INTRODUCTION

This is the case of patient R.G.E., a 47 year-old, female, married, an Iglesia Philadelphia, born on
July 22, 1971, and currently residing at 22 Sunnyside Tacay P1 Fairview, Baguio City, Benguet.
She was admitted last September 25, 2018, for the 4th time.

Ischemic stroke occurs when an artery to the brain is blocked. The brain depends on its arteries
to bring fresh blood from the heart and lungs. The blood carries oxygen and nutrients to the
brain, and takes away carbon dioxide and cellular waste. If an artery is blocked, the brain cells
(neurons) cannot make enough energy and will eventually stop working. If the artery remains
blocked for more than a few minutes, the brain cells may die. This is why immediate medical
treatment is critical.

PHYSICAL ASSESSMENT

GENERAL APPEARANCE
Patient R.G.E. is medium build, weight was not taken. She is 5’1 tall. She has light
brown complexion with dry and intact skin. She has a black hair. She has complete teeth. She is
neat in appearance. With claims of nape pain and generalized weakness and numbness especially
on the right side part of the body.

VITAL SIGNS
Initial vital signs are as follows: BP: 130/80 mmHg, CR: 93 bpm, RR: 19 cpm, T:
36.7 C, and spO2: 99%

INTEGUMENTARY
Skin is dry and warm to touch. Has good skin turgor. No any signs of pallor,
cyanosis, and jaundice. No skin rashes and sores noted. With pinkish lips and conjunctiva.

CARDIOVASCULAR
Patient has strong and normal palpable pulse of 93 bpm; regular in rhythm. No
murmurs upon auscultation. No edema and cyanosis. No complains of easy fatigability and chest
heaviness. With 1-2 seconds capillary refill.

RESPIRATORY
Patient is breathing spontaneously to room air and has symmetrical rise and fall of
the chest. No retractions and presence of cough noted. Resonant sound heard upon percussion.
No adventitious breath sounds was heard upon auscultation.

ABDOMEN
Flat, non-tender, non-distended, with normoactive bowel sounds, tympanic sound
heard upon percussion, no complains of pain upon palpation, and no any palpable mass noted.

GASTROINTESTINAL TRACT
With claims of nausea and episodes of vomiting, no claims of feeling of bloatedness.
With good appetite. No diarrhea and constipation.

GENITOURINARY
Patient is voiding freely; no dysuria and hematuria, and has voided to a straw-
colored urine.
 HEENT
Head: Symmetrical, no lesions, and no palpable mass
Eyes: With pink palpebral conjunctiva and anicteric sclera. Eyebrows are
symmetrically aligned and eyes are proportional to the face with no abnormal discharge. Both
pupils are responsive to light and accommodation, shape is vertically elongated.
Ears: Symmetrical and non-tender. No unusual discharges noted.
Nose and sinuses: Symmetrical and non-tender. No deviation and nasal discharges.
Mouth and throat: With pinkish and moist lips. No any mouth sores, lesions, and
bleeding gums noted. Not wearing dentures. No difficulty of swallowing. No difficulty speaking
noted.
MUSCULOSKELETAL
Patient need assistance in performing ADL’s. With claims of generalized weakness
and numbness especially on the right side of the body. With muscle strength of 3/5, 2/5. With
limited range of motion in lower extremities. 3/5, 2/5

NEUROLOGICAL
Patient’s memory is intact, conscious and has coherent, spontaneous speaking
ability. Patient is oriented to person, time, and place. She is responsive to verbal and non-verbal
stimuli. Patient was cooperative and responsive during the entire assessment.

ENDOCRINE
Patient does not experience flushing upon assessment. She does not have polydipsia,
polyphagia, and polyuria.

CHIEF COMPLAINT: Nape pain and weakness

History of Present Illness

4 days PTA, patient experienced headache rated as 8/10 located at frontal area
radiating to the occipital area, characterized as squeezing, aggravated by movement and
alleviated by rest. 1 day PTA, patient experienced right sided weakness with limited movement
associated with nausea and vomiting. She experienced difficulty in walking. Consultation done
in a private hospital, was given unrecalled pain reliever, Eperisone 50 mg/tab, and Eterecoxib
120 mg/tab as her home medications. With claims of relief. Few hours PTA, patient was not able
to move her both legs, persistence of the condition prompted the patient to seek consultation in
this institution, hence admission.

Past Medical History

Year 2011, patient was admitted and diagnosed with hypertension and had 2
incidents of cerebrovascular disease on the same year. Year 2018, she was again admitted due to
CVD. Patient is has a maintenance medication of Flunarizine, Cardiosel, and Arbloc; compliant.
No allergies to foods and drugs.

Family History

With family history of hypertension on both mother and father’s side. And asthma
and heart disease on father’s side.

Social and Environmental History

 Patient is currently unemployed; housewife. She is non-smoker and non-alcoholic
beverage drinker. She is living with her husband and children in a well ventilated concrete house.
Their drinking water is from a water refilling station. Their garbage is being collected weekly;
segregating. Not exposed to any toxic substances. Knows infection control like handwashing.
Knows proper preparation of foods.

Diagnostic examinations relevant to the case of the patient

Diagnostic/ Normal Values: Patient’s Relevance to Nursing Medical

Laboratory Value: Care:
Tests:
Glucose 74.06-106.14 mg/dl 128.66 mg/dl Hyperglycaemia is common among
patients with ischemic stroke, and
may be due to the physiological
stress of the stroke event. CBG
monitoring gives as a regular
feedback for the patient. CBG is
very important to monitor because
hyperglycemia is believed to
aggravate cerebral ischemia.
Cholesterol 0-200 mg/dl 203 mg/dl High cholesterol may increase the
risk for heart disease. Plaque build-
up in the arteries from high levels
of cholesterol also can block blood
flow to the brain and cause a stroke.
Because cholesterol does not
dissolve in the blood on its own, it
must be delivered to and from cells
by particles called lipoproteins. It is
very important to monitor to give a
necessary intervention to prevent
further complication.
LDL 100-129 mg/dl 133 mg/dl LDL cholesterol is often referred to as
“bad” cholesterol. This type of
cholesterol can cause plaque build-up,
a thick, hard substance that can clog
arteries. In time the plaque can in
time cause a narrowing of the arteries
or block them completely, causing a
heart attack. Monitoring LDL is very
important in order for us to report
elevation of LDL to the physician and
to administer medications that
prescribed to the patient.
HDL 45-65 mg/dl 63 mg/dl HDL carries cholesterol away from the
tissues to the liver, where it is filtered
out of the body. High levels of HDL,
also called “good” cholesterol, seem
 to protect against stroke and heart
attack. A

PATHOPHYSIOLOGY:
PRIORITIZATION:

Nursing Diagnosis Actual/ Explanation

Potential/Risk
Ineffective Cerebral Actual This is prioritized as number one since it affects
Tissue Perfusion r/t: the optimum level of the body because of its
Interruption of blood cellular dysfunction. The patient obtained
flow ischemic stroke where in the arteries of the brain
became narrowed/blocked, causing severely
reduced blood flow, damaging cells and tissue in
the brain affecting the tissue perfusion.
Insufficient blood flow leads to decreased
nutrient and oxygenation at cellular level.
Decreased perfusion is detrimental to the health
of the patient and may cause destructive effects.
 Chronic deprivation of nutrient and oxygenation
from decreased perfusion may damage other body
organs and may lead to death
Impaired Physical Actual
Mobility r/t:
Neuromuscular
Impairment
Impaired Comfort Potential
Self-Care Deficit Potential
Risk for Constipation Risk