Professional Documents
Culture Documents
A Care Study
With
Submitted to:
?
Clinical Instructor
Submitted by:
Group B6
X
TABLE OF CONTENTS
I. Introduction
V. Pathophysiology
XIII. Prognosis
XIV. Bibliography
I. Introduction
Thrombosis, embolism, and hemorrhage are the primary causes for CVA,
with thrombosis being the main cause of both CVAs and transient ischemic
attacks (TIAs). The most common vessels involved are the carotid arteries and
those of the vertebrobasilar system at the base of the brain. A thrombotic CVA
causes a slow evolution of symptoms, usually over several hours, and is
“completed” when the condition stabilizes. An embolic CVA occurs when a clot is
carried into cerebral circulation and causes a localized cerebral infarct.
Hemorrhagic CVA is caused by other conditions such as a ruptured aneurysm,
hypertension, arteriovenous (AV) malformations, or other bleeding disorders.
Symptoms depend on distribution of the cerebral vessel(s) involved. Ischemia
may be (1) transient and resolve within 24 hours, (2) reversible with resolution of
symptoms over a period of 1 week (reversible ischemic neurological deficit
[RIND]), or (3) progress to cerebral infarction with variable effects and degrees of
recovery.
Risk factors for stroke include advanced age, hypertension (high blood
pressure), previous stroke or TIA (transient ischaemic attack), diabetes mellitus,
high cholesterol, cigarette smoking, atrial fibrillation, migraine with aura, and
thrombophilia. In clinical practice, blood pressure is the most important
modifiable risk factor of stroke; however many other risk factors, such as
cigarette smoking cessation and treatment of atrial fibrillation with anticoagulant
drugs, are important.
This care study aims to know about the disease condition Cerebrovascular
Accident, its pathophysiology, its medical management and the nursing
interventions that a student nurse can apply. It also aims to gather pertinent
information about the clients’ health history and how this disease developed.
This study was done during the clinical duty at X specifically at the Station 5
dated September 20, 2007 and visitations on September 19, 22, and 23, X. The
period of the study is limited only to four days thus all events that will happen
after the said period is not included.
The scope of the study includes the factors that predisposes and precipitates
the client to acquire the said disease condition. It also includes obtaining history
of the clients’ present illness. Moreover, as a student nurse, it is our responsibility
to attend to our clients needs and to intervene properly according to my nursing
care plan with the supervision of my clinical instructor.
Religion: X Height: 5 ft
Address: ?
Occupation: ?
Husband: ?
Income: P2,600/Month
VITAL SIGNS:
BP: 150/100 mmHg
T: 37.5º C
PR: 75 bpm
RR: 28 cpm
Health History
Our patient was born via Normal Spontaneous Vaginal Delivery with the help
of “mananabang” last February 12, X. The patient’s watcher didn’t know if D.B.
Chavez has been immunized when she was still young. According to the
watcher, D.B.C. was still 19 when she got married to X and they were blessed
with 5 children. All of them were born via normal spontaneous vaginal delivery.
Year X, she had also experienced pneumonia. That very same year, she had
undergone a surgery due to the tumor found in her neck at Maria Reyna Hospital
and had been transfused with blood with no adverse reactions. His attending
physician at that time discovered that she was hypertensive. Due to this, she was
given medications but wasn’t able to maintain and follow it due to personal
reasons. This had been believed as the primary cause that predisposes her to
her condition now. Stress was also said to be one of the reason. She and her
husband had been finding ways to supply the needs of their three children which
are all now in college. Last 3 months, she was also diagnosed with UTI during
her check-up.
History of present illness
One day prior to her admission, she was very stressed in doing their
household chores alone. The night prior to her admission, she suddenly fainted
and was found flat and unconscious on floor after going to the comfort room. The
following morning, she was brought and admitted to X at X and was immediately
transferred to X for further observation. At X, she was diagnosed with Thrombotic
CVA.
III. Nursing System Review Chart
Vital Signs:
Pulse: _75 bpm BP: _150/100 mmHg Temp:_38º C Height: 5 ft Weight: 55kg
EENT:
[ ] impaired vision [ ] blind
[ ] pain redden [ ] drainage
[ ] gums [ ] difficulty of hearing [ ] deaf O2 inhalation @ 2L/m
[ ] burning [ ] edema [ ] lesion [ ] teeth
[ ] assess eyes ears nose Dry lips and Cough
[ ] throat for abnormality [ ] no problem
RESP: Scar (operation)
[ ] asymmetric [x ] tachypnea [ ] barrel chest
[ ] apnea [x ] rales [x ] cough Asymmetric RR
[ ] bradypnea [ ] shallow [ ] rhonchi
[ ] sputum [ ] diminished [ ] dyspnea
Tachypnea RR: 28cpm/ Rales
[ ] orthopnea [ ] labored [x ] wheezing
[ ] pain [ ] cyanotic
Dry skin/yellowish/ Warm to
[x ] assess resp. rate, rhythm, pulse blood touch/ Poor skin turgor
[x ] breath sounds, comfort [ ] no problem
CARDIOVASCULAR: Edema
[ ] arrhythmia [ ] tachycardia [ ]numbness
[ ] diminished pulses [x] edema [x] fatigue Scar(ligation)
[ ] irregular [ ] bradycardia [ ] murmur
[ ] tingling [ ] absent pulses [x] pain Distended GI
Assess heart sounds, rate rhythm, pulse, blood
Pressure, circ., fluid retention, comfort FBC (yellowish urine)
[ ] no problem
GASTROINTESTINAL TRACT:
[ ] obese [ ] distention [ ] mass
[ ] dysphagia [ ] rigidity [ ] pain
[x] assess abdomen, bowel habits, swallowing
[x] bowel sounds, comfort [x] no problem
GENITO – URINARY AND GYNE
[ ] pain [ ] urine [ ] color [ ] vaginal bleeding Dirty long nails
[ ] hematuria [ ] discharge [x] nocturia
[x] assess urine frequency, control, color, odor, comfort Immobility
[ ] gyne bleeding [ ] discharge [ ] no problem
NEURO: unconsciousness
[ ] paralysis [ ] stuporus [ ] unsteady [ ] seizure
[ ] lethargic [ ] comatose [ ] vertigo [ ] tremors dehydrated
[ ] confused [ ] vision [ ] grip
[x] assess motor function, sensation, LOC, strength IVF D5NSS 1L @ 40 gtts/m
[x] grip, gait, coordination, speech [ ] no problem
MUSCULOSKELETAL and SKIN: Paralysis
[ ] appliance [ ] stiffness [x] itching [ ] petechiae
[ ] hot [ ] drainage [ ] prosthesis [ ] swelling
[ ] lesion [x ] poor turgor [ ] cool [ ] flushed
[x] hematoma [x] rash [ ] pain [ ] ecchymosis [ ]
diaphoretic moist
[x] assess mobility, motion gait, alignment, joint function
[ X] skin color, texture, turgor, integrity [ ] no problem
SUBJECTIVE OBJECTIVE
COMMUNICATION:
[ ] hearing difficulty Comments: “dili nag [x] glasses [ ] languages
a buka iyang mata, [ ] contact lenses [x] hearing
[x] visual changes
usahay mu lihok siya difficulties due to age
[ ] denied kung storyahan.” As Pupil size:3 mm [x] speech
verbalized by the difficulties
patien’ts daughter. Reaction: PERRLA (Pupil Equally Round
Reactive to Light and Accomodation)
OXYGENATION: Resp. [ ] regular [x] irregular
[x] dyspnea Comments: “gahi iya Describe: Patient has rapid respiration and
[ ] smoking history ubo dayun pas-pas adventitious breath sounds noted upon
[x] cough iynag ginhawaan” as auscultion.
[x] sputum verbalized by the
[ ] denied patient’s husband. R: full and symmetrical to the left lung
L: full and symmetrical to the right lung
CIRCULATION:
[ ] chest pain Comments: “na Heart Rhythm [x ] regular []
comatose na mana irregular
[ ] leg pain
siya dili na niya ma Ankle Edema: Ankle edema is present on
[x] numbness of lihok iyang lawas” as both extremities
verbalized by the Pulse Car Rad. DP Fem*
extremities
patient’s daughter. R
[ ] denied 90bpm_+_______+_______+_____+___
__
L
90bpm_+_______+_______+_____+___
_
Comments: Right and left pulses are equal;
strong and palpable.
NUTRITION:
Diet:osteorized Comments: “I agi [ ]dentures [x]none
feeding through nalang aning tubo
NGT ang iyang pagkaon Full Partial with
[Character kay dili naman siya patient
[ ] recent change in ka tulon” as
weight verbalized by the Upper [] [x] [ ]
[x] swallowing patient’s daughter.
Difficulty Lower [] [x] [ ]
[ ] denied
ELIMINATION: Comments: “dili Bowel sounds
Usual bowel pattern [ ] urinary frequency namu Slightly not Audible
Once a [ ] urgency mahinumduman bowel sounds
day________ [ ] dysuria kanus-a siya Abdominal Distention
[ ] constipation [ ] hematuria nakalibang basta Present [ ] yes [x] no
remedy [ ] incontinence wala pa siya ka Urine* (color,
Date of last BM [ ] polyuria libang sugod pa sa consistency, odor)
Not recalled [x] foley in place iyang pagka admit” urine color is
[ ] diarrhea [ ] denied as verbalized by yellowish, slightly
character the patient’s hazy and with
daughter. aromatic odor
MGT. OF HEALTH & ILLNESS: Briefly describe the patient’s ability to
[ ] alcohol [x] denied follow treatments (diet, meds, etc.) for
(amount & frequency) chronic health problems (if present).
“wala man gani ko ga inum siya pa kaha” Patient is following accurately on his
treatment according to doctor’s order
as verbalized by the patient’s husband
religiously with the support of the
[ ] SBE Last Pap Smear: not recalled significant others.
LMP: Not recalled
SUBJECTIVE OBJECTIVE
SKIN
Comments: “uga na bitaw [x] dry [ ] cold [x]
INTEGRITY:
iyang panit karun pero pale
[x] dry wala man siyay mga [ ] flushed [x] warm
samad samad.” As [ ] moist [ ] cyanotic
[x] other
verbalized by the patient’s *rashes, ulcers, decubitus (describe
daughter. size, location, drainage: (-) rashes; (-)
[ ] denied
ulcers ; (-) decubitus (There were
presence pf hematomas on patients
anticubital areas and wrist).
ACTIVITY/
SAFETY: Comments: “na comatose [ ] LOC and orientation Patient is not
[ ] convulsion na mana siya, dili na niya oriented as to the place, date and
[ ] dizziness malihok iya lawas” as time.
[x] limited motion verbalized by the patient’s Gait: [ ] walker [ ] cane [ ]
of daughter.” other (ambulant)
Joints
[x] steady [ ]
Limitation in unsteady_________
Ability to [ ] sensory and motor losses in face
[ ] ambulate or
[ ] bathe self extremities presence of sensory and
[x] other motor losses on face or extremities
[ ] denied [x] ROM limitations: Patient can
perform passive ROM with the help of
the nurse or care provider.
COMFORT/SLEE
P/ Comments: “dili nag a [ ] facial grimaces
AWAKE: buka iyang mata, usahay [ ] guarding
[ ] pain mu lihok siya kung [ ] other signs of pain :
storyahan.” As verbalized No signs of pain noted
(location)
by the patien’ts daughter. [ ] side rail release form signed (60 +
Frequency
years)
Remedies
No side rails, supported by pillows
[] nocturia
[] sleep difficulties
[ ] denied
COPING:
Occupation: Observed non-verbal behavior: No
Members of household: 7 members in the Eye to eye contact
family (wife and 5 children) Phone number that can be reached
Most supportive person: husband (Mr. Chavez)anytime:
Contact #: 09277165120
SPECIAL PATIENT INFORMATION
______N/A Daily weight _N/A___ PT/OT __ N/A
_every 4 hour_ _ BP q shift ____N/A___ Irradiation
____N/A___ _ Neuro vs __ done _Urine test
____N/A_ _CVP/SG Reading _No Order__24 hour Urine Collection
Diagnostic/
Date Date I.V. Date
Laboratory Date done
ordered ordered Fluids/Blood Disc.
Exams
September .
22, 2007 Chest X-ray September September D5NSS 1L @40 Still
22, 2007 15,2007 cc/min hooked
September
September Hematology 22, 2007
21, 2007 Test
With Freud, our client is in her Genital stage. She has successfully
achieved this stage because she was able to identify herself as a woman and a
wife to her husband. She had a family and was able to cope struggles life on her
own. She can stand on her own and make decision for her self.
Mrs. Chavez in her stage of development she was not able to accomplish
the task during earlier age towards the later age. She failed to achieve the next
task which, it leads to unhappiness this was evidenced of being a housewife,
poor functioning in the society because of her educational attainment in life and
take early responsibility at age of 21. This implies that she never achieved her
social and civic responsibility.
11:52 pm
To ensure that the patient will be treated
properly with a physician of choice,
• Please admit under the service creating more intensive treatment to deal
of Dr. Agcopra with the current condition.
Legal measures to carry out prior to
providing to patient.
• Secure consent to care
To monitor the current physiologic status
of the patient and prevent deterioration of
• TPR every 4 hours complication.
SODIUM TEST
SGPT
ECG 12 lead
A/G mode
BUR: 16
FiO2: 100%
TV: 450 ml
To determine proper placement of ET
tube.
• CXR post - intubation
Determines adequacy of respiratory
function and to determine the specific rate
• ABG 1 hr – post MV settings for O2 therapy.
September 16, 2007 2:00 am
• CHON 35 g
• FATS, rest
Equal feeding 1:1 dilution
Drug Study
Hepatic – jaundice
Metabolic – hypoglycemia
GI – nausea, vomiting
CT Scan
Multiple sequential axial tomographic secretions of the head from skull base to
the vertex without IV contrast were obtained revealing the following findings:
There is a round hyperdensity involving the pons around 2.0 X 2.8 X 3.2 cm. The
fourth ventricle is compressed with mild dilatation of the lateral and third ventricle.
No middle shifting is seen.
Small-ill defined hypdensity seen at the let frontal periventricular white matter.
Another small hypodensity at the left caudate nucleus.
Impression:
Acute Hemorrhage involving the pons beginning mild dilatation of the lateral and
third ventricles secondary to extrinsic compression of the fourth ventricle.
Lacunar infarcts, left frontal periventricular white matter and the caudate nucleus.
Hematology Test
Basophils: 0.3
♦ Decreased: Effect of
mannitol
Radiologic Report
Examination: Chest PA
There is a wedged homogenous opacification in the right lower lobe. The rest
of the lungs field are clear. The heart is enlarged (CTR:0.57) exhibiting
inferolateral displacement of the cardiac apex midline structures are not
displaced. The CP sulci and hemidiaphragms are intact. The rest of the included
structures are unremarkable.
• Pneumonia, Right
• LV Cardiomegally is considered, ECG correlations suggested
Hematology Test
Chest XRAY
Follow-up study (done with obliquity) for the previous examination dated 9/16/07
shows increased haziness of the right lower lung field and new haziness of the
left lower lung field. Although, the mediastinal structures appear shifted to the left
due to positioning, the left cardiac border and hemidiaphragm have been
silhouted by new infiltrates.
Trachea is midline.
The osseous structures and the rest of the soft tissue structures are
unremarkable.
IMPRESSION:
• Pneumonia, bilateral, progressing
• Atherosclerotic thoracic aorta
• Intercurrent minimal pleural effusion, left not ruled out
• Pls. correlate clinically, follow-up suggested.
Time: 4:30 pm
F1O2: 100%
RR: 16
Normal Values
Chest PA (XRAY)
Comparative Study
IMPRESSION:
May be related to
Possibly evidenced by
ACTIONS/INTERVENTIONS RATIONALE
ACTIONS/INTERVENTIONS RATIONALE
Cerebral Perfusion Promotion (NIC) Thrombolytic agents are useful in
dissolving clot when started within 3 hr of
Collaborative initial symptoms. Thirty percent are likely
to recover with little or no disability.
Administer medications as indicated: Treatment is based on trying to limit the
size of the infarct, and use requires close
Alteplase (Activase), t-PA; monitoring for signs of intracranial
hemorrhage. Note: These agents are
Anticoagulants, e.g., warfarin sodium contraindicated in cranial hemorrhage as
(Coumadin), low-molecular-weight diagnosed by CT scan.
heparin (Lovenox); antiplatelet agents,
e.g., aspirin (ASA), dipyridamole May be used to improve cerebral blood
(Persantine), ticlopidine (Ticlid); flow and prevent further clotting when
embolus/thrombosis is the problem.
Antifibrolytics, e.g., aminocaproic acid Contraindicated in hypertensive patients
(Amicar); because of increased risk of hemorrhage.
May be related to
Possibly evidenced by
Inability to modulate speech, find and name words, identify objects; inability to
comprehend written/spoken language
Discuss familiar topics, e.g., job, family, Enables patient to feel esteemed,
hobbies. because intellectual abilities often remain
intact.
Respect patient’s preinjury capabilities;
avoid “speaking down” to patient or Assesses individual verbal capabilities
making patronizing remarks. and sensory, motor, and cognitive
functioning to identify deficits/therapy
Collaborative needs.
May be related to
Possibly evidenced by
Motor incoordination
Evaluate for visual deficits. Note loss of Presence of visual disorders can
visual field, changes in depth perception negatively affect patient’s ability to
(horizontal/vertical planes), presence of perceive environment and relearn motor
diplopia (double vision). skills and increases risk of
Approach patient from visually intact accident/injury.
side. Leave light on; position objects to
take advantage of intact visual fields. Provides for recognition of the presence
Patch affected eye if indicated. of persons/objects; may help with depth
perception problems; prevents patient
from being startled. Patching may
decrease the sensory confusion of double
vision.
ACTIONS/INTERVENTIONS RATIONALE
May be related to
Perceptual/cognitive impairment
Pain/discomfort
Depression
Possibly evidenced by
Impaired ability to perform ADLs, e.g., inability to bring food from receptacle to
mouth; inability to wash body part(s), regulate temperature of water; impaired
ability to put on/take off clothing; difficulty completing toileting tasks
Maintain a supportive, firm attitude. Allow Patients need empathy and to know
patient sufficient time to accomplish caregivers will be consistent in their
tasks. assistance.
Provide positive feedback for efforts and Enhances sense of self-worth, promotes
accomplishments. independence, and encourages patient to
continue endeavors.
Create plan for visual deficits that are
present, e.g.: Patient will be able to see to eat the food.
Place food and utensils on the tray Will be able to see when getting in/out of
related to patient’s unaffected side; bed and observe anyone who comes into
the room.
Situate the bed so that patient’s
unaffected side is facing the room with Provides for safety when patient is able to
the affected side to the wall; move around the room, reducing risk of
tripping/falling over furniture.
Position furniture against wall/out of
travel path. Enables patient to manage for self,
enhancing independence and self-
Provide self-help devices, e.g., esteem; reduces reliance on others for
button/zipper hook, knife-fork meeting own needs; and enables patient
combinations, long-handled brushes, to be more socially active.
extensions for picking things up from
floor; toilet riser, leg bag for catheter; Reestablishes sense of independence
shower chair. Assist and encourage and fosters self-worth and enhances
good grooming and makeup habits. rehabilitation process. Note: This may be
very difficult and frustrating for the
Encourage SO to allow patient to do as SO/caregiver, depending on degree of
much as possible for self. disability and time required for patient to
complete activity.
Assess patient’s ability to communicate
the need to void and/or ability to use Patient may have neurogenic bladder, be
urinal, bedpan. Take patient to the inattentive, or be unable to communicate
bathroom at frequent/periodic intervals needs in acute recovery phase, but
for voiding if appropriate. usually is able to regain independent
control of this function as recovery
Identify previous bowel habits and progresses.
reestablish normal regimen. Increase
bulk in diet; encourage fluid intake, Assists in development of retraining
increased activity. program (independence) and aids in
preventing constipation and impaction
(long-term effects).
ACTIONS/INTERVENTIONS RATIONALE
Neuromuscular/perceptual impairment
Possibly evidenced by
ACTIONS/INTERVENTIONS RATIONALE
S “gahi iya ubo dayun pas-pas iyang ginhawaan” as verbalized by the patient’s
husband.
O Productive cough
RR= 28 cpm
Rales
A Ineffective airway clearance related to productive cough and immobility
P At the end of 8 hours, patient will be able to maintain airway patency
I 1. Monitored respiratory status at least every 4 hours.
O Temp.: 38C
A Hyperthermia related to increase ICP secondary to disease processes
P At the end of 15-30 minutes, the patient’s temperature will be near normal
range.
I 1.tepid sponge bath done to promote heat loss by evaporation.
5.administered Paracetamol 500 mg 1 tab q4h PRN and Mannitol 100 cc IVT
every 8 hours as prescribed by Dr. Agcopra. to relieve fever through central
action in the hypothalamic heat-regulating center and increases osmotic
pressure of glomerular filtrate, inhibiting tubular
E At the end of 15-30 minutes, the patient’s temperature will be near normal
range of 37.5 C
S
“high blarun na jud na siya daan” as verbalized by the significant others.
S “Uga na bitaw iyang panit karun pero wala man siyay mga samad samad.” As
verbalized by the patient’s daughter.
O Patient is comatose
O - restlessness
DAY 1
Last September 18, 2007, we had our assessment for our last rotation at
Polymedic General Hospital (PGH) station 5. Our clinical instructor was Ma’am
Oro and she assigned each of us an individual patient. One of those was Mrs.
Chavez with the case of CVA and she was assigned to Kena Edao.
A thorough assessment was done by Kena Edao.to her patient Mrs. Chavez
from head to foot. She takes her vital signs and interviewed her watchers or
significant others about the history of the patient’s condition. And she was also
able to check the patient’s chart for some of its information such as; doctor’s
orders and laboratory results.
DAY 2
On September 19, 2007, we had our first duty and we were on 3-11 pm
shift. At 4:00 pm, Kena takes the patient’s vital signs and after that she then
monitor her condition. She was able also to give the patient’s medications
through NGT feeding because the patient was in comatose.
Kena had done a morning and bedside care to the patient by changing the
patient’s linens and washes the patient’s body with the use of a clean towel with
water. Also, suctioning was done to the patient to prevent aspiration. And lastly,
imparted health teachings to the patient’s significant others.
DAY 3
On September 20, 2007 10:00 am we had our first visit after our rotation
to our case study client and a follow-up visit at 4:30 in the afternoon. We first ask
the permission to her significant others if it’s ok for them that we will take Mrs.
Chavez as our patient for our case study. And when they approved it, we ask if
it’s ok to take pictures, then they permit us to it.
We then get her vital signs and asks her significant others of how was the
patient’s condition now. She was still in coma and had a tachypnea or labored
breathing that time. We also noticed that every time the patient breathes, there is
a presence of sputum.She also coughed during the assessment. Her daughter
then suctioned her in order to prevent aspiration to the patient. The family were
cooperative in giving informations.
DAY 4
The next day, September 21, 2007 after the examination around 5:30 in
the afternoon, we had our second visit after the rotation. The patient was still in
her room and the significant others haven’t decided yet her transfer to the ICU.
Necessary information was gathered to complete our data for the care study. We
noticed that the patient condition is not doing good and the need for her transfer
to ICU was badly needed.
The case study greatly helped our group to learn more about patient care
especially in the ward setting where patients confined present with different
conditions now that we are assigned in the ward. Our client for our case study
had Cerebrovascular Accident (THROMBOTIC).
During the days of our duty, we were able to learn about her condition
supported with the laboratory and diagnostic examinations done. We were able
to determine why the medications are prescribed through the drug study. The
doctor’s order also helped us to learn how conditions like these are managed in
actual versus what are presented as management in the medical books and
references.
The care study also inspired us to be efficient student nurses in our quest
for knowledge and skills necessary of a nurse. It is our honor to be able to care
for other people the way we cared ourselves and family members unrelated we
may be to them.
The quest for knowledge should not be limited to the confines of the four
corners of the classroom but also with the clinical exposures that we have and
that is why we nursing students are fortunate enough to learn and discover
“learning” in various ways. It is our initiative to study more and be prepared for
the future where skills and knowledge are greatly significant in patient care.
The group advised the patient’s significant others for strict compliance of
prescribed medications. After 4 days of nursing assessment and hospital care,
the proponents of this study were able to performed proper assessment of the
complication of the patient. During assessment, problems experienced by the
patient were identified and appropriate nursing interventions were designed to
address the needs of the patient. Nursing Care Plans were made; all of which are
implemented. Thus, the nursing interventions done were effective and were able
to alleviate the patient’s condition.
MEDICATION:
EXERCISE:
TREATMENT:
The family and/or SO were:
OUTPATIENT:
DIET:
XII. Prognosis
GOOD POOR
A. SEVERITY X
B. AGE X
C. MEDICATION COMPLIANCE X
D. FAMILY SUPPORT X
A.SEVERITY
As for the severity of the patient’s condition, we rated it poor since our patient
demonstrated no improvement regarding health status or health condition for the
past two days of assessment and nursing care. During our last visit, she was
already transferred to the Intensive Care Unit (ICU).
B. AGE
The patient is already 53 years old, she is relatively old and possesses a
poor immunity that may aid him to recover faster from his present condition.
Relative to this factor, we gave her a poor prognosis.
C. MEDICATION COMPLIANCE
The significant others poorly complied with the prescribed medications. The
patient took some of her medications via nasogastric tube (NGT) on time as
ordered by the physician. However, they were not able to buy all the medications
prescribed by the physician due to instability. This may be a poor indication of a
quicker recovery, we rated this prognosis as poor.
D. FAMILY SUPPORT
The patient’s family provides a strong support to him by caring the patient
and watching him by his bedside, making sure that he can be assisted as often
as necessary. Based on these observations, we gave the patient a good
prognosis.
OVERALL
Based on the criteria being rated. Our patient’s overall prognosis is poor with
a score of 1/4.
XIII. Bibliography
Black, Joyce M., MSN, RNC et al. Luckmann and Sorensen’s Medical
Surgical Nursing A Psychophysiologic Approach. Fourth Edition. W.B.
Saunder’s Company, 1993.
Comer, S, Delmar’s Critical Care: Nursing Care Plans. 2nd ed., 2005, Thomson
Delmar Learning, USA Pages : 115-119
Deglin, Judith H., Davi’s Drug Guide for Nurses, 9th Edition, 2005, F.A. Davis
Company.
Gulanick, et. al., Nursing Care Plans: Nursing Diagnosis and Intervention, 3rd
ed., 1994, Mosby, USA Pages: 211-213
Huether & McCance, Understanding Pathophysiology, 2nd edition, 2004,
Mosby, USA
Mosby’s Medical, Nursing, & Allied Health Dictionary, 6th edition, 2002, Mosby,
USA
Nettina, SM, The Lippincott Manual of Nursing Practice, 7th edition, 2001,
Lippincott Williams & Wilkins, Philadephia, USA Pages: 283-286
Sparks & Taylor, Nursing Diagnosis Reference Manual, 3rd edition, 1995,
Springhouse Corporation, Philadephia USA
http://www.emedicine.com/med/topic1776.htm
http://www.gicare.com/pated/ecdgs09.htm
http://www.mayoclinic.com/health/peptic-ulcer/DS00242/DSECTION=8
V. Pathophysiology
Definition: Stroke (or cerebrovascular accident or CVA) is the clinical designation for a rapidly developing loss of brain function
due to an interruption in the blood supply to all or part of the brain.
Cerebral Thrombosis
Predisposing Factor: Precipitating Factor:
Age(53) • Hypertension
Heridetary ( + Mother side) BP(150/100)
Atherosclerotic Process
Cerbral Atherosclerotic
Anaerobic Glycosis
Neurostransmital Communication:
Destruction: Aphaxia Perceptual Disturbances:
Weakness of Mouth Paralysis of symphathetic
of the upper motor in the and Throat:
Pyramidal Pathway nerves of the eyes.
(s&sx: Dysphagia)
(s&sx: Akinesia)
Loss of skills and
voluntary movement