Cva

HOLY ANGEL UNIVERSITY Angeles City College of Nursing

CerebroVascul arAccident Submitted by: Valarie Agustin Arianne De Jesus Leo Cesar Dela Cruz John Henrick Dingal Genevieve Gopez Fritzie Blanca Limiac Ralp Lauren Lumanlan Princess Dian Munoz Irien Nain Andrei Punzalan Jenelyn Talavera Paula Angeli P. Tayag Alraian Tuazon Submitted to: Mr. Nathaniel H. Gaddi RN, MD

March 1, 2010

2

INTRODUCTIO N

3

I.

INTRODUCTION

“The only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you’d rather not.” -Mark Twain A. BRIEF DESCRIPTION OF THE DISEASE CONDITION Cerebrovascular accident (CVA) is the medical term for what is commonly termed as 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 many facts. It has been noted that CVA is the leading cause of adult disability in the world. Worldwide, one-quarter of all strokes are fatal. Two-thirds of strokes occur in people over the age of 65. Strokes affect men more often than women, although women are more likely to die from a stroke. The incidence of strokes among people ages 30 to 60 is less than 1%. This figure triples by the age of 80. The quote says that everything occurring in our lives are the result of our previous choices- choices that may lead to a good present status or the opposite, especially in health were most of the conditions met by patients are results of their chosen lifestyle and other health practices. Some choices made by certain people may have detrimental health effects that may progress to a clinical condition. A person’s diet, activity of daily living, health beliefs and others can result to health illness. Like the case of this study, a person’s way of life, along with other non-modifiable factors resulted to the occurrence of weakness and slurred speech that lead to a condition called Cerebrovascular Accident (CVA). A stroke (sometimes called a cerebrovascular accident (CVA)) is the rapidly developing loss of brain function(s) due to disturbance in the blood supply to the brain, caused by a blocked or burst blood vessel. This can be due to ischemia (lack of glucose and oxygen supply) caused by thrombosis or embolism or due to a hemorrhage. As a result, the affected 4

area of the brain is unable to function, leading to inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or inability to see one side of the visual field. A stroke is a medical emergency and can cause permanent neurological damage, complications, and death. It is the leading cause of adult disability in the United States and Europe. It is the number two cause of death worldwide and may soon become the leading cause of death worldwide. Risk factors for stroke include advanced age, hypertension (high blood

pressure),

previous

stroke

or transient

ischemic

attack (TIA), diabetes, high

cholesterol, cigarette smoking and atrial fibrillation. High blood pressure is the most important modifiable risk factor of stroke. A stroke is occasionally treated with thrombolysis ("clot buster"), but usually with supportive care (speech and language therapy, physiotherapy and occupational therapy) in a "stroke unit" and secondary prevention with antiplatelet drugs (aspirin and often dipyridamole), blood

pressure

control, statins,

and

in

selected

patients

with carotid

endarterectomy and anticoagulation. Stroke symptoms typically start suddenly, over seconds to minutes, and in most cases do not progress further. The symptoms depend on the area of the brain affected. The more extensive the area of brain affected, the more functions that are likely to be lost. Some forms of stroke can cause additional symptoms: in intracranial hemorrhage, the affected area may compress other structures. Most forms of stroke are not associated with headache, apart from subarachnoid hemorrhage and cerebral venous thrombosis and occasionally intracerebral hemorrhage. Disability affects 75% of stroke survivors enough to decrease their employability. Stroke can affect patients physically, mentally, emotionally, or a combination of the three. The results of stroke vary widely depending on size and location of the lesion. Dysfunctions correspond to areas in the brain that have been damaged. Some of the physical disabilities that can result from stroke include paralysis, numbness, pressure sores, pneumonia, incontinence, apraxia (inability to perform learned movements), difficulties carrying out daily activities, appetite loss, speech loss, vision loss, and pain. If the stroke is severe enough, or in a certain location such as parts of the brainstem, coma or death can result. 5

Emotional problems resulting from stroke can result from direct damage to emotional centers in the brain or from frustration and difficulty adapting to new limitations. Post-stroke emotional

difficulties

include anxiety, panic

attacks, flat

affect (failure

to

express

emotions), mania, apathy, and psychosis. 30 to 50% of stroke survivors suffer post stroke depression, which is characterized by lethargy, irritability, sleep disturbances, lowered self esteem, and withdrawal. Depression can reduce motivation and worsen outcome, but can be treated with antidepressants. Emotional lability, another consequence of stroke, causes the patient to switch quickly between emotional highs and lows and to express emotions inappropriately, for instance with an excess of laughing or crying with little or no provocation. While these expressions of emotion usually correspond to the patient's actual emotions, a more severe form of emotional lability causes patients to laugh and cry pathologically, without regard to context or emotion. Some patients show the opposite of what they feel, for example crying when they are happy. Emotional lability occurs in about 20% of stroke patients. Cognitive

deficits

resulting

from

stroke

include

perceptual

disorders, speech

problems, dementia, and problems with attention and memory. A stroke sufferer may be unaware of his or her own disabilities, a condition called anosognosia. In a condition called hemispatial neglect, a patient is unable to attend to anything on the side of space opposite to the damaged hemisphere. Up to 10% of all stroke patients develop seizures, most commonly in the week subsequent to the event; the severity of the stroke increases the likelihood of a seizure. Hippocrates (460

to

370

BC)

was

first

to

describe

the

phenomenon

of

sudden paralysis that is often associated with ischemia. Apoplexy, from the Greek word meaning "struck down with violence,” first appeared in Hippocratic writings to describe this phenomenon. The word stroke was used as a synonym for apoplectic seizure as early as 1599, and is a fairly literal translation of the Greek term.

6

In 1658, in his Apoplexia, Johann Jacob Wepfer (1620–1695) identified the cause of hemorrhagic stroke when he suggested that people who had died of apoplexy had bleeding in their

brains.

Wepfer

also

identified

the

main arteries supplying

the

brain,

the vertebral and carotid arteries, and identified the cause of ischemic stroke [also known as cerebral infarction] when he suggested that apoplexy might be caused by a blockage to those vessels. Rudolf Virchow first described the mechanism of thromboembolism as a major factor. B. REASONS FOR CHOOSING THE CASE The group chose this case for their study because the group found it interesting. The student nurses wanted to learn more about the disease condition, its causes, symptoms and interventions that the student nurse need to know as they become future health care providers. In line with this, the group was able to enhance their knowledge and skills as nurses in order to render effective nursing care. C. STATISTICS Global Statistics According to the World Health Organization, 15 million people suffer stroke worldwide each year. Of these, 5 million die and another 5 million are permanently disabled. High blood pressure contributes to over 12.7 million strokes worldwide. Europe averages approximately 650,000 stroke deaths each year. In developed countries, the incidence of stroke is declining - largely due to efforts to lower blood pressure and reduce smoking. However, the overall rate of stroke remains high due to the aging of the population. Sources: World Health Report - 2007, from the World Health Organization; International Cardiovascular Disease Statistics (2007 Update), a publication from the American Heart Association.

UK Stroke is a major cause of mortality in the UK, accounting for around 53,000 deaths every year (around 9% of all deaths). As a single cause of death, stroke is second only to coronary heart 7

disease as the biggest killer in the UK. Stroke is also a major cause of premature mortality, responsible for over 9,500 deaths every year in people under the age of 75, about one in twenty of all deaths in this age group. There are a number of different forms of stroke, including subarachnoid haemorrhage, haemorrhagic stroke and ischaemic stroke. It is often difficult for medical practitioners to identify the particular stroke subtype without access to evidence from autopsy or a brain scan. Therefore a large number of stroke mortalities are recorded as either ‘unspecified stroke’ or ‘other cerebrovascular disease’. Because of this, it is not possible to know exactly how many deaths are caused each year by the individual stroke subtypes. (http://www.heartstats.org/datapage.asp?id=8164) May 2007 The burden of stroke •

Each year 16 million people experience a stroke and 5·7 million die.1

•

87% of global stroke mortality occurs in low- and middle-income countries.1

•

Unless there are population-wide interventions, by 2030 there will be 23 million strokes and 7·8 million deaths each year.1

•

Over the next two decades stroke mortality will triple in Latin America, the Middle East, and sub-Saharan Africa.2

•

Globally, stroke is the second leading cause of death above the age of 60 years, and the fifth leading cause in people aged 15 to 59 years old.3

•

Stroke is the third most common cause of death in developed countries, behind coronary heart disease (CHD) and cancer.3

•

Stroke is uncommon in people under 40 years.3

•

In many developed countries the incidence of stroke is declining but the actual number is increasing because of ageing populations.3

(http://www.worldheart.org/press/facts-figures/stroke/)

8

LOCAL STATISTICS MORTALITY MORTALITY: TEN LEADING (10) LEADING CAUSES Number and rate/100,000 Population Philippines 5-Year Average (2000-2004) & 2005 5 Year Average 2005* Cause

(2000-2004) Number Rate

No.

Rate

1. Diseases of the Heart

66,412

83.3 77,060

90.4

2. Diseases of the Vascular system

50,886

63.9 54,372

63.8

3. Malignant Neoplasm

38,578

48.4 41,697

48.9

4. Pneumonia

32,989

41.4 36,510

42.8

5. Accidents

33,455

42.0 33,327

39.1

6. Tuberculosis, all forms

27,211

34.2 26,588

31.2

7. Chronic lower respiratory diseases

18,015

22.6 20,951

24.6

8.Diabetes Mellitus

13,584

17.0 18,441

21.6

14,477

18.2 12,368

14.5

9.166 11.5 11,056 nephrosis Note: Excludes ill-defined and unknown causes of mortality

3.6

9. Certain conditions originating in the perinatal period 10. Nephritis, nephrotic syndrome and

(R00-R99) n=23,235 * reference year ** External Causes of Mortality Last Update: June 29, 2009

9

TEN LEADING (10) CAUSES OF MORTALITY AMONG MALES Number and Rate/100,000 Population Philippines, 2005

Cause

No.

Rate

1. Diseases of the Heart

43,809

102.1

2. Diseases of the Vascular system

30,531

71.2

3. Accidents

27,281

63.6

4. Malignant Neoplasms

21,993

51.3

5. Tuberculosis, all forms

18,229

42.5

6. Pneumonia

18,145

42.3

7. Chronic lower respiratory diseases

14,450

33.7

8,912

20.8

7,385

17.2

6,548

15.3

8. Diabetes Mellitus 9. Certain conditions originating in the perinatal period 10. Nephritis, nephrotic syndrome and nephrosis

Last Update: June 30, 2009

10

TEN LEADING (10) CAUSES OF MORTALITY AMONG FEMALES Number and Rate/100,000 Population Philippines, 2005 Cause

No.

Rate

1. Diseases of the Heart

33,251

78.5

2. Diseases of the Vascular system

23,841

56.3

3. Malignant Neoplasms

19,704

46.5

4. Pneumonia

18,365

43.3

5. Diabetes Mellitus

9,529

22.5

6. Tuberculosis, All Forms

8,359

19.7

7. Chronic lower respiratory diseases

6,501

15.3

8. Accidents

6,046

14.3

9. Certain conditions originating in the perinatal period

4,983

11.8

10. Nephritis, nephrotic syndrome and nephrosis

4,508

10.6

Note: Excludes ill-defined and unknown causes of mortality (R00-R99) for males (n=11,840) and females n=11,395 ** External Causes of Mortality Last Update: June 30, 2009 (http://www.doh.gov.ph/kp/statistics/leading_mortality.html)

11

CURRENT TRENDS Breakthrough for fast 3D stroke imaging

Cerebrovascular diseases (for example, ischemic stroke) are the second leading cause of death worldwide and this trend is expected to continue and even grow until 2030 [1]. Unfortunately, most people with stroke symptoms still do not get to the hospital in time. This hinders them from being considered for time-dependent treatments that can reduce disability or death. Such incidents show that the system of care for stroke victims can be improved. In the first 3 hours after a suspected cerebrovascular accident (CVA), non-contrast head computed tomography (CT) is the primary imaging modality for the differential diagnosis of acute stroke. However, the latest research shows significantly improved clinical outcomes in patients with acute stroke after lysis therapy with Alteplase even in the range of three to four and a half hours after the first stroke symptoms [2]. Based on these results we expect that using perfusion CT in addition could be even more beneficial in order to reduce serious adverse events and predict a beneficial outcome for these patients by looking at the relation between core infarct and tissue at risk. This has been not performed in this study and has to be proven in future studies.

Faster stroke diagnosis CT perfusion imaging with syngo® Volume Perfusion CT Neuro can be used to diagnose acute ischemic stroke in the emergency department quicker than with magnetic resonance imaging (MRI), according to results of a large single-center study [2]. The study shows that CT perfusion had 100 percent accuracy for detecting the acute ischemic stroke (AIS). If adopted, the researchers say that this advancement in stroke detection will mean dramatically faster 12

diagnosis times - less than half the time of MRI screening - and enable physicians to provide more accurate and targeted care, thereby avoiding potentially life-threatening complications that can occur when thrombolytic drug therapy is used inappropriately. The study also reveals that within five minutes of the patient getting on the CT scanner table, results can be achieved, as opposed to MRI, which takes half an hour. The study also reveals that the widespread use of CT perfusion is a practical way to help busy emergency departments to significantly save time in acute stroke diagnosis, target treatment, and reduce the risks of inappropriate thrombolytic use. According to the researchers, it is remarkable that the average time between an emergency room neurological exam and CT scan was only 35 minutes. They confirmed that CT perfusion imaging is very effective for diagnosing acute stroke and concluded that their result could change national stroke triage protocols.

Precise information Apart from the speed advantage, dynamic perfusion CT has become an increasingly accepted examination for the differential diagnosis of acute stroke patients. Multislice CT, with a continuously increasing number of detector rows, has quickly made high-resolution CTA of the cerebral vasculature a clinical routine examination. It has, however, not really overcome the limitations with respect to traditional CT perfusion imaging, which is restricted to the detector width. Innovative technology such as the unique Adaptive 4D Spiral mode of the Siemens SOMATOM® Definition family overcomes the limitations of static detector designs and now allows volume perfusion imaging of the whole brain in clinical routine. Key Benefits of syngo Volume Perfusion CT Neuro •

Whole brain and 3D tissue at risk evaluation with dynamic information*

•

All perfusion parameters at hand: cerebral blood flow (CBF), cerebral blood volume

(CBV), time to peak (TTP) and mean transit time (MTT) •

Auto Stroke: therapeutic decision without complex user interaction ready for 24/7 use.

•

Increased confidence: integrated automated motion corrections compensates for patient

movement 13

•

* Requires Adaptive 4D Spiral

___________ [1] World Health Statistics 2008 [2] The Role of CT Perfusion Imaging in Acute Stroke Diagnosis: A Large Single-Center Experience, Rai et al., The Journal of Emergency Medicine, Volume 35, Issue 3, Pages 237354, October 2008) The antidepressant Lexapro may help protect key thinking functions if taken soon after a stroke, U.S. researchers said. People who took Forest Laboratories Inc's (FRX.N) Lexapro, or escitalopram, after a stroke recovered more of their thinking, learning and memory skills than others who had counseling-type therapy normally used to treat depression or who were given a placebo. It is not clear why Lexapro helped, but they said there is increasing evidence that antidepressants cause changes in key brain structures needed for memory and thinking -including the visual cortex, hippocampus and cerebral cortex -- that may help explain the memory improvements. New research finds that one out of 12 people who have a stroke will likely soon have another stroke, and one out of four will likely die within one year. Researchers say the findings highlight the vital need for better secondary stroke prevention. These findings suggest that South Carolina and possibly other parts of the United States may have a long way to go in preventing and reducing the risk factors for recurrent strokes. Eating chocolate may lower your risk of having a stroke, according to an analysis of available research that will be presented at the American Academy of Neurology's 62nd Annual Meeting in Toronto April 10 to April 17, 2010. Another study found that eating chocolate may lower the risk of death after suffering a stroke. Chocolate is rich in antioxidants called flavonoids, which may have a protective effect against stroke, but more research is needed. The first study found that 44,489 people who ate one serving of chocolate per week were 22 percent less likely to have a stroke than people who ate no chocolate. The second study found that 1,169 people who ate 50 grams of chocolate once a week were 46 percent less likely to die following a stroke than people who did not eat chocolate.

14

D. NURSING OBJECTIVES After 2 days of Nurse-Patient Interaction the student nurse will be able to: Cognitive: •

Identify specific theoretical causes and clinical manifestations, and trace the pathophysiology of the involved disease entity;

•

Identify nursing problems and construct nursing care plans specifically;

•

Understand the normal anatomy and physiology of the affected organs that are affected by the underlying disease condition;

Affective: •

describe predisposing and precipitating factors that could possibly contribute to the occurrence of the disease;

Psychomotor: •

Accurately gather nursing history

•

Enumerate ways of preventing the occurrence of the disease or problem

15

NURSING ASSESSMENT

16

II.

NURSING ASSESSMENT

Personal History Mr. CVA is 62 years old and is married. He was born on April 26, 1947 at San Pedro, Mexico, Pampanga. He resides with his family at Mexico, Pampanga. He was admitted last February 23, 2010. Mr. CVA lives with his wife and children. His children are responsible for the welfare of their parents since both of their parents are not working anymore. Their family is a Baptist Christian. They don’t necessarily believe in the so-called manghihilot. They rely much on doctors when it comes with their health status. The family of Mr. CVA lives at Sapang Makulangut. The place where they live is known for many “tambays”. Mrs. CVA dVerbalized description of their community as “Ay! Nuko, ding tao Karin pag alduk da ing emperador…”. It is also seen to have many street vendors who sell street foods such as barbeque, quail eggs and fried chicken skin. Mr. CVA eats his meal on a regular basis (breakfast, lunch and dinner). He even has snacks in between his meals approximately three times a day. They usually eat pork, rice and vegetables. He often buys street foods such as isaw, chicken skin, chicken feet, fish ball, halo halo, turon and quail eggs. Mr. CVA is fond of drinking coffee and softdrinks. According to his wife he can consume a liter of softdrinks in one sitting. This persists even after he was diagnosed with diabetes. He is also an occasional alcohol drinker and a smoker. Whenever he is engaged with situations wherein he is forced to drink he can consume an average of 4 bottles of Red Horse. He smokes for like 2-3 sticks per day since his mid-20 (with a pack years of 6.3 pack years). His sleep cycle goes from around 7pm-4am. He takes his breakfast around 8am while reading his daily newspaper. He usually eats pandesal and coffee for breakfast. After eating, he takes a 30 minute nap. Upon awakening, he eats a meryenda such as turon where he buys at a store in front of their house accompanied by another cup of coffee. For lunch, he often eats meat and rarely eat vegetables as his ulam with an average of 2-3 cups of rice as his meal. For his afternoon meryenda, he eats street foods available nearby their house accompanied with softdrinks. And for his dinner, it is usually the same with his lunch preference. He doesn’t have any forms of exercise. His forms of usual

17

activities for the day are watching tv, reading newspaper and sleeping. His wife even said, “Sarap ng buhay niyan, kain at tulog lang”

Computation for Pack Years: (# of sticks per day (3 sticks)/ 20) X 42 years

18

Family Health Illness History

Mr. CVA

19

It is very evident that Mr. CVA is at high risk of developing Cerebrovascular Accident (CVA). One of his grandparents experienced of having CVA and the other two grandparents have the factors that contribute to occurrence of CVA such as Diabetes Mellitus (DM) and Hypertension. His mother inherited DM for his grandfather while his father had a history of CVA and hypertension. His Aunts and Uncles in both sides had hypertension. Two of his siblings died from CVA, and the other one had a hypertension. Based from his family history, it is very apparent on how Mr. CVA developed hypertension and DM that made him at risk for CVA. History of Past Illness Mr. CVA was never hospitalized and had no history of chickenpox, mumps and measles. Usually, according to his wife, Mr. CVA only experience common coughs, fever and colds due to weather changes.

He self-medicates with Paracetamol for fever, Robitussin for common

coughs and Neozep for colds. There was an instance wherein he was brought to a clinic for severe stomach ache due to hyperacidity last 2007. The doctor who checked him told Mr. CVA that his fondness of drinking softdrinks contributed to his hyperacidity. He was asked to take antacids as his medications. History of Present Illness It was around 2006 when Mr. CVA was diagnosed by the doctor with DM Type II.

And

around mid-2008, Mr. CVA was first hospitalized for his first attack of stroke. According to Mr. CVA’s wife, he was brought to the hospital that time because the patient was complaining of slurred speech and dizziness while he was watching tv. From then on he was taking maintenance drugs for his DM which is Metformin (taken every evening) and Insulin (25 units during morning and another 15 units during evening). According to his wife, oftentimes it is Mr. CVA who injects insulin to himself. Another maintenance drug for his hypertension is Bascorten which he takes 10mg of it every day. Whenever he experiences hypertension his BP is around 140-200 for the systole and 90-110 for the diastole. Few days before his symptoms occurred, he complained to his wife a feeling of being nervous when he found out that their neighbor died because of DM and having the same disease condition this triggered him to be anxious, this feeling manifested the day before he was admitted to the hospital (February 22, 2010).

According to Mr. CVA’s wife, it was around 20

3:00pm of February 23, 2010 when her husband felt something uncommon. Around 9:00 am of February 23, 2010 he was feeling slight light-headedness while he was taking his breakfast. He just lay down thinking that he would feel okay after doing so. This feeling persisted for about 2 hours as verbalized by the patient’s wife. And around 2:00pm, while he was taking his lunch, the patient was asking for a glass of water to his wife but he could not speak clearly. All they could hear were a bit of groaning and slurd speech. Some of the words the patient tries to say weren’t that clear. The wife of Mr. CVA immediately got worried thinking that these symptoms were the same as with his first episode of stroke. Mr. CVA’s wife also noticed that when they asked him to walk he was having difficulty because of his dizziness and that he is also complaining that he can’t move properly the right side of his body especially his arms and legs. Immediately after that, they rushed him to the hospital and around 3:00pm later that day Mr. CVA was admitted. His chief complaint was slurd speech and right sided weakness.

21

PHYSICAL ASSESSMENT

22

III.

PHYSICAL ASSESSMENT

Physical Assessment as lifted from the chart: (February 23, 2010) Head Eyes Ears Nose Throat- Pinkish palpebral conjunctiva; anecteric sclera Chest and Lungs- Equal chest expansion, clear breath sounds, absence of rales, absence of wheezes Cardiac- dynamic heart sounds, normal respiratory rate and rhythm, absence of murmur Abdomen- soft, normal active bowel sounds, non-tender Extremities- strong pulses, absence of cyanosis February 23, 2010 1st day of Nurse-Patient Interaction Vital Signs: BP: 140/100mmHg Temperature: 37.1 C/axilla PR: 97bpm RR: 29bpm 1. GENERAL SURVEY 

Wears reading glasses 

Approximately two weeks prior to the incident Mr. CVA exhibited disorientation as evidenced by frequent query of the date



Absence of chest pain felt and verbalized



Loss all of his teeth



Height of 5’8”



Weight of 70 kilograms



There is absence of difficulty in urinating reported; absence of discharges, swelling, ulcerations and nodules in the genital area as verbalized



Absence of masses felt by Mr. CVA on the rectal lining



There is absence of verbalized constipation or any difficulty or pain during defecation

23

2. SKIN Inspection 

With fair complexion 

The neck area has a ruddy color while the rest of his skin is uniform in color except areas not exposed to the sun (e.g. axillae) which are slightly lighter

Palpation 

Has warm temperature at 37.1oC and the skin is warm to touch



Exhibits a good skin turgor - skin springs back to previous state when pinched.

3. HEAD AND FACE Inspection 

The head is slightly tilted to the left which is oval in shape but the right side is drooping compared to the other side.



Patient can easily move his head towards his left side but is having difficulty in other directions



The hair is thin and is evenly distributed throughout the upper part of the skull



Hair is black with white streaks and is slightly greasy in texture when touched

a. Eyes Inspection 

Symmetrically aligned and is able to focus properly



The iris is symmetrical and are brown in color 

Pupils are black and equally round and reactive to light and accommodation



Sclera is anicteric



Has pale pink palpebral conjunctiva



Able to close and open the left upper eyelids

24

The right eyelid is able to close properly but exhibits weakness upon



opening There is a red, nodular lump in his right eyelid which has a yellowish spot;



absence of discharges noted but the eyes are moist 

Lacrimal glands are not enlarged



Eyebrows are evenly distributed on both eyes



Eyelashes are evenly distributed on the lids of the eye and are not turning inward

b. Ears Inspection Exhibits a good sense of hearing as observed upon interrogation, Mr.



CVA responds whenever his name is called Has auricles that has the same color as his facial skin, symmetrically



aligned with the outer canthus of the eye 

He has a preauricular pit on the helical root of his right ear



There is minimal accumulation of brownish waxy cerumen on both ears Palpation Absence of swelling and tenderness

 c. Nose

Inspection 

Displays symmetry on both sides of the nose, air moves freely as Mr. CVA breathes through the nares



Absence of nasal discharges coming out, absence of tenderness and inflammation observed



Septum is equally symmetrical on both sides and there are absences of deviations seen Palpation



Absence of masses palpated from both maxillary and frontal sinuses

d. Oral cavity Inspection 25

Upper and lower lips have uniform brown to pink color, absence of cracks



and fissures seen 

Mr. CVA is wearing smooth, intact dentures during the interview



Gums are pinkish and moist



The tongue which is slightly deviated to the left is pinkish in color



Can move freely to the left but movement to the right side is limited



Absence of difficulty in swallowing



Uvula is positioned on the midline of the soft palate



Tonsils are pink and smooth



Palatine tonsils are pinkish and not inflamed



Gag reflex is present Palpation



Lips are smooth and moist e. Neck Inspection 

Head is symmetrically centered above 

Exhibits a limited range of motion having difficulty to tilt head from left to right

4. CHEST AND LUNGS a. Chest Inspection 

Has proportion and symmetry in shape on the thoracic cavity



Presence of pulsations in the suprasternal notch 

Absence of dynamic precordium Palpation



Absence of nodules and lumps Percussion



There is a resonant sound upon percussion b. Lungs Inspection 26



Exhibits symmetrical respirations at 29 breaths per minute



With symmetrical chest expansion as observed Percussion



There is resonance upon percussion Auscultation



Exhibits clear breath sounds upon auscultation

5. HEART Auscultation 

Absence of murmurs



With apical pulse of 100 beats per minute 

Radial pulse is palpable with a pulse rate of 97 beats per minute in the right and 96 beats per minute in the left hand which are noted to be soft equal pulses



The posterior tibial pulse is palpable with a pulse of 93 beats per minute in the right and 98 in the left which are noted to be soft equal pulses



There is regular heart rhythm and there is a low-pitched and relatively long “lubb-dub” observed upon auscultation



Blood pressure is 140/100 mmHg

6. BREAST Inspection 

Nipples are round, everted, dark brown in color and are symmetrically positioned on both chest and are equal in size



Absence of discharges coming out



Absence of rashes noted Palpation



Absence of tenderness palpated and both breasts are firm

7. ABDOMEN Inspection 

Absence of rashes, lesions or any dilated veins seen



Absence of abdominal distention noted 27



Abdomen is neither bulging nor distended



Umbilicus is not inverted Auscultation



With 15 bowel sounds per minute Palpation



Has flat and soft abdomen Percussion



With tympanic sound upon percussion 8. GENITALS Inspection



Mr. CVA is wearing a diaper during the interview 9. EXTREMITIES AND BACK Inspection 

There is proportionality and symmetry with the four extremities with their sizes and shape



The right foot has its second toe crossed over the big toe



On the left foot there is a 1.5 cm space between the third and the fourth toe



Nails are convex in curvature, smooth in texture



The nail bed is peach in color, intact with the epidermis, dirty and untrimmed with dirt accumulations on the fingertips



There is prompt return of pinkish color for about 2 seconds during blanch test (capillary refill test)



The spinal column is vertically aligned without any postural defects noted

28



Upon assessment of the Muscle Strength the right arm scored 2; the left arm 4; the right leg 3; the left leg 4

2

4

3

4

Muscle strength 5- Normal strength. Muscle is able to move through a full range of motion (ROM) against gravity and applied resistance 4- Muscle is able to move through a full ROM against gravity but with weakness to applied resistance 3- Muscle is able to move actively against gravity alone 2- Muscle is able to move with support against gravity 1- Muscle contraction is palpable and visible 0- Muscle contraction or movement is undetectable

29

10. NEUROLOGIC EXAMINATION a. Mental Status 

Patient is conscious and disoriented about the date and time although he is aware of the place and the person accompanying him



He is able to respond with yes or no questions



Unable to completely verbalize a sentence



Speech is limited to one word

b. Intellect: Memory, Judgment and Reasoning, Thought Process 

Short attention span, there is a frequent need to repeat instruction 

He is unable to provide information when asked about his diet during the last 24 hours and other questions regarding his past because of speech difficulties



Assessment was limited about new learning and judgement because Mr. CVA could neither verbalize nor write his answer. CRANIAL NERVES ASSESSMENT

Nerve

Classification

Major

Assessment

functions

I Olfactory

Sensory

Smell

Have patient sniff a

Mr. CVA was able to

familiar scent (alcohol

distinguish alcohol

and perfume) with eyes

but failed to identify

closed then was asked

the scent of the

to open his eyes and

perfume, he

point out the scent.

classified it as the scent of alcohol.

II Optic

Sensory

Vision

Have patient read from

Mr. CVA was not

a card or newspaper,

able read but

one eye at a time. Test

confirmed that he

visual fields by having

can see the object

patient cover one eye,

handed infront of him

focus on the examiner’s through squeezing nose, and identify the

the examiners hand.

number of fingers held 30

up in each of four visual quadrants. Check pupillary

Both pupils constrict

responses by shining a

upon exposure to

bright light on each

direct light from the

pupil; both pupils

penlight. There is

should constrict. To

also constriction as

elevation;

check accommodation,

the examiners finger

most

move one finger toward

move toward Mr

Mr CVA’s nose; the

CVA’s nose.

Eyelid

III Oculomotor

Motor

EOMs; pupil size

pupils should constrict

and

and converge. Check

reactivity

Mr. CVA was able to

EOMs by having patient look up, down, upper look up, down, laterally,

left, lower left but

and diagonally (cardinal unable to look right, positions of gaze).

lower right and upper right

Extraocular Check EOMs by having eye

IV Trochlear

Motor

V Trigeminal

Sensory

Opthalmic branch

Mr. CVA was able to

patient look up, down,

look up, down, upper

movement

laterally, and diagonally

left, lower left but

(turns eye

(cardinal positions of

unable to look right,

downward

gaze).

lower right and upper

and

right

laterally)

Chewing;

Palpate temporal and

facial and

masseter muscles teeth able to bite down or

mouth sensation;

clenched

Mr. CVA was not chew. Although Mr. CVA was able to 31

corneal

identify the cotton

reflex

Maxillary branch

Sensory

Mandibular

(sensory)

chin and both

Somatic

cheeks.

sensations

The right cheek is

of face, oral Test corneal reflex, touch forehead, cavity,

drooping compared

teeth

branch

Somatic Sensory and Motor

sensation lower face and mastication

VI Abducens

Motor

wisp in his forehead,

to the left side.

cheeks, and chin with cotton wisp Symmetrical comparisons Bite down or chew Have patient move the

Mr. CVA was able to

eyes from side to side.

move his eyes to the left easily but

Lateral eye

showed some

movement

restriction upon turning to the right side.

Facial VII Facial

Sensory and Motor

expression Taste, anterior 2/3 tongue

Ask patient to smile,

Mr. CVA was not

frown and puff cheeks.

able to perform a

Have patient identify

smile, frown or even

salt or sugar placed on

puffing of his cheeks.

the tongue(N/A Mr.

The taste test was

CVA was placed on

not applicable at that

under nothing per orem

time because he was

(NPO))

placed under nothing per orem(NPO) by the doctor.

VIII Acoustic

Sensory

Hearing;

Observe balance and

Mr. CVA can only

equilibrium

hearing acquity. Hold

hold his left arm up

32

up one finger and have

and was unable to

Mr. CVA quickly and

point the examiner’s

repeatedly move his

finger precisely. Mr.

finger back and forth

CVA could not

from the examiner’s

precisely touch his

finger to his nose. Then

nose with his left

have him alternately

index finger with or

touch his nose with his

without his eyes

right and left index

closed

fingers. Finally, have him repeat these tasks with his eyes closed. The movements should be precise and smooth Identifies taste

The taste test was

Test gag reflex with

not applicable at that

tongue depressor, note

time because he was

swallowing

rise of uvula with

placed under nothing

“ahhhh”

per orem(NPO) by

Gagging and IX

Sensory and

(sensory);

Glossopharyngeal

Motor

taste,

the doctor. Gag

posterior

reflex was present

1/3 of

and there is a rise of

tongue

the uvula with “ahhhh”

X Vagus

Sensory and

Sensation

Identifies taste

The taste test was

Motor

in pharynx,

Test gag reflex with

not applicable at that

larynx, and

tongue depressor, note

time because he was

external ear rise of uvula with

placed under nothing

Swallowing

per orem(NPO) by

“ahhhh”

the doctor. Gag reflex was present and there is a rise of the uvula with 33

“ahhhh”

Shoulder XI Spinal accessory

Motor

Push chin against

Mr. CVA was unable

hand, shrug shoulder

to push his chin

movement;

against the

head

examiners hand. He

rotation

could not also shrug his shoulders Move tongue side to

Mr. CVA has

side against a tongue

difficulty in

depressor

articulation; the word

Assess articulation.

“oo” is barely understandable. The tongue can only

Tongue XII Hypoglossal

Motor

movement; speech

move towards the left side against the tongue depressor; he was unable to move his tongue upward, downward and to the ride side, with or without the pressure from the tongue depressor.

GLASGOW COMA SCALE

34

Measure

Eye Response

Response Opens spontaneously

Score 4

Opens to verbal command

3

Opens to pain

2

No response Reacts to verbal command

1 6

Reacts to painful stimuli Motor Response

Verbal Response

Identifies localized pain

5

Flexes and withdraws

4

Assumes flexor posture

3

Assumes extensor posture

2

No response Is oriented and converses

1 5

Is disoriented but converses

4

Uses inappropriate words

3

Makes unintelligible sounds

2

No response

1

35

February 24, 2010 2nd Nurse Patient Interaction BP: 130/80mmHg Temperature: 37.3 C/axilla PR: 97bpm RR: 25bpm 1. GENERAL SURVEY >

Changed diaper 2 times

2. SKIN Palpation Has warm temperature at 37.3oC and the skin is warm to touch



3. HEAD AND FACE Inspection The head is slightly tilted to the left which is oval in shape but the right



side is drooping compared to the other side. Patient can easily move his head towards his left side but is having



difficulty in other directions a. Eyes Inspection 

Presence of yellowish rheum in both eyes The right eyelid is able to close properly but exhibits weakness upon



opening There is a red, nodular lump in his right eyelid which has a yellowish spot;



absence of discharges noted but the eyes are moist b. Ears Inspection 

presence of white flakes and scaly skin on the auricles

c. Nose d. Oral cavity 36

Inspection 

Lips are dry and the presence of cracks are noted



The tongue has a thin bluish coating 

The tongue which is slightly deviated to the left is pinkish in color



Can move freely to the left but movement to the right side is limited

e. Neck Inspection Exhibits a limited range of motion having difficulty to tilt head from left to



right 4. CHEST AND LUNGS a. Chest Inspection 

Presence of pulsations in the suprasternal notch b. Lungs Inspection 

Exhibits symmetrical respirations at 25 breaths per minute

5. HEART Auscultation 

With apical pulse of 99 beats per minute 

Radial pulse is palpable with a pulse rate of 97 beats per minute in the right and 98 beats per minute in the left hand which are noted to be soft equal pulses



The posterior tibial pulse is palpable with a pulse of 95 beats per minute in the right and 96 in the left which are noted to be soft equal pulses



Blood pressure is 130/80 mmHg

6. BREAST 7. ABDOMEN 37



With 17 bowel sounds per minute 8. GENITALS 9. EXTREMITIES AND BACK

38



Upon assessment of the Muscle Strength the right arm scored 3; the left arm 4; the right leg 3; the left leg 4

2

4

3

4

Muscle strength 5- Normal strength. Muscle is able to move through a full range of motion (ROM) against gravity and applied resistance 4- Muscle is able to move through a full ROM against gravity but with weakness to applied resistance 3- Muscle is able to move actively against gravity alone 2- Muscle is able to move with support against gravity 1- Muscle contraction is palpable and visible 0- Muscle contraction or movement is undetectable

39

10. NEUROLOGIC EXAMINATION a. Mental Status 

Mr. CVA is conscious and still disoriented about the date and time although he is aware of the place and that he is accompanied by his wife



He is able to respond with yes or no questions



Still unable to completely verbalize a sentence



Speech is limited to two to three words b. Intellect: Memory, Judgment and Reasoning, Thought Process 

Mr. CVA was able to follow directions and maintain eye contact throughout the interview



He is unable to provide information when asked about his diet during the last 24 hours and other questions regarding his past because of speech difficulties



Assessment was limited about new learning and judgment because Mr. CVA could neither verbalize nor write his answer. CRANIAL NERVES ASSESSMENT

Nerve

Classification

Major

Assessment

functions

I Olfactory

Sensory

Smell

Have patient sniff a

Mr. CVA was able to

familiar scent (alcohol

distinguish alcohol

and perfume) with eyes

but failed to identify

closed then was asked

the scent of the

to open his eyes and

perfume, he

point out the scent.

classified it as the scent of alcohol.

III Oculomotor

Motor

Eyelid elevation; most EOMs;

Check pupillary

Mr. CVA was able to

responses by shining a

look up, down, upper

bright light on each

left, lower left but

pupil; both pupils

unable to look right, 40

should constrict. To

lower right and upper

check accommodation,

right

move one finger toward pupil size and reactivity

Mr CVA’s nose; the pupils should constrict and converge. Check EOMs by having patient look up, down, laterally, and diagonally (cardinal positions of gaze).

Extraocular Check EOMs by having eye

IV Trochlear

Motor

Mr. CVA is still

patient look up, down,

unable to look right,

movement

laterally, and diagonally

lower right and upper

(turns eye

(cardinal positions of

right

downward

gaze)

and laterally)

V Trigeminal Opthalmic branch

Chewing;

Palpate temporal and

facial and

masseter muscles teeth able to bite down or

mouth Sensory

Maxillary branch

clenched

sensation;

drooping compared

reflex branch

chew. The right cheek is

corneal

Mandibular

Mr. CVA was not

to the left side.

(sensory) Sensory

Somatic sensations of face, oral Test corneal reflex, touch forehead, cavity, teeth

cheeks, and chin with

41

Somatic Sensory and Motor

cotton wisp

sensation lower face

Symmetrical

and

comparisons

mastication Bite down or chew

VI Abducens

Motor

Have patient move the

Mr. CVA was able to

eyes from side to side.

move his eyes to the left easily but

Lateral eye

showed some

movement

restriction upon turning to the right side.

Facial VII Facial

Sensory and Motor

expression Taste, anterior 2/3 tongue

Ask patient to smile,

Mr. CVA was able to

frown and puff cheeks.

perform a smile and

Have patient identify

frown but not puffing

salt or sugar placed on

of his cheeks. The

the tongue(N/A Mr.

taste test was not

CVA was placed on

applicable at that

under clear liquid diet)

time because he was placed under clear liquid diet by the doctor.

VIII Acoustic

Sensory

Hearing;

Observe balance and

Mr. CVA can only

equilibrium

hearing acquity. Hold

hold his left arm up

up one finger and have

and was unable to

Mr. CVA quickly and

point the examiner’s

repeatedly move his

finger precisely. Mr.

finger back and forth

CVA could not

from the examiner’s

precisely touch his

finger to his nose. Then

nose with his left

have him alternately

index finger with or

touch his nose with his

without his eyes

right and left index

closed 42

fingers. Finally, have him repeat these tasks with his eyes closed. The movements should be precise and smooth

Shoulder XI Spinal accessory

Motor

Push chin against

Mr. CVA was unable

hand, shrug shoulder

to push his chin

movement;

against the

head

examiners hand. He

rotation

could not also shrug his shoulders Move tongue side to

Mr. CVA has

side against a tongue

difficulty in

depressor

articulation; the word

Assess articulation.

“oo” is barely understandable. The tongue can only

Tongue XII Hypoglossal

Motor

movement; speech

move towards the left side against the tongue depressor; he was unable to move his tongue upward, downward and to the ride side, with or without the pressure from the tongue depressor.

43

GLASGOW COMA SCALE Measure

Eye Response

Response Opens spontaneously

Score 4

Opens to verbal command

3

Opens to pain

2

No response Reacts to verbal command

1 6

Reacts to painful stimuli Motor Response

Verbal Response

Identifies localized pain

5

Flexes and withdraws

4

Assumes flexor posture

3

Assumes extensor posture

2

No response Is oriented and converses

1 5

Is disoriented but converses

4

Uses inappropriate words

3

Makes unintelligible sounds

2

No response

1

44

45

DIAGNOSTIC AND LABORATORY PROCEDURES

46

47

IV.

DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic/Laboratory

Date

Indication or

Procedures

ordered/Date

Purpose

Chest X-ray

Results

Normal Values

Analysis and Interpretation of

result in Ordered

Mr. CVA

There are no

A normal chest x

the result The results show

February 23,

undergone chest x-

pulmonary

ray will show

that Mr. CVA’s

2010

ray to check if there

infiltrates, cardiac

normal structures

heart is not

are pulmonary

size and

for the age and

enlarged.

Result

infiltrates, check

configuration are

medical history of

February 24,

the cardiac size

normal.

the patient.

2010

and configuration

The diaphragm,

Findings, whether

dynamic

sulci and ribs are

normal or

precordium was

intact.

abnormal, will be

noted upon

provided to the

admission which is

referring physician

an indicator of

in the form of a

enlarged heart.

written report.

Nursing Responsibilities: Prior : •

Explain the procedure to the pt why it is indicated.

•

A chest x-ray examination itself is a painless procedure

After: •

Explain to pt that the results of a chest x-ray can be available almost immediately for review by the physician

Diagnostic/

Date ordered/Date

Indication or

Results

Normal

Analysis and 48

Laboratory Procedures CT scan

result in February 23, 2010

Purpose

Values

the result The test indicates

Mr. CVA

Plain multiple axial views of the

undergone CT

head using incremental CT

that there is

scan to have

reveals a small hypodense Foci

presence of an

multiple axial

on the anterior limb on the left

infarct at left lobe of

views of the

internal capsule and the left

the brain explaining

head to

putamen.

right sided

distinguish the

N.A.

Interpretation of

weakness

cause of the

There is also a hypodense focus

signs and

on the left parietal cortex.

symptoms present.

The ventricles and cistern are not dilated The middle line structures are not displaced. The sella furica posterior fossal and basal skull structures are intact. Impression: Acute infarct, anterior limb or left internal capsule left putamen and left parietal cortex.

Nursing Responsibilities: 49

•

Explain the procedure to the pt. and why it is indicated.

•

Explain that this test is done to take excellent pictures of the brain to locate any problem areas if they exist.

•

Assess the client for allergies to iodine, seafood and contrast medium.

•

Evaluate the client for restlessness. Clients unable to remain still 30-90 minutes during the scan may need a sedative.

•

Ensure an informed consent has been obtained if contrast medium is used.

•

Remove metal objects such as jewelries, glasses, and dental bridges from the head and neck before the procedure.

•

Restrict food and fluids for 8 hours before the scan if contrast medium is injected.

•

Do not restrict food, fluids, or medications when contrast medium is not used for scan.

50

Diagnostic/

Date

Indication or Purpose

Results

Laboratory

ordered/

Interpretation of the

Procedures

Date result

result

Blood Chem

in February

This test was ordered to monitor

23, 2010

Mr. CVA ’s renal function,

CVA ’s renal function is

specifically the ability of the

well, specifically

kidney to excrete urea and

expressed through the

protein.

ability of his kidneys to

BUN 4.76 mmol/L

Normal Values

2.5-7.5 mmol/L

Analysis and

This indicates that Mr.

excrete urea and This test was ordered to monitor

Crea 132.6

44.2-150.1

protein. Creatinine level is within

Mr. CVA’s renal function,

normal range.

specifically the ability of the

This indicates that Mr.

kidney to excrete urea and

CVA ’s kidneys are able

protein.

to excrete urea and protein, thus reflects that his kidneys are in good condition.

This test was ordered to check for Mr. CVA’s water balance.

Na

133

137-145

Hyponatremia indicates Shift of water from intracellular compartment to

51

extracellular compartment with resultant dilution of sodium. This usually occurs with hyperglycemia, which is This test was order to Mr. CVA to

K

3.6

3.6-5.0

inherent with Mr. CVA . Potassium is within

measure acid base balance and

accepted range. Results

normal muscle activity.

indicate acceptable acid base balance and standard muscle activity. This test may rule out Hypokalemia as the cause of Mr. CVA ’s weakness.

February

-This test was ordered to

Glucose

24, 2010

measure and monitor the amount

(FBS) 8.90

4.22 – 6.11

Fasting plasma glucose level above 7.0 mmol/L

of sugar in Mr. CVA ’s blood. This

indicates that Mr. CVA

is a more accurate determinant

has Hyperglycemia

than RBS. This test was ordered to Mr. CVA to determine the total cholesterol

Cholesterol 3.57

Up to 5.16

Mr. CVA’s cholesterol is within the acceptable

52

in his blood.

range thus this test may rule out the narrowing of the blood vessels due to cholesterol blockage as the cause of his

- This test was ordered to

Tryglycerides 1.08

0.45 – 1.81

to the thickening of the

Mr.CVA to determine the

arterial wall caused by

triglyceride or the glycerol

fatty materials

esterified with three fatty acids in

deposition. The result

the blood

may rule out

-this is also a test which assesses

atherosclerosis as the

the risk of developing heart

cause of the Mr. CVA’s

disease and stroke - This test was ordered to

condition Triglycerides are linked

HDLC 1.02

0.75 – 1. 73

stroke With the help of a form

Mr.CVA to determine measures

of cholesterol HDL (high

amount of HDL or good

density lipoprotein),

cholesterol in the body

packets of cholesterol

-To determine risk of developing

are formed to help move

heart disease and stroke

cholesterol through the blood suggesting that cholesterol formation and deposition in the arterial walls are less 53

likely the cause of LDLC

2.06

Less than 3.88

- This test was ordered to Mr.CVA to determine measures the amount of LDL or the bad cholesterol in the blood -assess the risk of developing heart disease and stroke

Mr.CVA’s stroke LDL does not aid in the transportation of cholesterol out of the body, instead it deposits cholesterol onto the vessel wall. This results indicates that Mr. CVA is less likely to form deposits of cholesterol onto his vessel walls.

Nursing Responsibilities: Prior : •

Explain the procedure to the pt. and why it is indicated

•

Inform the patient that fluid and food restriction is required especially for FBS which is a 12 hour fast.

•

Inform the patient that a blood sample will be taken.

•

Tell the patient that he may experience transient discomfort from the needle pincture

•

Fill up laboratory request form properly and send it to the laboratory technician during the collection of sample/specimen.

•

For glucose, do not give their insulin/anitdiabetic agents until blood is drawn.

During the procedure: •

For cholesterol, seat the client at least 5 minutes before the venipuncture is performed to reduce fluctuations in serum levels associated with postural changes.

54

•

Inform the patient that pain may be felt through prick in the needle

•

Instruct the patient to calm down to avoid uneasiness.

After: •

Apply brief pressure to prevent bleeding

•

Apply warm compress if Hematoma will develop at the venipuncture site.

•

For creatinine, assess fluid and nutritional status of client for clues of renal impairment and other diseases causing changes in creatinine levels.

•

Continuously monitor fluid balance through daily weights and intake and output recordings.

•

For glucose, ensure the client receives food promptly in accordance with the ordered diet.

55

Diagnostic/

Date ordered/Date

Laboratory

result in

Procedures Hemo Glucose

Indication or Purpose

Results

Normal Values

Analysis and Interpretation of the result

February 23, 2010

Test

5pm

blood glucose level

A high result in

of less than or

HGT show increase

181

equal to 120

in normal values. It

6am glucose within an acceptable

198

mg/dL.

may indicate low

6pm range as determined by their

221

February 24, 2010

Mr. CVA has undergone Blood

374 mg/L

glucose monitoring to identify

12am intervention to maintain his blood

insulin levels.

doctors. This is a more immediate and convenient way to test his blood glucose. Nursing Responsibilities: Prior : •

Explain the procedure to the pt. and why it is indicated

•

Inform the patient that a blood sample will be taken.

•

Tell the patient that he may experience transient discomfort from the needle pincture

During the procedure: •

Inform the patient that pain may be felt through prick in the needle

•

Instruct the patient to calm down to avoid uneasiness.

After: •

Apply brief pressure to prevent bleeding.

•

Observe for signs and symptoms of hyperglycemia or hypoglycemia.

56

Diagnostic/

Date

Indication or Purpose

Results

Normal Values

Analysis and

Laboratory

ordered/

Procedures Hematology

Date result in February 24,

-To evaluate the

result Mr. CVA’s result is

2010

hemoglobin content (iron

within the acceptable

status and O2 carrying

range. This could

Interpretation of the

capacity) of erythrocytes

Hemoglobin

15.4 g/dl

11.6 – 15.5

indicate that Mr.

by measuring the no. of

CVA’s red blood cells

grams of hemoglobin /dl of

freely carry oxygen

blood

to the body Mr. CVA’s result is within the acceptable range. A lowered

- Measures the volume of RBCs in whole blood expressed as a

hematocrit can Hematocrit

43.5 %

36.0 – 47.0

indicate hemorrhage thus the result may

percentage.

indicate that hemorrhage is not

-Measures the number of RBCs

RBC

4.80 X10 12/L

4.20 – 5.40

the cause of his CVA Mr. CVA’s result is within the acceptable range. A decrease in the RBC’s could indicate hemorrhage thus the results may

57

indicate that hemorrhage is not the cause of his CVA Absence of a decrease or increase within the normal -Measures the number of WBCs

WBC

8.23 X10 9/L

4.8-10.8

range could indicate that Mr. CVA’s body is not currently fighting off any infection The result is within the acceptable

-To provide a numeric estimate of the client’s

range. This could Neutrophils

69.9 %

40-74

immune status.

indicate that his body is not currently fighting off a bacterial

-To determine immune

Lymphocytes

24.5 %

19-48

infection The result is within

function, provides a gross

the acceptable

measure in nutritional

range. This could

status.

indicate that his body is not currently fighting off a viral infection

58

The result is within the acceptable -To provide a numeric

Eosinophils

2.4 %

0-7

range. This could

estimate of the client’s

Monocytes

3.2 %

3-9

indicate that his body

immune status.

Basophils

0.0 %

0-2

is not currently fighting off a parasitic infection The patient is not prone to excessive

-Measures the number of platelets (Thrombocytes)

bleeding or Platelet

256 X10 9/L

per mm3 of blood.

150-400

thrombosis. This may also indicate that bleeding is not the cause of stroke.

Nursing Responsibilities: Prior : •

Explain the procedure to the pt. and why it is indicated

•

Inform the patient that fluid and food restriction is not required

•

Inform the patient that a blood sample will be taken.

•

Tell the patient that he may experience transient discomfort from the needle pincture

•

Fill up laboratory request form properly and send it to the laboratory technician during the collection of sample/specimen.

During the procedure: •

Inform the patient that pain may be felt through prick in the needle 59

•

Instruct the patient to calm down to avoid uneasiness.

After: •

Apply brief pressure to prevent bleeding

•

Apply warm compress if Hematoma will develop at the venipuncture site.

•

If BUN levels are >40mg/dl without signs and symptoms of dehydration, monitor intake and output, complete dietary assessment, and check with health care provider regarding protein restriction.

•

Monitor for lethargy, confusion, and change in mental status. Provide necessary safety precautions.

•

Observe for signs and symptoms GI bleeding, which is associated with decreased red blood cells.

60

THE PATIENT AND HIS ILLNESS

61

V.

THE PATIENT AND HIS ILLNESS

Anatomy and Physiology Nervous System

The nervous system is the body's information gatherer, storage center and control system. Its overall functions are to collect information about the body's external/internal states and transfer this information to the brain (afferent system), to analyze this information, and to send impulses out (efferent system) to initiate appropriate motor responses to meet the body's needs. The system is composed of specialized cells, termed nerve cells or neurons that communicate with each other and with other cells in the body. A neuron has three parts: 1. the cell body, containing the nucleus 2. dendrites, hair-like structures surrounding the cell body, which conduct incoming signals. 3. the axon (or nerve fiber), varying in length from a millimeter to a meter, which conduct outgoing signals emitted by the neuron. Axons are encased in a fat-like sheath, called myelin, which acts like an insulator and, along with the Nodes of Ranvier, speeds impulse transmission. 62

Typically a given neuron is connected to many thousands of neurons. The specific point of contact between the axon of one cell and a dendrite of another is called a synapse. Messages passed to and from the brain take the form of electrical impulses, or action potentials, produced by a chemical change that progresses along the axon. At the synapse, the impulse causes the release of neurotransmitters (like acetylcholine or dopamine) and this, in turn, drives the impulse to the next neuron. These impulses travel very fast along these chain of neurons -- up to 250 miles per hour. This contrasts with other systems, such as the endocrine system, which may take many hours to respond with hormones. The nerve cell bodies are generally located in groups. Within the brain and spinal cord, the collections of neurons are called nuclei and constitute the gray matter, so-called because of their color. Outside the brain and spinal cord the groups are called ganglia. The remaining areas of the nervous system are tracts of axons, the white matter, so-called because of white myelin sheath. Tracts carrying information of a specific type, such as pain or vision, generally have specific names. . Major Divisions of the Nervous System The nerves of the body are organized into two major systems: •

the central nervous system (CNS), consisting of of the brain and spinal cord,

•

the peripheral nervous system (PNS), the vast network of spinal and cranial nerves linking the body to the brain and spinal cord. The PNS is subdivided into: 1. the autonomic nervous system (involuntary control of internal organs, blood vessels, smooth and cardiac muscles), consisting of the sympathetic NS and parasympathetic NS 2. the somatic nervous system (voluntary control of skin, bones, joints, and skeletal muscle).

The two systems function together, with nerves from the periphery entering and becoming part of the central nervous system, and vice versa.

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Brain Structures

The brain, the body's "control central," is one of the largest of adult organs, consisting of over 100 billion neurons and weighing about 3 pounds. It is typically divided into four parts: the cerebrum, the cerebellum, the diencephalon (thalamus, hypothalamus, sometimes classed as cerebral structures) and the brain stem (medulla oblongata, pons, midbrain), which is an extension of the spinal cord. Cerebrum The largest division of the brain, the cerebrum, consists of two sides, the right and left cerebral hemispheres, which are interconnected by the corpus callosum. The two hemispheres are "twins," each with centers for receiving sensory (afferent) information and for intiating motor (efferent) responses. The left side sends and receives information to/from the right side of the body, and vice versa. Various intellectual functions are concentrated in either the left or right hemispheres. The hemispheres are covered by a thin layer of gray matter known as the cerebral cortex. The interior portion consists of white matter, tracts, and nuclei (gray matter) where synapses occur. Each hemisphere of the cerebral cortex is divided into four "lobes" by various sulci and gyri: The sulci (or fissures) are the grooves and the gyri are the "bumps" on the brain's surface.

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The four lobes perform specific functions: a) Frontal - controls fine movements (Betz cells)/ upper motor neuron) and smell. Also, center for abstract thinking, judgment, and language (left hemisphere) b) Parietal - coordinates afferent information dealing with pain, temperature, form, shape, texture, pressure, and position. Some memory functions are also found here. c) Temporal - handles dreams, memory, and emotions. Center for auditory function. d) Occipital - governs vision In addition to the four lobes, is the basal ganglia. The basal ganglia aggregates of neurons (gray matter), constitute the extrapyramidal system. The extrapyramidal system governs postural adjustment and gross voluntary movements, as opposed to fine movements, controlled by the frontal lobe. The basal ganglia receive afferent input from the cerebral cortex and thalamus. Their axons synapse in the brain stem and the spinal cord. Cerebellum The cerebellum, the second largest brain structure, sits below the cerebrum. Like the cerebrum, the cerebellum has an outer cortex of gray matter and two hemispheres. It receives/relays information via the brain stem. The cerebellum performs 3 major functions, all of which have to do with skeletal-muscle control: Function summary: •

Balance/ Equilibrium of the trunk (See also: Vestibular System)

•

Muscle tension, spinal nerve reflexes, posture and balance of the limbs

•

Fine motor control, eye movement. (Incoming information is transferred from the cerebral cortex via the pons. Outgoing information goes back to the cortex via the thalamus.)

Cerebellar disease (abscess, hemorrhage, tumors, and trauma) results in ataxia (muscle incoordination), tremors, and disturbances of gait and equilibrium. This can also interfere with a

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person's ability to talk, eat, and perform other self care tasks. Paralysis does not result from loss of cerebellar function. Diencephalon The diencephalon, located between the cerebrum and the midbrain, consists of several important structures, two of which are the: •

Thalamus: large, bilateral (right thalamus/left thalamus) egg-shaped mass of gray matter serving as the main synaptic relay center. Receives/relays sensory information to/from the cerebral cortex, including pain/pleasure centers.

•

Hypothalamus: a collection of ganglia located below the thalamus and associated with the pituitary gland. It has a variety of functions: senses changes in body temperature; controls autonomic activities and hence regulates the sympathetic and parasympathetic nervous systems; links to the endocrine system/controls the pituitary gland; regulates appetite; functions as part of the arousal or alerting mechanism; and links the mind (emotions) to the body -- sometimes, unfortunately, to the degree of producing "psychosomatic disease."

Brain-Stem The medulla oblongata, pons, and midbrain (mesencephalon or cerebral peduncles) -- often referred to collectively as the brain stem -- control the most basic life functions. Of these three, the medulla is the most important. In fact, so vital is the medulla to survival that diseases or injuries affecting it often prove fatal. All functions of the brain stem are associated with cranial nerves III-XII. Function summary: •

Breathing/respiration (pons, medulla)

•

Heart rate/ action (medulla)

•

Blood pressure (vasoconstriction)/ blood vessel diameter (medulla)

•

Reflex centers for pupillary reflexes and eye movements (midbrain, pons); and for vomiting, coughing, sneezing, swallowing, and hiccupping (medulla).

Blood supply An intricate arterial structure supplies the brain with oxygen-rich blood. At the brain stem, two vertebral arteries, entering through the first cervical vertebrae, join to form the basilar artery. The basilar artery along with two internal carotid arteries, entering through holes at the base of the skull, interconnect at the Circle of Willis. From there, the anterior and middle cerebral arteries arise; the posterior cerebral artery arises from the basilar system.

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Cranial Nerves There are 12 pairs of cranial nerves. Some bring information from the sense organs to the brain; some control muscles; others are connected to glands or internal organs.

Cranial Nerves I. Olfactory II. Optic III. Occulomotor IV. Trochlear

Major Function Smell Vision Eyelid and eyeball movement Innervates superior oblique turns eye

V. Trigeminal VI. Abducens VII. Facial

downward and laterally Chewing face & mouth touch & pain Turns eye laterally Controls most facial expressions secretion

VIII. Vestibulocochlear IX. Glossopharyngeal X. Vagus

of tears & saliva taste Hearing equilibrium sensation Taste senses carotid blood pressure Senses aortic blood pressure slows heart

XI. Spinal Accessory

rate stimulates digestive organs taste Controls trapezius & sternocleidomastoid,

XII. Hypoglossal

controls swallowing movements Controls tongue movements

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The pancreas is a glandular organ that secretes digestive enzymes (internal secretions) and hormones (external secretions). In humans, the pancreas is a yellowish organ about 7 inches (17.8 cm) long and 1.5 inches. (3.8 cm) wide.

The Pancreas The pancreas (Figs. 1097, 1098) is a compound racemose gland, analogous in its structures to the salivary glands, though softer and less compactly arranged than those organs. Its secretion, the pancreatic juice, carried by the pancreatic duct to the duodenum, is an important digestive fluid. In addition the pancreas has an important internal secretion, probably elaborated by the cells of Langerhans, which is taken up by the blood stream and is concerned with sugar metabolism. It is long and irregularly prismatic in shape; its right extremity, being broad, is called the head, and is connected to the main portion of the organ, orbody, by a slight constriction, the neck; while its left extremity gradually tapers to form the tail. It is situated transversely across the posterior wall of the abdomen, at the back of the epigastric and left hypochondriac regions. Its length varies from 12.5 to 15 cm., and its weight from 60 to 100 gm.

FIG. 1097– Transverse section through the middle of the first lumbar vertebra, showing the relations of the pancreas. (Braune.)

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FIG. 1098– The duodenum and pancreas

FIG. 1099– The pancreas and duodenum from behind. (From model by His.)

Relations.—The Head (caput pancreatis) is flattened from before backward, and is lodged within the curve of the duodenum. Its upper border is overlapped by the superior part of the duodenum and its lower overlaps the horizontal part; its right and left borders overlap in front, and insinuate themselves behind, the descending and ascending parts of the duodenum respectively. The angle of junction of the lower and left lateral borders forms a prolongation, termed the uncinate process. In the groove between the duodenum and the right lateral and lower borders in front are the anastomosing superior and inferior pancreaticoduodenal arteries; the common bile duct descends behind, close to the right border, to its termination in the descending part of the duodenum.

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Anterior Surface.—The greater part of the right half of this surface is in contact with the transverse colon, only areolar tissue intervening. From its upper part the neck springs, its right limit being marked by a groove for the gastroduodenal artery. The lower part of the right half, below the transverse colon, is covered by peritoneum continuous with the inferior layer of the transverse mesocolon, and is in contact with the coils of the small intestine. The superior mesenteric artery passes down in front of the left half across the uncinate process; the superior mesenteric vein runs upward on the right side of the artery and, behind the neck, joins with the lienal vein to form the portal vein. Posterior Surface.—The posterior surface is in relation with the inferior vena cava, the common bile duct, the renal veins, the right crus of the diaphragm, and the aorta. The Neck springs from the right upper portion of the front of the head. It is about 2.5 cm. long, and is directed at first upward and forward, and then upward and to the left to join the body; it is somewhat flattened from above downward and backward. Its antero-superior surface supports the pylorus; its postero-inferior surface is in relation with the commencement of the portal vein; on the right it is grooved by the gastroduodenal artery. The Body (corpus pancreatis) is somewhat prismatic in shape, and has three surfaces: anterior, posterior, and inferior. The anterior surface (facies anterior) is somewhat concave; and is directed forward and upward: it is covered by the postero-inferior surface of the stomach which rests upon it, the two organs being separated by the omental bursa. Where it joins the neck there is a wellmarked prominence, the tuber omentale, which abuts against the posterior surface of the lesser omentum. The posterior surface (facies posterior) is devoid of peritoneum, and is in contact with the aorta, the lienal vein, the left kidney and its vessels, the left suprarenal gland, the origin of the superior mesenteric artery, and the crura of the diaphragm. The inferior surface (facies inferior) is narrow on the right but broader on the left, and is covered by peritoneum; it lies upon the duodenojejunal flexure and on some coils of the jejunum; its left extremity rests on the left colic flexure. The superior border (margo superior) is blunt and flat to the right; narrow and sharp to the left, near the tail. It commences on the right in the omental tuberosity, and is in relation with the celiac artery, from which the hepatic artery courses to the right just above the gland, while the lienal artery runs toward the left in a groove along this border. The anterior border (margo anterior) separates the anterior from the inferior surface, and along this border the two layers of the transverse mesocolon diverge from one another;

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one passing upward over the anterior surface, the other backward over the inferior surface. The inferior border (margo inferior) separates the posterior from the inferior surface; the superior mesenteric vessels emerge under its right extremity. The Tail (cauda pancreatis) is narrow; it extends to the left as far as the lower part of the gastric surface of the spleen, lying in the phrenicolienal ligament, and it is in contact with the left colic flexure. Birmingham described the body of the pancreas as projecting forward as a prominent ridge into the abdominal cavity and forming part of a shelf on which the stomach lies. “The portion of the pancreas to the left of the middle line has a very considerable anteroposterior thickness; as a result the anterior surface is of considerable extent; it looks strongly upward, and forms a large and important part of the shelf. As the pancreas extends to the left toward the spleen it crosses the upper part of the kidney, and is so moulded on to it that the top of the kidney forms an extension inward and backward of the upper surface of the pancreas and extends the bed in this direction. On the other hand, the extremity of the pancreas comes in contact with the spleen in such a way that the plane of its upper surface runs with little interruption upward and backward into the concave gastric surface of the spleen, which completes the bed behind and to the left, and, running upward, forms a partial cap for the wide end of the stomach.

FIG. 1100– The pancreatic duct. The Pancreatic Duct (ductus pancreaticus [Wirsungi]; duct of Wirsung) extends

1

transversely from left to right through the substance of the pancreas (Fig. 1100). It

5

commences by the junction of the small ducts of the lobules situated in the tail of the pancreas, and, running from left to right through the body, it receives the ducts of the various lobules composing the gland. Considerably augmented in size, it reaches the neck, and turning downward, backward, and to the right, it comes into relation with the common bile duct, which lies to its right side; leaving the head of the gland, it passes very obliquely 71

through the mucous and muscular coats of the duodenum, and ends by an orifice common to it and the common bile duct upon the summit of the duodenal papilla, situated at the medial side of the descending portion of the duodenum, 7.5 to 10 cm. below the pylorus. The pancreatic duct, near the duodenum, is about the size of an ordinary quill. Sometimes the pancreatic duct and the common bile duct open separately into the duodenum. Frequently there is an additional duct, which is given off from the pancreatic duct in the neck of the pancreas and opens into the duodenum about 2.5 cm. above the duodenal papilla. It receives the ducts from the lower part of the head, and is known as the accessory pancreatic duct (duct of Santorini). Development (Figs. 1101, 1102).—The pancreas is developed in two parts, a dorsal and

1

a ventral. The former arises as a diverticulum from the dorsal aspect of the duodenum a

6

short distance above the hepatic diverticulum, and, growing upward and backward into the dorsal mesogastrium, forms a part of the head and uncinate process and the whole of the body and tail of the pancreas. The ventral part appears in the form of a diverticulum from the primitive bile-duct and forms the remainder of the head and uncinate process of the pancreas. The duct of the dorsal part (accessory pancreatic duct) therefore opens independently into the duodenum, while that of the ventral part (pancreatic duct) opens with the common bile-duct. About the sixth week the two parts of the pancreas meet and fuse and a communication is established between their ducts. After this has occurred the terminal part of the accessory duct, i. e., the part between the duodenum and the point of meeting of the two ducts, undergoes little or no enlargement, while the pancreatic duct increases in size and forms the main duct of the gland. The opening of the accessory duct into the duodenum is sometimes obliterated, and even when it remains patent it is probable that the whole of the pancreatic secretion is conveyed through the pancreatic duct.

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BOOKBASED PATHOPHYSIOLOGY Precipitating Factor Overweight/ Obesity

↑Serum Cholesterol level

Stress

↑Fat on the abdomen and hips

↑LDL ↑Workload of the heart

↓HDL

Eat more

Smoke more

Smoking

Stimulati on of catechol amines

Vasoconstrict

↑LDL ↓Oxygen carry capacity of blood

↑RBC ↑vascular resistance

↑Serum Cholesterol ↑blood sugar

Accumulate of LDL

↑blood thickness ↓Tissue? perfusion

↑BP

↑blood viscosity

Diet high in Fats, Sodium and Cholesterol

Cocaine use/ abuse

↑Carbon monoxide in blood

↓Tissue perfusion

↑clot formation

↑risk of injury to intimal arterial wall

Sedentary Lifestyle

Induce vasospasm

Enhance of tablet activity

↑BP Poor circulation

Accumulation of fatty streaks in the arterial wall Increases cardiovascular disorder

Increase attraction of water in the blood Increase in blood volume

Deposits of fatty materials in the arterial walls of arteries Vascular changes

Increase blood cholesterol level and blood pressure Hypertension

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Predisposing Factor Age

Gender

Degenerative changes in the function of the heart

Male hormones

Inc workload of the heart

Uncontrolled cardiomegaly Inc. vascular resistance

Inc pressure in cerebral blood vessels

Loss of elaticity

Impaired cerebral autoregula tion

Rupture of cerebral blood vessel

Previous heart disease

Altered arterial wall integrity

↓HDL

Heart weakens over time

↓elastin Dec. cardiac output

↓elasticity of the blood vessels Atherosclerosis

Dec. vessel flexibility

Hardening of arterial wall

Increased risk for vessel injury

Increased lipid/platelet adherence to vessel walls

Accumulation of LDL in the arterial wall

Increased risk for rupture

↑lipid/platelet adherence to vessel walls

Atheroma/ clot formation

Thrombus formation

Diabetes

↑blood sugar ↑blood viscosity ↑BP ↑workload of the heart ↑size of heart Weaker heart

Familial History ↓cardiac output ↑risk for DM , heart diseases, hypercoagualable state, hypercholesterolemia

↓tissue perfusion Microvascular changes Chronic inc. blood glucose Altered macrovascular integrity

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Thrombotic stroke

Development of atherosclerosis of the blood vessel wall

Plsgues develop on the inner wall of the affected blood vessel

First step

Accumulation of LDL within the arterial wall

Undegoes chemical changes

Stimulate methodical cells to adhere to monocytes and feels

Second step

Maturation of monocytes into macrophages

Ingest LDL particle

Third step

Macrophage ingest a critical mass of LDL

Becomes foam cells

Constitutes fatty streaks on the inner arterial wall (earliest manifestation of arterial plague)

Fourth step

Additional growth of the lesion through influence of inflammatory molecules

Form a fibrous cover over the liquid core

OVER 75

Separates it from blood flow through the vessel

Fifth step

Plaque rupture

Exposes foam cells to clot-promoting elements in the blood

Clot formation

Dislodgement

ISCHEMIC CASCADE

Embolic stroke

If at sufficient size

Ischemia

May interrupt blood flow to the brain tissue implies

Neutroxins (oxygen free radical nitric oxide glutamate) released

Local acidosis develop

Membrane depolarization occur

Influx of calcium sodium

Cytoxic edema and Cell death

Stroke area or core

Zone of hypoperfusion (penumbra) becomes prone to death if circulation is not restored

neurologic damage

OVER 76

Ischemia develop

Embolus dislodgement

Travels to the cerebral arteries via carotid artery or vertebrobasilar system

Lodge in smaller cerebral arteries blood vessel at point of bifurcation or where the lumen narrow

Emboli occlude the vessel

Ischemia develop

Ischemic Cascade

If embolus breaks off into fragments

If damage to vessel wall is significant

Enters small blood vessels

Embolus is absorbed

Vessel integrity interrupted

Vasospas m

Cerebral hemorrhage

Nuchal rigidity Headache Increase in blood pressure

Remission of s/sx

Decrease cerebral perfusion Ischemic cascade

neurologic damage

Hemorrhagic Stroke

HYPOXIA

Altered level of consciousness

Inflammatory process Release leukocytes in interstitial space and neutrophils for phagocytosis

Entry of blood to meningeal space

Increase intracranial pressure CEREBRAL COMPRESSION AND INJURY coma

death

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HYPOXIA

BRAIN TISSUE INFARCT

NEUROLOGICAL DEFICITS Middle cerebral artery (MCA) most commonly affected Internal carotid artery second most frequently affected

Massive infarction of most lateral hemisphere and deeper structure of the frontal, parietal and temporal lobes

Hemiplegia

hemipharesis

apraxia

Aphasia/ Dysarthia

Sensory Deficits

Dysphagia

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In a healthy, anatomical structure of the body, the carotid arteries form the main blood supply to the brain. Following a stroke, voluntary control of the muscles may be lost, depending on the type of stroke the victim is encountering. Strokes can also result from embolism or due to a ruptured blood vessel. Embolism blocks small arteries within the brain, causing dysfunction to occur. Spontaneous rupture of a blood vessel in the brain causes a hemorrhagic stroke. Another form of cerebrovascular disease includes aneurysms. In females with defective collagen, the weak branching points of arteries give rise to protrusions with a very thin covering of endothelium that can tear to bleed easily with minimal rise of blood pressure. This can also occur with defective capillaries caused by tissue cholesterol deposition especially in hypertensive subjects with or without dyslipidemia. If bleeding occurs in this process, the resulting effect is a hemorrhagic stroke in the form of subarachnoid hemorrhage, intracerebral hemorrhage or both. Ischemia is the loss of blood flow to the focal region of the brain. The beginning process of this is quite rapid. The duration of a stroke is usually two to fifteen minutes. One side of the face, hand, or arm may swell up. During this time, the person may lose conscious control and faint. Brain deficits may improve over a maximum of 72 hrs. Deficits do not resolve in all cases. The neurological recovery period includes stable, to improving, brain function. Stable is the period by which neither nutrient supply is regained, nor is it lost. Improving, depending on a hospital code, generally means that the arteries gain control and blood flow functions consistently within the brain. The cartoid arteries connect to the vertebral arteries. These branch off into the cerebellar and posterior meningenial arteries, which supply the back of the brain. Also, during ischemia, interneurons weaken, causing an insufficient amount to perform vital functions to be present. The neuroglis become congested or maintain loss during a cerebrovascular accident. If impulse amount ceases, then life itself will cease and the victim may enter the stage of clinical death. Neural pathways weaken, therefore decreasing action potential. The neural arc, which in general consists of sensory and motor neurons, weaken as well. The muscles become paralyzed, in some cases for life. Paralysis also includes the weakening of the receptors in the body, unless improvement is made. Cerebrovascular damage to the brain is what makes it difficult for receptors to receive the impulse and transmit it of a neuron. This chemical reaction is then transmitted creating a poor reflex to the body. The meninges that also protect the brain and spinal cord are deeply weakened, allowing the victim to suffer vast transmission of diseases or unstable growth or maintenance if the victim is not in resting position. 79

During the stage of paralysis, the spinal tracts do not have much to do with the enduring condition of cerebrovascular disease, either, in time may shorten the life of a victim who is suffering because the nutrient supply is weakened in transmission during cerebrovascular disease. Descending and ascending tracts will generally be cut off during cerebrovascular disease, which conducts impulses down from the cord of the brain. This is known as anesthesia in a minor case. PREDISPOSING FACTORS: Age (above 60 years old) — the chance of having a stroke about doubles for each decade of life after age 55. While stroke is common among the elderly, over 25 percent of people who have strokes are under age 65. Increasing age causes degenerative changes to the blood vessels thus increasing the risk for arterial wall injury. Gender -- Stroke is more common in men than in women. In most age groups, more men than women will have a stroke in a given year. At older ages, the incidence is higher in women than in men. Overall, more women than men die of stroke. Female hormones decrease LDL levels and Increase HDL level while male hormones does otherwise. Familial disposition-chance of stroke is greater in people who have a family history of stroke Previous heart disease-- A diseased heart increases the risk of stroke. The percentage of people with a first myocardial infarction who will have a stroke within five years at ages 40–69 is 4 percent of men and 12 percent of women. At age 70 and older, 6 percent of men and 11 percent of women will have a stroke after having a heart attack. Atrial fibrillation (the rapid, uncoordinated quivering of the heart’s upper chambers), in particular, raises the risk for stroke. Heart attack is also the major cause of death among stroke survivors PRECIPITATING FACTORS: Diet Cigarette smoking — Cigarette smoking is an important risk factor for stroke. The nicotine and carbon monoxide in cigarette smoke damage the cardiovascular system in many ways. Physical inactivity — An inactive lifestyle is a risk factor for coronary heart disease. Regular, moderate-to-vigorous physical activity is important in preventing heart and blood vessel disease. Even moderate-intensity physical activities are beneficial if done regularly and long-term. More vigorous activities are associated with more benefits. Physical activity can help control blood cholesterol, diabetes and obesity, as well as help lower blood pressure. High blood pressure — High blood pressure increases the heart’s workload, causing the heart to enlarge and weaken over time. It also increases the risk of stroke, heart attack, kidney failure 80

and heart failure. When high blood pressure exists with obesity, smoking, high blood cholesterol levels or diabetes, the risk of heart attack or stroke increases several times. Obesity and overweight — People who have excess body fat — especially if a lot of it is in the waist area — are more likely to develop heart disease and stroke even if they have no other risk factors. Excess weight increases the strain on the heart, raises blood pressure and blood cholesterol and triglyceride levels, and lowers HDL (good) cholesterol levels. It can also make diabetes more likely to develop. Many obese and overweight people have difficulty losing weight. If you can lose as little as 10 to 20 pounds, you can help lower your heart disease risk. Stress — Individual response to stress may be a contributing factor. Some scientists have noted a relationship between coronary heart disease risk and stress in a person’s life, their health behaviors and socioeconomic status. These factors may affect established risk factors. For example, people under stress may overeat, start smoking or smoke more than they otherwise would. Sickle cell anemia — This genetic disorder mainly affects African-American and Hispanic children. "Sickled" red blood cells are less able to carry oxygen to the body’s tissues and organs. These cells also tend to stick to blood vessel walls, which can block arteries to the brain and cause a stroke. Certain kinds of drug abuse — Intravenous drug abuse carries a high risk of stroke from a cerebral embolism (blood clot in the brain). Cocaine use has been closely related to strokes, heart attacks and a variety of other cardiovascular complications. Some of them have been fatal even in first-time cocaine users. Diabetes is an independent risk factor for stroke and is strongly correlated with high blood pressure. While diabetes is treatable, having it still increases a person’s risk of stroke. People with diabetes often also have high cholesterol and are overweight, increasing their risk even more.

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CLIENT CENTERED PATHOPHYSIOLOGY Precipitating Factor

Accumulation of fatty streaks in the arterial wall Increases cardiovascular disorder

Smoking

Diet high in Fats, Sodium and Cholesterol

Sedentary Lifestyle

Vasoconstriction

↑LDL

Poor circulation Increase attraction of water in the blood Increase in blood volume

Deposits of fatty materials in the arterial walls of arteries Vascular changes

Increase blood cholesterol level and blood pressure

↓Oxygen carry capacity of blood

↑RBC

↑vascular resistance

↑Carbon monoxide in blood

↑blood thickness

↓Tissue perfusion

↑BP

↓Tissue perfusion

↑clot formation

↑risk of injury to intimal arterial wall

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Hypertension 140/100mmHg

Dynamic precordium

Predisposing Factor Age

Gender

Previous CVA

Degenerative changes in the function of the heart

Male hormones

Altered arterial wall integrity

Inc workload of the heart Uncontrolled cardiomegaly ↑ vascular resistance Inc pressure in cerebral blood vessels Loss of elaticity

Impaired cerebral autoregulation

Rupture of cerebral blood vessel

Heart weakens over time

↓HDL

↓elastin

↓ cardiac output

↓elasticity of the blood vessels Atherosclerosis

Dec. vessel flexibility

Accumulation of LDL in the arterial wall

Hardening of arterial wall

Increased risk for vessel injury

Increased risk for rupture

Atheroma/ clot formation

Thrombus formation

↑blood sugar ↑blood viscosity ↑BP ↑workload of the heart ↑size of heart Weaker heart

Familial History

↑risk for DM , heart diseases Increased lipid/platelet adherence to vessel walls

↑lipid/platelet adherence to vessel walls

Diabetes 37

↓cardiac output ↓tissue perfusion Microvascular changes Chronic inc. blood glucose Altered macrovascular integrity

83

Thrombotic stroke

Development of atherosclerosis of the blood vessel wall

Plaques develop on the inner wall of the affected blood vessel

First step

Accumulation of LDL within the arterial wall

Undergoes chemical changes

Stimulate methodical cells to adhere to monocytes and feels

Second step

Maturation of monocytes into macrophages

Ingest LDL particle

Third step

Macrophage ingest a critical mass of LDL

Becomes foam cells

Constitutes fatty streaks on the inner arterial wall (earliest manifestation of arterial plague)

Fourth step

Additional growth of the lesion through influence of inflammatory molecules

Form a fibrous cover over the liquid core

OVER 84

Separates it from blood flow through the vessel

Fifth step

Plaque rupture

Exposes foam cells to clot-promoting elements in the blood

ISCHEMIC CASCADE

Clot formation

May interrupt blood flow to the brain tissue implies

Ischemia

Neutroxins (oxygen free radical nitric oxide glutamate) released

Local acidosis develop

Membrane depolarization occur

Influx of calcium sodium

Cytoxic edema and Cell death

Zone of hypoperfusion (penumbra) becomes prone to death if circulation is not restored

Stroke area or core

neurologic damage

85

Cerebral Hypoxia

Presence of an infarct at left lobe of the brain explaining right sided weakness ( CT scan Feb. 23, 2010)

Hemiparesis of the right side of the body as observed by S.O. in am of Feb 23

↓ muscle strength

Apraxia S.O. assists pt in ADLs post stroke

Dysarthria Pt exhibited slurring of speech Mrs. CVA Described this as ‘NAuutal’

Dysphagia @ lunch time, prior to admission

Sensory Deficits

Dizziness

Lack of balance when walking

Limited ROM

right rm:3/5; right leg:2/5; left arm: 4/5; left leg:4/5

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THE PATIENT AND HIS CARE

87

VI.

THE PATIENT AND HIS CARE

1. Medical Management a. Intravenous Fluid Medical Management Plain Normal Saline Solution 1L x 30gtts/min

Indication(s) or

General Description An aqueous solution of 0.9 percent sodium

Purpose(s)

Client’s Date Ordered Response to the

Administered to prevent February. 23,

Treatment Mr. CVA

dehydration for Mr. CVA

verbalized

chloride, isotonic, in

2010

who cannot consume

sterile form, as a solvent liquids and nutrients by for drugs that are to be administered

difficulty “masakit, di ba maalis to?”

mouth and use as a solvent for drugs that are

parenterally to replace

to be administered

body fluids and is the

parenterally

safest fluid to give quickly in large volumes. Nursing Responsibilities: Before: 1. Check the doctor’s order regarding to what type of IVF to be used and also its volume and rate. 2. Explain the procedure to the patient. 3. Gather all materials needed for the insertion of IVF to save time and not to waste time for looking for other materials. 4. Wash hands before and after the procedure to prevent contamination from insertion site. During: 1. Place patient in a comfortable position to facilitate easy insertion of IV line and to decrease patient’s fear about the procedure. 2. Make sure that we give the proper IV fluid and drop rate accurately because patient may experience fluid overload or dehydration. 3. Check for its patency by observing the backflow of blood upon insertion. After: 1. Press the site where the needle was inserted and secure it with micropore. 88

2. Check the site of hand where the needle is inserted if bulging is not visible. If so, reinsertion is to be undertaken. 3. Advice patient to avoid scratching the site less movement of the hand where the needle was inserted to keep it in place. 4. Instruct patient and significant others to inform the nurse on duty if bulging of the site is visible, if there is back flow of blood of if IVF is not infusing well. 5. Observe the IV site at least every hour for signs of infiltration or other complications fluid or electrolyte overload and air embolism. 6. IVF regulation should be checked and monitored upon receiving patient. 7. Always check the doctor’s order for new orders regarding the IVF supplement of the patient. 8. Always check if the IVF is infusing well and intact. 9. Monitor the patient’s skin integrity. 10. Provide comfort for the patient. 11. Remove and dispose used items. 12. Report and record as appropriate.

89

b. Drugs Generic Name

General Action

and Brand

Indication and

Date Ordered,

Purpose

Date Started,

Name

Client Response

Nursing Responsibilities

Date Changed

Citicoline Na

Citicoline is a complex

Mr. CVA was

or Discontinue Ordered:

According to Mr.

Cholinerve

organic molecule that

given this type

02/23/10

CVA there were

not be

functions as an

of medication

no noticeable or

administered

intermediate in the

in order to treat

Started:

unnecessary

along with

biosynthesis of cell

cognitive

02/23/10

effect happened

medications

membrane

dysfunction

while he taking

containing

phospholipids. It is

and prevent

the medication.

meclophenoxate.

also known as CDP-

further brain

After taking the

choline or cytidine

damage.

medication, the

Doctor’s order: 1 gram/ IV q12

diphosphate choline

GCS of Mr. CVA

(cytidine 5'-

did not worsen.

• Cholinerve must

diphosphocholine). CDP-choline belongs to the group of biomolecules in living systems known as nucleotides that play important roles in cellular metabolism.

90

.

Generic Name and Brand Name

General Action

Indication and

Date Ordered,

Purpose

Date Started,

Client Response

Nursing Responsibilities

Date Changed or

91

Discontinue

• Close

Clonidine HCl

Stimulates

Mr. CVA was

Ordered:

According to Mr.

Catapres

peripheral alpha-

given this type of

02/23/10

CVA this not the

monitoring of

adrenergic

medication

first time that he

Blood Pressure

receptors in the

because upon

Started:

takes this kind of

and Pulse.

CNS to produce

admission his

02/23/10

medication. And

transient

blood pressure is

vasoconstriction

too high that

and then

needs immediate

stimulates central

intervention.

Doctor’s order: 75mg/Tab NOW

• Pt. should take

there were no

the last dose

Discontinue:

noticeable or

immediately

02/23/10

unnecessary

before bedtime.

effect happened

• Watch out for

alpha adrenergic

while he taking

dizziness and

receptors in the

the medication.

drowsiness.

brain stem to

Mr. CVA blood

reduce peripheral

pressure

vascular

decreased from

resistance, heart

170/100 to

rate, and systolic

120/80.

and diastolic blood pressure.

92

Generic Name

General Action

and Brand Name

Indication and

Date Ordered,

Purpose

Date Started,

Client Response

Nursing Responsibilities

Date Changed or Discontinue Ordered:

Neutral human

Mr. CVA was

insulin

insulin of

given this type of

Humulin R

recombinant DNA

medication

origin. A short-

because upon

Started:

acting preparation

admission his

02/23/10

that may be

HGT result is

administered by

374mg/dl,

SC or IV injection.

because of this

Onset of action

he needs

(rebound

occurs at

immediate

effect).

approximately 30

intervention to

min, with a

decrease the

level for

duration of about

level of glucose in

effectiveness of

5 hrs and peak

the body.

the drug.

Doctor’s order: 10 ‘u’ NOW

02/23/10

Mr. CVA glucose

• Drug should be

Neutral human

level decrease

given

from 374mg/dl to

subcutaneously.

221 mg/dl.

• Don’t rub the site after injection.

Discontinue: 02/23/10

• Monitor pt. for hyperglycemia

• Check glucose

activity at 1-3 hrs.

93

Generic Name

General Action

and Brand Name

Indication and

Date Ordered,

Purpose

Date Started,

Client Response

Nursing Responsibilities

Date Changed Nitroglycerin

May interact with

Mr. CVA was

or Discontinue Ordered:

Nitroglycerin

nitrate receptors in

given this type

02/23/10

Patch

vascular smooth-

of medication to

muscle membrane.

prevent angina

Started:

unnecessary effect

hairless part of

This interaction

and to manage

02/23/10

happened while the

chest.

reduces

hypertension

Doctor’s order: 5 mg NOW

nitroglycerin to nictric oxide, which

According to Mr. CVA there were no noticeable or

patch is pasted in Discontinue: 02/23/10

• Closely monitor vital signs. • Paste in the

• Patch should be

his chest. After

remove before

administering the

defibrillation.

activates the

medication, Mr.

enzyme guanylate

CVA ’s Dynamic

cyclase, increasing

heart sound was no

intracellular

longer present. Mr.

formation of cGMP.

CVA blood pressure decreased from 170/100 to 120/80.

94

Generic Name

General Action

Indication

Date Ordered,

and Brand

and

Date Started,

Name

Purpose

Date Changed or Discontinue Ordered:

Client Response

Responsibilities

Metabolic anti-

Mr. CVA was

Trimetazidine

ischemic agent.

given this

Vastarel

Trimetazidine is a

type of

metabolic agent, a

medication to

Started:

unnecessary effect

specific and selective

treat and

02/23/10

happened while taking

inhibitor of the 3-

prevent

the medication. He

KAT. This inhibition

another

also no longer

of β-oxidation allows

episode of

experienced any

a recoupling of

angina.

episodes of angina.

Doctor’s order: 35 mg/tab BID

02/23/10

Nursing

According to Mr. CVA

• Watch out for the

there were no

sign of nausea and

noticeable or

vomiting. • Monitor Vital Signs.

glycolysis and an increase in glucose oxidation for better energy production under ischemic conditions.

Generic Name and Brand Name

General Action

Indication

Date Ordered,

Client

Nursing

and Purpose

Date Started,

Response

Responsibilities

Date Changed or 95

Discontinue

Atorvastatin Avamax Doctor’s order: 40 mg/tab HS

Generic Name and Brand Name

• Pt. should be

Reduce plasma

Mr. CVA was

Ordered:

According to Mr.

cholesterol and

given this

02/24/10

CVA there were

advice to follow

lipoprotein levels by

type of

no noticeable or

a low

inhibiting HMG-CoA

medication to

Started:

unnecessary

cholesterol diet

reductase and cholesterol

decrease

02/24/10

effect happened

before and

synthesis in the liver and

cholesterol

while taking the

after

by increasing the number

level.

medication.

medication

of LDL receptors on liver

therapy.

cells to enhance LDL uptake and breakdown.

General Action

Indication

Date Ordered,

and Purpose

Date Started,

Client Response

Nursing Responsibilities

Date Changed or Discontinue 96

• Assess pt.

Blocks binding of

Mr. CVA was

Ordered:

According to Mr.

angiotensin II to

given this

02/24/10

CVA there were no

condition before

receptors sites in many

type of

noticeable or

therapy.

tissues, including

medication to

Started:

unnecessary effect

Losartan K

vascular smooth

maintain

02/24/10

happened while he

Lifezar

muscle and adrenal

blood

taking the

glands. Angiotensin II

pressure.

medication. Mr.

of Blood Pressure and Pulse.

• Assess for heart failure. • Close monitoring

Doctor’s

is a potent

CVA blood

order:

vasoconstrictor that

pressure was

also stimulates the

maintained at

50 mg/tab ½

function via

adrenal cortex to

normal status.

tab BID

creatinine and

secrete aldosterone.

• Assess pt. renal

BUN levels.

The inhibiting effects of

• Pt should avoid

angiotensin II reduce

sat substitutes.

blood pressure.

Generic Name

Indication

Date Ordered,

and Brand

and

Date Started,

Name

Purpose

Date Changed or

Binds with

Mr. CVA was

Discontinue Ordered:

adenosine

given this

diphosphate

type of

Clopidogrel

General Action

02/24/10

Client Response

Nursing Responsibilities

According to Mr. CVA

• Tell pt. to refrain

there were no

from activities in

noticeable or

which trauma and 97

bisulfate

receptorson the

medication to

Started:

unnecessary effect

Plogrel

surface of activated

prevent

02/24/10

happened while taking

platelets. This

further

action bloks ADP,

damage that

which deactivates

cause by

nearby glycoprotein

CVA.

without regard to

IIb/ IIIa receptors

Specifically

meals.

and prevents

to reduce

fibrinogen from

atherosclero

attaching to

sis events.

Doctor’s order: 75 mg/tab OD

the medication.

bleeding may occur. • If bleeding occur. Call the physician immediately. • Drug may be taken

receptors. Without fibrinogen, platelet can’t aggregate and form thrombi.

Nursing Responsibilities Prior: •

Check for the doctor’s order and medication chart

•

Prepare materials needed

•

Check for the Expiration date of the drug.

•

Before giving drug ask the patient about allergic reactions to certain drugs. A negative history of the drug allergy is not a guarantee against a future allergic reaction.

98

•

Obtain specimen for culture and sensitivity test before giving first dose. Therapy may begin pending results.

•

Check the Vital Signs.

During: •

Remember the 10 R’s in giving medications.

After: •

Tell the patient/ SO to take the entire quantity of the drug exactly as prescribed even after the patient feels well.

•

Encouraged patient to increase fluid intake

•

Check Vital Signs

•

Inform patient to notify prescriber if rash, fever or chills develop. A rash is a most common allergic reaction.

99

c. Diet Date Type

Ordered

of Diet

Date

Client’s response General Description

Indication(s) or

and/or reaction to

Purpose(s)

the

Started NPO

activity/exercise

February.

Mr. CVA was instructed

It was ordered so

Mr. CVA was very

23, 2010

to have Nothing Per

as not to alter

reluctant to comply

Orem/Nothing Via

diagnostic test

with his diet. His

Mouth. He is prohibited

results.

S.O. however

from ingesting food,

monitored his food

beverage, or medicine.

intake.

Nursing responsibilities: Prior : 1. Food and fluid intake should be avoided when NPO. 2. Verify doctor’s order 3. Discuss the importance of the ordered diet During the procedure: 1. Provide comfort measures such as stretching of bed linens and assist the client to a comfortable position 2. Support the patient if he/she has hard time it taking diet. After: 1. Monitor client’s reaction 2. Assess for patient’s condition, how he respond to the diet 3. Record procedure done

100

Date Type

Changed

Client’s response General Description

Indication(s) or

and/or reaction to

Purpose(s)

the

of Diet

activity/exercise Clear

February.

Mr. CVA was instructed

It was ordered so

Mr. CVA started to

liquid

24, 2010

to have a clear liquid

as to prepare his

take his medicines

diet to help maintain

intestines in

with “gatorade” and

adequate hydration,

resuming to his

practice frequent

provide some important

normal diet

sips of the said

diet

electrolytes when a full

beverage.

diet is not recommended. Clear liquids might have color, but you should still be able to see through it. Nursing responsibilities: Prior : 1. Noodles in the soup and milk products are to be avoided in a clear liquid diet 2. Verify doctor’s order 3. Discuss the importance of the ordered diet During the procedure: 1. Provide comfort measures such as stretching of bed linens and assist the client to a comfortable position 2. Support the patient if he/she has hard time it taking diet. After: 1. Monitor client’s reaction 2. Assess for patient’s condition, how he respond to the diet 3. Record procedure done

101

NURSING CARE PLANS

102

NURSING CARE PLANS Impaired Physical Mobility Assessment S>θ O > Patient manifest: - weak and pale appearance - difficulty in standing and sitting - slowed movement - limited range of motion

Nursing Diagnosis Impaired Physical Mobility r/t neuromuscular impairment aeb slowed movement

Scientific explanation Limitation in independent, purposeful physical movement of the body or of one more extremities. Due to the patient’s general status because of his brain damage secondary to CVA, patient develops weakness due to affectation in his cerebral artery. This can result in decrease perfusion and the development of infarct. The reflex or muscular strength of a particular limb affected becomes weak, because of its

Objectives After 2 hours of Nursing Intervention, the patient will demonstrate technique or behaviors that enable resumption of activities.

Nursing Interventions Instruct to change positions at least every 2 hours and placed on affected side. Position in prone position once or twice a day if patient can tolerate.

Rationale Reduces risk of tissue ischemia/injury. Helps maintain functional hip extension but may cause increase anxiety, especially about ability to breath.

monitor affected side for color edema, or other signs of compromised circulation.

Edematous tissue is more easily traumatized and heals more slowly.

Support affected body parts using pillows

To maintain position of function and reduce risk of pressure ulcers

Schedule activities with adequate rest periods during the day

To reduce fatigue.

Expected Outcome The patient demonstrated techniques that enable resumption of activities.

103

altered control and function. Due to the brain affectation, with this prolonged status on the muscle limb it further weakens the body that may result to activity intolerance and there insufficient physiological or psychological energy to endure or complete required or desired daily activities.

Encourage participation in selfcare, occupational activities

Enhances selfconcept and sense of independence.

Identify energyconserving techniques for ADLs.

Limits fatigue, maximizing participation

104

Risk for unilateral neglect Assessment Nursing Diagnosis S- O Risk for O- muscle unilateral strength neglect r/t test of right muscle arm:3/5; weakness right secondary to leg:2/5; left CVA arm: 4/5; left leg:4/5 -needs assistance in performing ADLs

Scientific Explanation

Objectives

A cerebrovascular accident (CVA) is a sudden loss of function resulting from disruption of the blood supply to a part of the brain. A stroke is an upper motor neuron lesion and results in loss of voluntary control over motor movements. Because the upper motor neurons decussate (cross), a disturbance of voluntary motor control on one side of the body may reflect damage to the

Short Term: After 15-20 mins of NI, the pt will participate in the performance of range of motion exercises on the extremities. Long Term: After 2 days of NI, the pt will increase the utilization of the affected extremities with due assistance from the SO as evidenced by an increase in the muscle strength test.

Nursing Interventions > Monitor and assessed vital signs > reassess patient’s general physical condition

Rationale To obtain baseline data > To note for any abnormality

> Perform PM Care

> To enhance well-being & provide comfort

> Frequently monitor vital signs

> To note significant changes in vital signs

> Perform muscle strength test regularly

> To determine muscle functioning on the extremities

> Instruct patient and significant others on a passive range of motion on the right

> To increase strength and mobility

Expected Outcomes Short Term: The pt shall have participated in the performance of range of motion exercises on the extremities. Long Term: The pt shall have increased the utilization of the affected extremities with due assistance from the SO.

105

upper motor neurons on the opposite side of the brain.

extremities > Promot adequate rest

> To promote comfort and relaxation

> Assist patient with self-care activities

> To prevent Injury and fatigue

> Maintain body alignment in functional position

> To promote and stimulate circulation

> Shift patient’s attention towards the affected side

> To stimulate and increase patient’s awareness on the affected side

> Administer due meds

> To treat underlying medical condition

106

Risk for impaired skin integrity Assessment Nursing Scientific Diagnosis explanation S>Ø Risk for Pressure ulcers impaired skin develop when soft O> Patient integrity r/t tissue (skin, SQ tissue manifested: decreased bed and muscle) are mobility a.e.b compressed between >right sided limited/difficulty a bony prominence paralysis of movements. and a firm surface for >limited a prolonged period of /difficulty of time. movements

Objectives After 1-hour of Nursing intervention, the client and SO will verbalize and demonstrate understanding on the proper bed positioning that can help reduce risk of developing pressure ulcers.

Nursing Interventions -monitor V/S

Rationale -gather baseline data for further comparison

-provide bedside care

-to give comfort to the patient

-support affected body parts using pillows

-to maintain position of function and reduce risk of pressure ulcers.

-encourage adequate fluid intake

-to avoid dehydration and skin dryness.

-change clients bed position every two(2) hours

-to generate blood flow and reduce the risk of pressure ulcers.

Evaluation After 1-hour of Nursing intervention, the client and SO have verbalized and demonstrated understanding on the proper bed positioning that can help reduce risk of developing pressure ulcers.

107

Impaired verbal communication Assessment S> Ѳ O> The patient manifested:  Slurring of speech  Glasgow Coma Scale: verbal response score of 4 out of 5  Absence of eye contact  Difficulty in use of facial expression

Nursing Diagnosis Impaired verbal communication related to neuromuscular impairment

Scientific explanation Infarction in the brain may lead to impairment in hearing and speech thus predisposing the patient to verbal impairment. For this case, the frontal area which is responsible for the personality, behavior, motor function, Broca’s area (expressive speech center), concentration, and abstract thought was affected. This led to aphasia which was the partial or complete inability to use or comprehend language resulting to

Objectives Short term: After 2 hours of nursing interventions, the patient will be able to indicate an understanding of the communicatio n problem and the importance of establishing a method of communicatio n. Long term: After 2 das of nursing interventions, the patient will be able to demonstrate congruent verbal and nonverbal communicatio n with the help of his family

Nursing Interventions INDEPENDENT:  Assess type/degree of dysfunction

 Listen for errors in conversation and provide feed back.

 Ask patient to follow simple commands (e.g. “Close your eyes, point to the door”); and repeat simple words or sentences.

Rationale  Helps determine area and degree of brain involvement and difficulty the patient has with any or all steps of the communication process. The patient has difficulty forming words but can understand spoken words.  Patient may lose ability to monitor verbal output and be unaware that communication is not sensible. Feedback helps the patient realize why the health care provider is not responding appropriately and provides opportunity to clarify content/meaning.  Tests for receptive aphasia



Expected Outcome Short term: The patient and his SO were able to understand the importance of establishing an alternative method of communication and stated “Ah, pwedi ming gawan yan.” Long term: The patient was able to demonstrate congruent verbal and nonverbal communication to SO and health care provider.

Identifies dysarthria 108

impaired verbal communication .

 Have the patient produce simple sounds like “ah”, “sh”, cat

 Provide alternative methods of communication: e.g. writing on a piece of paper, magic slate, using pictures.

because motor components of speech (tongue, lip movement, breath control) can affect articulation and may/may not be accompanied by expressive aphasia  Provides for communication needs and desires based on underlying deficit

 Anticipate and provide patient’s needs

 Helpful in decreasing frustration when dependent on others and unable to communicate desires.

 Talk directly to the patient, speaking slowly and distinctly. Use yes/no questions to begin with, progressing in complexity as the patient responds.

 Reduces confusion or anxiety at having to process and respond to large amount of information at one time. As retraining progresses, advancing complexity of communication stimulates memory and further enhances word/idea association  The patient is not necessarily hearing 109

 Speak with normal volume and avoid talking too fast. Give the patient ample time to respond. Talk with pressing for a response.

 Encourage SO to persist in efforts to communicate with the patient like reading mail, discussing family happenings even if he is unable to respond appropriately  Discuss familiar topics such as job, family, hobbies.

COLLABORATIVE:  Consult with/refer to speech therapist

impaired and raising voice may irritate him. Forcing responses can result to frustration and may cause him to resort to “automatic speech” like garbled speech, obscenities.  It is important for family members to continue talking to the patient to reduce isolation, promote establishment of effective communication, and maintain sense of connectedness with family.  Promotes meaningful conversation and provides opportunities to practice skill

 Assesses individual verbal capabilities and sensory, motor and cognitive functioning to identify deficits and therapy 110

needs

111

DISCHARGE PLAN

112

DISCHARGE PLAN Topic: Prevention of Cerebrovascular Disease Time Allotment: 30 minutes Venue: Hospital in Angeles City Objectives At

the

Content end

discussion

of -Brief description of the the disease including its risk

patient shall have:

factors and the common manifestations.

• Identify the

-Effects of neglecting the

effects of not

affected part and the

using the

complications of stoke

affected side.

Time Allotment 30 minutes

Teaching Strategies -Discussion with

Expected Outcome At the end of

Visual discussion:

Aids

-The patient would be able -Question and to participate by asking Answer questions and answering the questions of the student nurse.

-Managements on how

- Patient

to prevent the

would be able

possible

occurrence of Stroke

to Identify the

complications of

and their rationale.

effects of not

• Determine

stroke. • Distinguish and follow the means to control blood

 Exercise

using the

 Weight control

affected side.

 Avoid smoking  Avoid too much alcohol

pressure and

 Healthy Diet

diabetes mellitus

 Enough sleep

to decrease the risk for the occurrence of stroke or CVA.

 Compliance to medications.

-Patient would be able to Distinguish and follow the means to control blood pressure and diabetes

• Discern importance

mellitus to decrease the risk for the 113

of strict

occurrence of

compliance

stroke or

to home

CVA.

medicines. -Patient would be able to Discern importance of strict compliance to home medicines.

114

LEARNING DERIVED

115

LEARNING DERIVED Valarie Agustin

"Health is worth more than learning." --Thomas Jefferson

This disease condition is somewhat familiar to me because this was my grandfather’s illness before he died. So, when the group agreed to take this case as our subject for drug study, I got a bit excited because I know I can relate to it. During the study, we have interviewed the wife of the sick. We gathered some data in order to know about the current condition of the patient. I noticed that the mother doesn’t really want to participate well with us because he is just answering us without elaborating the condition of his husband well. I also observed that he looks really tired of taking care of his husband. It was like she wants to give up. Well, that’s just my opinion. Maybe she felt that way because I know that it’s really not easy to take care of a Stroke patient. I knew that because I used to take care of my grandfather when he is still alive. You need to have more patience because sometimes they’re really moody and hard headed. But in my case I tolerated that feeling of giving up, because I know that was the only way to show my love for my grandfather and to thank him for everything he has done for us. I don’t usually participate during case study preparation but with this I can say that I did my part. It may not be that much but at least I know I made a help. This study made me realize that being a caregiver is a very important role. Because when patient’s relatives feels like giving up on them, we are the next person to show them that they’re still taken cared off and that there’s always hope as long as you keep fighting.

116

Arianne De Jesus

On our case study, we made mentioned this quote: “The only way to keep your health is to eat what you don't want, drink what you don't like and do what you'd rather not.” By Mark Twain. According to this quote, I’ve learned that one of our cherished possessions as a human being is our own health. On our case study regarding CVA, I’ve learned the complexity of the disease condition itself. Its complicated pathophysiology and underlying factors which contributes to the disease triggered us to come out with a very informative study. Our patient (Mr. CVA) is very cooperative during the assessment phase of this study. Even his wife was eager enough to answer our questions though sometimes there were some instances when they are a bit aloof. I know that through this study I did developed the attitude of being intuitive enough and being able to come out with the best whatever we are doing. This study for sure would contribute to me as a future nurse.

117

Leo Cesar Dela Cruz

Stroke or cerebrovascular accident (CVA) is one of the common causes of morbidity and even mortality in the Philippines as well as all around the globe. In the Philippines, it has been a well-famed topic among elderly and had caused various misled information. Even though there had been a lot of cases of CVA (a.k.a stroke), the knowledge of the public regarding the disorder still inadequate. Even those people are of high risk still lack knowledge regarding CVA. This reflects lack of dissemination of information regarding CVA. Many may think that CVA are cases that is no longer curable when in fact CVA is being managed today as treatable problem if recognized early; however, due to the limited knowledge of the public about early warning signs, many client still suffers from CVA. Some of the disabilities that can result from stroke include paralysis, cognitive deficits, speech problems, emotional difficulties, pressure sores, pneumonia, incontinence problems and daily living problems, and pain. If the stroke is severe enough, coma or death can result. Treatment of the client with strokes carries at maximizing function and preventing disability. My role as health care providers is indeed important in order to attain the optimum level of wellness of our client. Suitable care must be carried out and health teachings must be given to the client and/or relatives so that the needed care of the client is not only bounded in the hospital rather could also be extended at home. This case study made me realize the important role in information and health distribution regarding false ideals. It is through this that they were able to gain enough knowledge to be equipped for future management of patients with similar case. Through the case handled, I was able to appreciate the value of preventing the risks that may possibly arise CVA and able to gain everlasting knowledge the will be sure of great help in rendering effective and therapeutic care for stroke patient.

118

John Henrick Dingal I learned to polish my skills such as physical assessment, teamwork and therapeutic communication. This case study is about CVA. We were able to assess the patient last February 23 and 24. I was in a small group of when conducting physical assessment and this strategy is effective because if one student failed to ask a certain question, the other student may ask the question. The other students were asking for the patient’s wife for the nursing history. It is really important to gain the trust by using therapeutic communication so that the conversation can go smoothly. It is also significant to pay attention to the small detail as well because data can be extracted from those and can interpret something. We learned that one of the causes of the patient’s CVA is diabetes. I was able to gather data from the chart while they were asking further questions. I learned to improve teamwork. We divided activities to work more efficiently. Being in this field requires a whole lot of characteristics and attitudes. Being flexible is a must. We can’t choose our patients nor chose what cases to be handled. Learning how to adjust is important because every patient is different. The way of initially talking to them can either make or break the relationship. So to avoid such, reading the chart is necessary before going so that a small background can be learned and that questions can be formulated than rather on the spot. Since there are a lot of medications being administered, knowing the purpose and effect is important.

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Genevieve Gopez

"Tell me and I forget. Show me and I remember. Involve me and I learn." – Anon In this life, there will be lots of circumstances, problems, obstacles that we will stumble upon. Some may sway us and make us quit while some pushes us to be strong and confident. As young as we can be we should learn how to value life and be prepared for a very difficult path to take. Some may have difficult problems while others go through having serious disease conditions like for this case study. The quote can be well applied in our chosen field. Tell me and I forget, like in ordinary classroom discussions, we tend to have “amnesia” as they say. Show me and I remember, like using videos, pictures, and diagrams can that be recalled easily. Lastly, involve me and I learn, like for this case study. We were involved in the formulation of this paper and so we learned. As we all know, CVA or simply known as stroke is a disease caused by many factors. One of which is old age. It can also be a complication of other disease conditions. The end result can be paralysis or even death for severe cases. As statistics states, men are more prone to this condition but in most cases they can survive and be cured. Women, on the other hand, are not usually affected by the condition, but they might suffer severe cases when they got affected. Knowing the risk factors of CVA can help us in various ways. We, as future health care providers, can teach our patients to be cautious with their health and we also know how to take care of ourselves. We know the importance of striving hard to become physically fit, to eat healthy food and take care of our body and we can share that knowledge to others. Being involved in this case study made me learn lots of things and gain experiences. It also enhanced our skills as student nurses. Our ADPIE Nursing process, our critical thinking, our rational judgment were very much enhanced. It really was like “save the best for last”. We had the best clinical instructors so nothing more can be asked for. So, for our student nurses’ life, our last case study was the best. The learning’s and experiences will never be forgotten. Laus Deo Semper!

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Fritzie Blanca Limiac

This case study is perhaps the most challenging I had, but it was one that interests me. Stroke is probably one of the dreaded conditions. Though not as vivid, I could recall several of people talking about it, way back then, with faces drowned in hopelessness. Usually, people have the misconception that stroke is lethal. To a certain degree, this is true; however it is treatable and preventable. With the advent of nanotechnology, people are can now easily access information regarding their health. In the completion of this study, we encountered several sites discussing stroke in a very simple, straightforward manner for the consumption of the general public. The internet has become a great tool to promote awareness which is vital in the prevention of stroke or if not, prevention of its further damage. In stroke, every minute counts, knowledge of the signs and symptoms could help families address the situation immediately, thus medical care could be initialized. Awareness is not the only key, however. The success of the medical treatment in patients with CVA lies in both the healthcare team and the patient. The patient’s willingness to actively participate in his care means having the battle half won. In this case study, our patient is very passive, or even, noncompliant. He would rather have it his way. Though his attitude had repercussions on his health, this helped us develop our therapeutic communication skills. By employing this, we were able to do a comprehensive assessment of the patient, one that we usually fail to do due to several unavoidable circumstances. One that I am most like about the study is that the risk factors were asked to be explained in detail. That way, they weren’t just words. They were given value.

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Ralp Lauren Lumanlan ‘’In order to gain the heart of a NURSE, You must first become a PATIENT” In becoming a nurse, one encounters many kinds of diseases that patients experience and undergoes. So as to educate oneself of these conditions, a nurse must read a lot about them, their causes , their signs and symptoms and their treatment but doing this case study has made me realize that reading a condition in a book is totally different from knowing someone who had experienced the disease and gave their first-hand look on what they have undergone. This case study had helped me developed my three faculties to become a more competent nurse. Reading about the patient’s condition and medical management has enhanced my cognitive skill and my critical skills to think. Listening to the patient’s experience of the condition, on how they verbalize their anguish or their anxiety to regain their health has improved my affective skill to feel more and put myself in the shoes of my patient and lastly, the interventions that we do to relieve the sickness of our patient by applying our theoretical knowledge into action had developed my psychomotor skill to become a nurse who provide the best quality care to a patient. Thus, through all this case study, it had left a mark in my mind that a true nurse must use his not only his HEAD and HAND in handling his patient but more importantly his HEART.

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Princess Dian Munoz It was my first time to do CVA case study and I find that case interesting and at the same time difficult. We had a very thorough patient history taking and physical assessment. We really assess our patient and made sure that we had gathered all the needed data. The patient was very accommodating and also her wife. We were asking the wife regarding the nursing history of the patient since the patient had difficulty speaking. Throughout the interview I had learned that the patient had diabetes mellitus and I realized that this disease really aggravate CVA. I also learned that the patient was hypertensive. He had most of the signs and symptoms of CVA. The patient had a right sided paralysis which indicates that he had a left brain affectation. While doing the case study we had learned the signs and symptoms of CVA, the predisposing and precipitating factors and the medications taken by CVA patients.

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Irien Nain

To be have a relative with cerebral vascular accident or stroke is quite difficult. However, having this disease is much difficult, knowing that you cannot normally move half of your body due to paralysis or weakness. This situation is like you’re half dead, you cannot do your activity of daily living, you can’t talk normally, and you can’t see anything on the affected side and sometimes you cannot understand what the other is saying depending on the part of the brain affected. At this time, support from a family is really important to assist and care you. But this doesn’t mean that the patient will be dependent on them. You also need to help yourself. How? Try not to neglect the affected side so that your body still knows that your affected side is still functioning. Stroke is a sudden, localized damage in the brain which can be due to interrupted blood supply and oxygen in the brain or an abnormal bleeding in the brain. Brain is one of the essential organs for us to live in this world. Prevention from any head injury or diseases that causes brain damage is very important. There some time that if a brain injury or damage wasn’t treated well, it might cause an irreversible functioning of a part of our body and the worst is death. It is very vital to prevent the occurrence of this disease if you know that you are one of the candidates to have stroke. This may also cause some disabilities if not prevented. In our patient, it is his second incident of Stroke. He also had a history of Hypertension and Diabetes Mellitus, making hi more vulnerable to get this disease. According to his SO, he was not that aware of his health, knowing the fact that he had a previous attack of stroke. Discipline is really needed to prevent this situation. Patient need to become more careful and strictly complies with the treatment regimen, not just through pharmacological aspect as well as maintaining a healthy lifestyle.

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Andrei Punzalan

We have accomplished our case study about Cerebrovascular Accident (CVA) for our last rotation this nursing life. Once again, we had gained new experience, additional knowledge and had involved ourselves with the conduction of information. Handling our patient was not difficult.

The patient was cooperative during different

procedures done to her. There were six of us who visited him and interviewed his wife and we did the physical examination to the patient. We had established rapport beforehand and he felt at ease with us. We learned about CVA and researched on the signs and symptoms which were proven evident in the client. Seeing them in reality makes it different learning them from theories and books. Not only did we gain knowledge but also developed our skills in communication and performing nursing procedures. Lastly, in the completion of our case study, we have learned how to value each other’s presence. Cooperation and participation of each member is highly appreciated. Everyone had their roles and did well.

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Jenelyn Talavera

A good nurse must be equipped with enough knowledge and competent skills in helping the clients to achieve an optimum level of functioning. We have chosen this case so that we will be primed with the knowledge on what cardiovascular is all about, including its signs and symptoms that the patient may experience. In completing the case study. I've gained a deeper understanding of the condition, treatment and care of a patient afflicted with CVA. I was able to determine the cause or the predisposing factors of the patient's condition as maybe related to his past and present health history by mulling over the patient's profile. I believed that learning should not only be confined in the four corners of the class room, but it should be derived from the people we bestow our utmost concerns. The completion of this case study gave me the opportunity to enhance my understanding and competence.

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Paula Angeli Tayag When I first heard that our group will be conducting a case study regarding Stroke or Cerebro Vascular Accident I was kind of intimidated with the topic, since it is a complicated one. I was able to handle a stroke patient in a Hospital in Angeles City when I was in 2nd yr. Unfortunately I didn’t learn as much since I was only allowed to take the vital signs then. When I was performing my nurse-patient interaction the SO was the one answering for the patient, since the patient was not able to talk at that time. I begun to wonder, what’s with the disease? Will he be able to talk straight again? Will he be able to return to his work? I had so many questions in my mind at that time. Time passed and left those questions unanswered. Until came my 3rd yr and 4th yr my questions are finally answered. I’ve learned that the most essential element in stroke patients is TIME, that every minute matters. The damage can be controlled or can progress in just a nick of time. I just hope that our government will provide more information regarding stroke, so that people can be educated and learn how to prevent and handle this kind of condition. Everyone needs to be educated even if they’re not in the medical field.

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Alraian Tuazon

One is enough, two is too much -apparently not for this guy This case study is truly interesting not only because of the nature of the patient’s disease but also his attitude towards it. Usually persons who got a first stroke, they take precaution, preventive measures, making sure that it would never happen again. But he, instead made use of his time to take pleasure in eating and drinking everything he wanted which somehow contributed to the reoccurrence of his stroke. Unlike other case study, this case study is necessary to give information about the client’s neuro system. It gave opportunity for me, and my other groupmates to harness our skills in assessing his mental status, cranial nerves, and even use the Glasgow coma scale. This experience does not often land on our footsteps. This is the last case study, the last case study presentation, the last cross examination with a panel, so we are determined to make it our best!

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