm Reaction: Pupils Equally round and react to light and accommodation

R right lung is symmetrical to the left lung. L left lung is symmetrical to the right lung. Heart Rhythm × Regular  Irregular Ankle edema: Presence of ankle edema Pulse Car. Rad. DP Femoral* R ___+_______+______+______+____ L ___+______ +______+____ _+_____ COMMENT: all pulses are present and palpable * If applicable × Dentures

 None

Upper

Full 

Partial ×

Lower





COMMENT: Patient has a normal bowel movement. Her urine color is yellowish and aromatic in odor.

W/ patient   Bowel sounds: Normo active bowel sounds Abdominal Distention: Present  Yes × No Urine* Urine is yellowish in color * If Foley is in place Patients FBC to Urobag is in place.

Briefly describe patient’s ability to follow treatments for chronic health problems (if present): Patient follows treatment regimen properly.

32

SUBJECTIVE SKIN INTEGRITY: ×Dry Itching  Other Denied

ACTIVITY / SAFETY:  Convulsion ×Dizziness  Limited motion of joints

OBJECTIVE COMMENT: “gamala akong panit karon kay dili man gud ko galigo, tigulang napud gud”

COMMENT: “dili man nako pa kaya magkatindog kay gakalipong ko”

Limitations in ability to:  Ambulate × Bathe self  Others  Denied

×Dry  Cold  Pale  Flushed  Warm  Moist  Cyanotic rashes, ulcers, decubitus ulcers (describe size, location, drainage): none LOC and Orientation: Patient is oriented to time and space. Gait:

 Walker  Cane  Others × Steady  Unsteady

Sensory and motor losses extremities: There is having diplopia.

in

face

or

ROM Limitations: The patient cannot bath by itself appropriately and needs guidance when doing it.

COMFORT / SLEEP / AWAKE:  Pain (Location, COMMENT: “Maaayo Freq., Remedies) man hinuon ang ako  Nocturia pagkatulog”  Sleep Difficulties Denied

 Facial Grimaces  Guarding  Other signs of pain: none_  side rail release from signed(60+years) None

COPING:

Observed nonverbal behavior:

Occupation: Retired Teacher Mumbers of household: _3__ Most supportive person:_husband______

Patient follows instructions, cooperative, but sometimes she easily get depressedof her situation and she likes to talk things about her life and family.

33

VII. NURSING MANAGEMENT A.IDEAL NURSING INTERVENTIONS Nursing Diagnosis: Ineffective cerebral tissue perfusion related to hemorrhage Interventions

Rationale

Independent: 1. Determine factors related to

individual

 Influences

situation/

choice

of

interventions.

cause for coma/ cerebral tissue

perfusion

and

potential increased in ICP. 2. Monitor

or

document  Assesses trends in level of

neurolohgical frequently

status

and

consciousness

compare

and

potential

increase in ICP and is useful in

with baseline.

determining

location,

extent

and progression of the CNS 3. Monitor vital signs

damage.  Fluctuations in pressure may occur

because

of

cerebral

pressure/ injury in vasomotor area of the brain. Change in 4. Position with head slightly elevated position

and and

in

rate of heart rhythm can occur

neutral

because of the brain damage.

maintain  Reduces arterial pressure by

bedrest.

promoting

venous

drainage

and

improve

cerebral

may

circulation or perfusion.

34

Dependent: 5. Administer prescribed

 Reduces hypoxemia,

medications, supplemental

increase of

oxygen,anticoagulants,

ICP and may use to improve

antihypertensive drugs as

cerebral blood flow.

ordered. Nursing Diagnosis: Impaired physical mobility related to neuromuscular involvement

Interventions

Rationale

Independent: 1. Assess

functional

extent

of

ability/ 

impairment

Identifies

deficiencies and may provide

initially and on a regular

information

basis.

recovery.

2. Change position

strengths/

at least  Reduces

regarding risk

of

tissue

every 2hrs. and possibly

ischemia/injury. Affected side

more often on the affected

has

side. 3. Inspect

skin

particularly prominences. massage

any

predisposed

bony Gently

reddened

 Pressure

exercisse unaffected

movement

and

using

the

extremity

to

support or move weaker

to

skin

points

over

bony

priminences are most at risk for

as sheepskin pads as 4. Encourage necessary. patient to assist the

and

breakdown/ decubitus.

areas and provide aids such

with

circulation

reduced sensation and is more

regularly, over

poorer

decreased

ischemia.

perfusion/ Circulatory

stimulstion and ,padding help prevent

ski

breakdown

and

decubitus development.  May respond as if the affected 35

side.

side is no linger part of the body

a

nd

encouragement

and

needs active

training to reincorporate it as a part of its own body.

Dependent: 5. Consult with the physical

 Individualized program can

therapist regarding active

develop to meet particular

resistive exercises and

needs/ deal with deficits in

patient ambulation.

balance, coordination and strength.

Nursing Diagnosis: Disturbed Sensory perception related to altered sensory receptor

Interventions

Rationale

36

Independent: 1. Observe behavioral responses

 Individual

responses

variable, such

but

as

are

commonalities

emotional

ability,

lowered frustration threshold, apathy, and impulsiveness may complicate care. 2. Eliminate extrenous noise/ stimuli as necessary.

3. Speak in calm, quiet voice, using short sentences.

 Reduces

anxiety

and

exaggerated

emotional

responses/

confusion

associated

with

sensory

overload.

Maintain eye contact.  Patient

may

attention with 4. Ascertain/ validate patient’ perceptions. Reorient

span

have or

limited problems

comprehension.

These

measures can help the patient to attend to communication.

patient frequently to environment , staff, procedures.

 Assists

patient

inconsistencies

to in

identify reception

and integration of stimuli and 5. Evaluate visual deficits. Note loss of visual field,

may

reduce

perceptual

distortion of reality.

changes in depth perception , presence of diplopia(double vision)

 Presence of visual disorders can negatively affect patient’s ability to perceive environment

37

and relearn motor skills and increases injury.

B. ACTUAL NURSING INTERVENTION S o A P I E

38

risk

of

accident/

B. S “ Kani man ang ako liog ang nag sakit ug pag – ayo, unya ga doble na ang ako panan-aw” o

 BP – 160/100 mmhg  Appeared weak  Diplopia  Presence of eyepatch

A Ineffective cerebral tissue perfusion related to hemorrhage. P

Long term: At the end of 2 days duty I will be able to

I Independent 1. Positioned with head slightly elevated.

 Reduces arterial pressure by promoting venous drainage and may improve cerebral circulation or perfusion. 39

1. Maintained bed rest.

 Continual stimulation or activity ma increase intracranial pressure. 1. Provided quiet environment. 

Absolute rest and quiet environment may be needed to prevent rebleeding.

1. Prevented straining at stool, holding breath. 

Valsava manuever increase ICP and potential risk of rebleeding.

Dependent 1. Administer 

and stool softeners per doctor’s order.

Prevent straining during bowel movement and corresponds to increase ICP.

E

S “ Gakalipong paman ko, mao pud gain ga hungitan pako sa ako anak or asawa, ka para dili ko maglisod. Unya duha pa gyod ako panan-aw.” 40

o  Eye patch placed alternately q2h A Risk for injury related to visual disturbance. P

Long term: At the end of 8 hours the patient with the help of relatives and health care provider will be able to modify environment as indicated to enhance safety and use resources appropriately. Short term: At the end of 1 hour the patient will be able to identify individual risk factors.

I



To know the extent of disturbance and further interventions to be done.

2. Oriented patient on possible risk factors and on the environment.  To familiarize patient on her environment and identify and avoid where danger is at its peak. 3. Adjust bed and keep side rails raised up, especially if patient is at rest.  To prevent further injury from falls. 4. Placed unnecessary objects away from clients’ sight.  To enhance safety appropriate use of necessary 41

resources. 5. Administer medication as prescribe by the physician. E At the end of 8 hours shift the patiently with the help of relatives and health care provider was able to modify environment a indicated to enhance safety and use of resources appropriately.

VIII. Referrals and Follow-up Patient was transferred to Cebu as what was planned by the family and together with Dr. Surdilla for proper treatment of the patients condition.

Patient,

together

with

the

family

was

advised

to

follow

medications and treatment regimen. Emotional and spiritual support towards the patient should be given attention, because the patient easily gets depressed and is sometimes loose hope on her situation. Follow – up check ups should also be follow according to the schedule. This is very important so that the patient and the family may be aware if there are any problems found from the patients of how the patients responds on the treatment process.

42

IX. Evaluation and Implication

After conducting this care study, I was able to appreciate more the essence of utilizing the nursing process in the care and management of my patient. It was indeed a tough job on conducting this study yet, it gave me a big impact regarding how useful it is in my chosen profession. Nursing really demands a tender loving care attitude. It demands patience and it is calling that cannot be merely taken for granted. This study will serve as a reference material in rendering competent care to my client especially those with similar situation. Through this, I will be able 43

to develop my knowledge as well as my skills and attitudes in applying the prescribed procedure to improve the health status of the patient. Moreover, this care study taught us to stand on our own by not depending on others just to make this. This provides us, the students, a big learning regarding on how well we take care of or patients in the real clinical setting. Most of all, this study teaches the students to provide clients care more efficiently and competently to achieve an effective and quality nursing care.

X.

BIBLIOGRAPHY

BOOKS  Suzzanne C. Smeltzer, EdD, RN,FAAN,et.al Medical Surgical Nursing 11th Edition, page 1118 44

 Lippincott Williams and Wilkins Manual of Nursing Practice 7th Edition page 570-571 © 2001 by Lippincott Williams and Wilkins  Robert Berhow M.D, et al Home Edition, page 562 ©1997 by Merck Co. Inc  Microsoft ® Encarta ® Reference Library 2004 ©1993-2003 Microsoft Corporation WEB  www.nursingcrib.com  http://www.wisegeek.com/what-is-cva.htm  http://en.wikipedia.org/wiki/cerebrovascularacciddent  http://www.Emedicinehealth.com/cerebrovascularaccident/pages.em.ht m

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