A Case Study On Cerebrovascular Disease, Hemorrhagic

I.INTRODUCTION
Cerebrovascular disease is a group of brain dysfunctions related to disease of the blood vessels supplying the brain. Hypertension is the most important cause; it damages the blood vessel lining, endothelium, exposing the underlying collagen where platelets aggregate to initiate a repairing process which is not always complete and perfect. Sustained hypertension permanently changes the architecture of the blood vessels making them narrow, stiff, deformed, uneven and more vulnerable to fluctuations in blood pressure. A fall in blood pressure during sleep can then lead to a marked reduction in blood flow in the narrowed blood vessels causing hemorrhagic stroke in the morning. Conversely, a sudden rise in blood pressure due to excitation during the daytime can cause tearing of the blood vessels resulting in intracranial hemorrhage. Cerebrovascular disease primarily affects people who are elderly or have a history of diabetes, smoking, or ischemic heart disease. The results of cerebrovascular disease can include a stroke, or occasionally a hemorrhagic. Ischemia or other blood vessel dysfunctions can affect the person during a cerebrovascular accident. Hemorrhagic stroke is a condition that occurs mainly due to a rupture of a blood vessel in the brain. The blood vessel bursts and releases blood into the brain. Research shows that nearly 20 percent of the strokes that occur overall are hemorrhagic in nature. A systematic review of stroke incidence worldwide found that between 1970 and 2008, stroke incidence decreased 42% in high-income countries and increased more than 100% in low- to middle-income nations; between 2000 and 2008, the overall stroke incidence in low- to middle-income countries was 20% higher. (emedicine.com) Once the arteries rupture they are incapable of carrying blood and oxygen to the brain and it causes the cells to die. Another reason for hemorrhagic stroke is the blood that flows into the brain due to the rupture forms a clot inside the brain and damages the brain tissue. This could severely damage the brain functioning. A hemorrhagic stroke is the least common. However, it is more frequently fatal when compared to an ischemic stroke overall. Hemorrhagic stroke is of two types. Each one is named after the part of the brain that is affected by the bleeding. The subarachnoid hemorrhage is a condition that refers to the bleeding that takes place in the gap between the top of the brain and the skull. The most common cause of a subarachnoid hemorrhagic stroke is aneurysm. It is characterized by an abnormal

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A Case Study On Cerebrovascular Disease, Hemorrhagic

swelling of a blood vessel within the brain followed by rupturing of that swollen blood vessel. We chose this case because we think that patients having Cerebrovascular disease needs full attention as to prevention of complications, which we think is our primordial responsibility as student nurses. Our concern is not only on the physical aspect but also on the emotions and feelings of our patient having this disease condition who may not be able to do the usual activities they used to deal on brought about by the condition. Hence we wanted to widen our knowledge on how to take good care of these particular patients so that we will be able to provide quality care and satisfaction to our future patients having the same disease condition. General Objective: This case presentation seeks to enhance the students knowledge with regards to the patients general health and disease condition, its pathophysiology, possible complications, treatment plan and medical regimen. This also seeks to assimilate the students skills through application of several nursing interventions and medical management. Furthermore, this case presentation intends to improve the students attitude by conveying open-mindedness and utilizing therapeutic communication all throughout the activity.

Scope and Limitation: The scope of this study is within the context of the patient's condition based on the assessment of the patient's present health condition and other precipitating and predisposing factors that influenced the course of the disease, the anatomy and physiology of the involved body systems, pathophysiology of the condition, patients diagnosis and diagnostic exams, nursing and medical management, drug study, discharge plan, prognosis and recommendation of the case study. The data presented in this case was primarily obtained from student nurse- patient interaction as well as with the significant other who partly served as informant. Further information is based on the patients chart.

The case study is limited to the available resources during the making of this study such as book sources, internet sources, and patients chart, information coming from the family and as well the observation of the patients during the span of duty.
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A Case Study On Cerebrovascular Disease, Hemorrhagic

Furthermore, this case study will only show the changes of the patients condition from August 22, 2011 until August 24, 2011.

II.CLIENTS PROFILE This is a case of a 73 years old female Filipino, a resident of Poblacion 3, Villaneuva Misamis Oriental. Patient X was born on December 8, 1938. She is married and has 9 children all are in good health. Patient X was a high school graduate. She is a housewife. Patient X was admitted on August 20, 2011; 5:55pm at Capitol University Medical City Intensive Care Unit. A.VITAL SIGNS Upon assessment, the following data was obtained from Patient X: BP: 162/68mmHg, HR: 112 bpm, RR: 25 cpm, Temp.36.9c. Patient X weighs 40 kg and is 51 in height. B.CHIEF COMPLAINT Patient X has a chief complaint of altered level of consciousness. C. Family Health Illness History According to the significant others that the patient has known genetic disease that runs in the family which is hypertension. Patient is non-compliant with her medications. D.HISTORY OF PRESENT ILLNESS 2 days prior to admission patient had 2 episodes of LBM watery, non-mucoid, non-bloody stools associated with generalized body weakness. Sought consult at Tagoloan Polymedic General Hospital managed as a case of AGE however, noted change in sensorium, CT scan was done revealing acute hemorrhage involving the right frontal lobe extending to corpus callosum and partly to left side frontal lobe approximately 64ml, minimal subarachnoid hemorrhage. Started meds and referred for further management. With positive cough, masks yellowish phlegm. E.HISTORY OF PAST ILLNESS

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A Case Study On Cerebrovascular Disease, Hemorrhagic

According to the significant others the patient had several health conditions such as fever, common cough and cold but havent sought any medical consultation. F.STATEMENT OF THE PATIENTS GENERAL APPERANCE Patient X looked pale, weak, drowsy and responsive to verbal stimuli but seen to be inconsistent with her answers.

G. NUTRITIONAL AND METABOLIC PATTERN Pre-hospitalization: Patient X eats three times daily. She consumed 1/ 2 share of served food with good appetite. She drinks 8-10 glasses of water a day. During hospitalization: Patient X is in osteorized feeding of 166cc every 8am/12nn; 4pm/8pm; 12mn/4am. She was hooked to an Intravenous Fluid of IL PNSS regulated @ 20gtts/min infusing well on the left arm. H.ELIMINATION Pre hospitalization: Patient X defecates once a day, with yellowish to brownish stool and soft in consistency and no discomfort felt during defecation. She urinates three times daily with dark yellow colored urine in variable amount. During hospitalization: Patient X do not have a bowel movement for 2 days, she was inserted with Foley catheter attached to urobag draining with yellowish colored urine. I.ACTIVITY AND EXERCISE PATTERN Patient X doesnt any particular exercise regimen but she usually do brisk walking every morning at the seashore. ACTIVITIES OF DAILY LIVING Feeding 4 total dependence Bathing 4 total dependence DRESSING 4 total dependence Grooming 4 total dependence Meal preparation 4 total dependence Cleaning 4 total dependence Laundry 4 total dependence Toileting 4 total dependence Bed mobility 4 total dependence Chair/toilet transfer 4 total dependence Ambulation 4 total dependence R.O.M 2 assist with person
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A Case Study On Cerebrovascular Disease, Hemorrhagic

J.COGNITIVE AND PERCEPTUAL PATTERN Patient X speaks Cebuano and able to respond to some questions but she is inconsistent with her answers. K.SLEEP REST PATTERN Pre- hospitalization: Patient X sleeps 8 hours a day. During hospitalization: Patient X still sleeps 8 hours a day. L.SEXUALITY-REPRODUCTIVE PATTERN Patient X is already menopause since 60 years old. G9, P9 (9009) . PHYSICAL ASSESSMENT Together with medical history, the physical examination aids in determining the correct diagnoses and devising the treatment plan. This part of the study will present the normal and regressed health function of Patient X pointing out the salient, manifestations of the disease. I. Neurologic Assessment Drowsy Confused Calm Cooperative, responsive 12 (E-3;V-4;M-5)

Level of consciousness Orientation Emotional state Appropriate behavior Glassgow Coma Scale

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PHYSICAL ASSESSMENT
Component Head: August 21, 2011 Her head is normocephalic with symmetrical facial movements. Fontanels are closed. Hair is dry with normal/even distribution. Eyes: Scalp is clean. Eyelids are symmetrical. Conjunctiva is pale. Bilateral Pupil size is 2mm (constricted) with sluggish Ears: reaction to light. The external pinnae are normoset and there is no presence of any form of discharge from the external Nose: canal. There is no presence of alar flaring. Septum is midline, mucusa is pinkish and both Mouth: are patent. Her lips are pale in color and slightly dry and crack. Gums and mucosa are light pink in color. Tongue is located at midline. Has Pharynx: dentures. Uvula is midline. No presence of deviation and is pinkish in color. Tonsils are not inflamed nor the Neck: posterior pharynx. Trachea is midline, no deviations present and the Skin: thyroids are non-palpable. Skin is pale, senile turgor. Nails are convex in shape with a capillary refill > 4 seconds. Nail beds are Abdomen: pale in color. The general contour of her abdomen is flat. Abdominal skin is fair. Masses are not observed. Presence of superficial veins, striae. With symmetrical configuration and bowel sounds appear to

A Case Study On Cerebrovascular with Disease, Hemorrhagic symmetrical facial

movements. Fontanels are closed. Hair is dry with normal/even distribution. Scalp is clean. Eyelids are symmetrical. Conjunctiva is pale. Pupils size is 2mm with sluggish reaction to light. The external pinnae are normoset and there is no presence of any form of discharge from the external canal. There is no presence of alar flaring. Septum is midline, mucusa is pinkish and both are patent. Her lips are pale in color and slightly dry and crack. Gums and mucosa are light pink in color. Tongue is located at midline. Has dentures. Uvula is midline. No presence of deviation and is pinkish in color. Tonsils are not inflamed nor the posterior pharynx. Trachea is midline, no deviations present and the thyroids are non-palpable. Skin is pale, senile turgor. Nails are convex in shape with a capillary refill >4 seconds. Nail beds are pale in color. The general contour of her abdomen is flat. Abdominal skin is fair. Masses are not observed. Presence of superficial veins, striae.Page 6 With symmetrical configuration and bowel sounds appear to be

August 23, 2011 Her head is normocephalic

A Case Study On Cerebrovascular Disease, Hemorrhagic

Review of Systems EENT: [X] impaired vision [] blind [ ] pain [ ] reddened [] drainage [] gums [] hard of hearing [] deaf [] burning [] edema [] lesion [X] teeth Assess eyes, ears, nose, throat for abnormality [] No problem RESP: [] asymmetric [X] tachypnea [] apnea [x] crackles [ X ] cough [] barrel chest [] bradypnea [] shallow [] rhonchi [] sputum [] diminished [X] dyspnea [] orthopnea [] labored [] wheezing [] pain [] cyanotic Assess resp. rate, rhythm, depth, pattern, breath sounds, comfort [] no problem With IVF of 1L CARDIOVASCULAR: PNSS regulated @ [X] arrhythmia [X] tachycardia [] numbness 20 gtts/min [] diminished pulses [] edema [] fatigue infusing well at the [X] irregular [] bradycardia [] murmur left arm. [] tingling [] absent pulses [] pain Assess heart sounds, rate rhythm, pulse, blood Pressure, circ., fluid retention, comfort [] no problem GASTROINTESTINAL TRACT: [] obese [] distention [] mass [X] dysphagia [] rigidty [] pain Assess abdomen, bowel habits[X], swallowing, Bowel sounds[X], comfort [] no problem GENITO URINARY AND GYNE: [] pain [X] urine color(yellowish) [] vaginal bleeding [] hematuria [] discharge [] nocturia With O2 Assess urine freq., control, color, odor, inhalation Comfort / Gyn-bleeding, discharge regulated @ [ X ] No problem 3LPM; with Naso NEURO: Gastric tube in [] paresis [] stuporous [] unsteady [X] drowsy [] lethargic [] comatose [] vertigo [] tremors [X] confused [X] vision [] grip Assess motor function, sensation, LOC, strength Grip, gait[], coordination, orientation, speech [] no problem MUSCULOSKELETAL and SKIN: With foley catheter [] appliance [] stiffness [] itching [] petechie attached to urobag [] hot [] drainage [] prosthesis [] swelling darining well with [] lesion [] poor turgor [X] cool [] deformity yellowish colored [] wound [] rash [X] skin color [pallor] flushed
urine Page 7

A Case Study On Cerebrovascular Disease, Hemorrhagic

[] atrophy [] pain [] ecchymosis [] diaphoretic [] Moist [X] skin turgor Assess mobility, motion gait, alignment, joint function/ Skin color, texture, integrity [] no problem

Muscle Strength

3/5

3/5

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A Case Study On Cerebrovascular Disease, Hemorrhagic

DEVELOPMENTAL DATA
Erikson's psychosocial development Care: Generativity vs. Stagnation (Middle Adulthood, 45 to 65 years) Generativity is the concern of establishing and guiding the next generation. Sociallyvalued work and disciplines are expressions of generativity. Simply having or wanting children does not in and of itself achieve generativity. Patient X has fulfilled this stage of development for she was able to have a family of her own, has her own grand children and worked for the society. Freud psychosexual developmental theory Genital stage The fifth stage of psychosexual development is the genital stage that spans puberty and adult life, and thus occupies most of the life of a man and of a woman; its purpose is the psychologic detachment and independence from the parents. The genital stage affords the person the ability to confront and resolve his or her remaining psychosexual childhood conflicts. As in the phallic stage, the genital stage is centered upon the genitalia, but the sexuality is consensual and adult, rather than solitary and infantile. The psychological difference between the phallic and genital stages is that the ego is established in the latter; the persons concern shifts from primary-drive gratification (instinct) to applying secondary process-thinking to gratify desire symbolically and intellectually by means of friendships, a love relationship, family and adult responsibilities. Patient X belongs to this stage; he has this now what we call responsibility to fulfill for his family. Robert Havighurst (middle adulthood, 30-60 years old) The fifth stage of developmental task by Havighurst which composed of fulfilling civic & social responsibilities, maintenance of an economic standard of living, assist adolescent children to become responsible, happy adults, relate ones partner, adjust to physiological changes, adjust to aging parents. Patient X belong to this developmental task wherein she was able to fulfill, she was able to provide a living to his family as well
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as he is still adjusting to the physical changes he has having her husband as a partner in terms of adjusting to the condition she has now.

III.ANATOMY AND PHYSIOLOGY

The human nervous system consists of the central nervous system (CNS) and peripheral nervous system (PNS). The former consists of the brain and spinal cord, while the latter composes the nerves extending to and from the brain and spinal cord. The primary functions of the nervous system are to monitor, integrate (process) and respond to information inside and outside the body. The brain consists of soft, delicate, non-replaceable neural tissue. It is supported and protected by the surrounding skin, skull, meninges and cerebrospinal fluid. The CNS consists of the brain which serves many important functions. It gives meaning to things that happen in the world surrounding us. Through the five senses of sight, smell, hearing, touch and taste, the brain receives messages, often many at the same time. The brain controls thoughts, memory and speech, arm and leg movements, and the function of many organs within the body. It also determines how people respond to stressful situations (i.e. writing of an exam, loss of a job, birth of a child, illness, etc.) by regulating heart and breathing rates. The brain is an organized structure, divided into many components that serve specific and important functions. The weight of the brain changes from birth through adulthood. At birth, the average brain weighs about one pound, and grows to about two pounds during childhood. The average weight of an adult female brain is about 2.7 pounds, while the brain of an adult male weighs about three pounds and which is located in the dorsal body cavity. The brain is surrounded by the cranium; the brain is continuous with the spinal cord at the foramen magnum. In addition to bone, the CNS is surrounded by connective membranes, meninges, and tissue called by

cerebrospinal fluid. The brain is divided into the cerebrum, diencephalons, brain stem, and cerebellum.
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A Case Study On Cerebrovascular Disease, Hemorrhagic

Meninges
The meninges (Figure 23) are three connective tissue membranes enclosing the brain and the spinal cord. Their functions are to protect the CNS and blood vessels, enclose the venous sinuses, retain the cerebrospinal fluid, and form partitions within the skull. Theoutermost meninx is the dura mater, which encloses the arachnoid mater and the innermost pia mater.

Frontal Lobe
The frontal lobes are one of the four main lobes or regions of the cerebral cortex. They are positioned at the front most region of the cerebral cortex and are involved in movement, decision-making, problem solving, and planning. There are three main divisions of the frontal lobes. They are the prefrontal cortex, the premotor area and the motor area. The prefrontal cortex is responsible for personality expression and the planning of complex cognitive behaviors. The premotor and motor areas of the frontal lobes contain nerves that control the execution of voluntary muscle movement. Function: The frontal lobes are involved in several functions of the body including:

Motor Functions Higher Order Functions Planning

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Reasoning Judgement Impulse Control Memory

Corpus Callosum
The corpus callosum is a thick band of nerve fibers that divides the cerebrum into left and right hemispheres. It connects the left and right sides of the brain allowing for communication between both hemispheres. The corpus callosum transfers motor, sensory, and cognitive information between the brain hemispheres. Function: The corpus callosum is involved in several functions of the body including:

Communication Between Brain Hemispheres Eye Movement Maintaining the Balance of Arousal and Attention Tactile Localization

Location: Directionally, the corpus callosum is located underneath the cerebrum at the center of the brain.

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A Case Study On Cerebrovascular Disease, Hemorrhagic

IV. PATHOPHYSIOLOGY

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V. Diagnostic Procedure and Laboratory Result

REASON WHY DIAGNOSTIC and LABORATORY PROCEDURE WAS DONE Complete Blood Count A complete blood count (CBC), also known as full blood count (FBC) or full blood exam (FBE) or blood panel, is a test requested by a doctor or other medical professional that gives information about the cells in a patient's blood. A lab technician (diploma holder) or technologist (bachelor holder) performs the requested testing and provides the requesting Medical Professional with the results of the CBC. A CBC is also known as a "hemogram".

Blood Chemistry Test Blood Chemistry is needed to assess a wide range of conditions and the function of organs. It also a test to check electrolytes, the minerals that help keep the bodys fluid level in balance, and are necessary to help the muscles, heart, and other organs work properly. This also helps assess kidney function and blood sugar, and other substances in the blood.

Urinalysis A urinalysis is a group of manual and/or automated qualitative and semiquantitative tests performed on a urine sample. A routine urinalysis usually includes the following tests: color, transparency, specific gravity, pH, protein, glucose, ketones, blood, bilirubin, nitrite, urobilinogen, and leukocyte esterase. Some laboratories include a microscopic examination of urinary sediment with all routine urinalysis tests. If not, it is

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customary to perform the microscopic exam, if transparency, glucose, protein, blood, nitrite, or leukocyte esterase is abnormal.

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Hematology Report August 20, 2011

TEST

RESULT

UNIT

REFERENCE

INDICATION Determines any inflammation and infection.

INTERPRETATION Result is above normal range which indicates infection due to the presence of necrotic tissue. A normal number of RBC may indicate normal hemoglobin concentration in the blood.

WBC

12,800

10^3/L

5,000-10,000

Determines the oxygen carrying RBC 4.87 10^6/L 4.2-5.4 capacity of the blood.

Hemoglobin

14.3

g/dL

12.0-16.0

Usually done to a pt. with renal disease to determine if the kidneys ability to release erythropoietin factor is already affected Used to measure RBC number and volume. It is an integral part of the evaluation of anemic patients.

Result is within normal level, thus indicating enough oxygen carrying capacity of the blood.

Hematocrit

43.0

37.0-47.0

Result is within the normal range thus, normal hemoconcentration.

Differential Count Determines any chronic bacterial infection or viral infection. Determines any acute bacterial infection. Result is within normal level. Showing presence of infection

Lymphocyte

50.0

17.4-48.2

Neutrophil

81.2

43.4-76.2

Value is above normal range. This shows positive bacterial infection. Result is within normal range.

Basophils

1.5

0.0-2.0

Used to help evaluate allergic, blood, neoplastic and infections caused by parasites. To diagnose and/or monitor bleeding and clotting disorders.

Platelet

221,000

10^3/L

200-400

Result is within normal level.

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August 23, 2011

TEST

RESULT

UNIT 10^3/ L

REFERENCE

INDICATION Determines any inflammation and infection. Determines the

INTERPRETATION Increased and may indicate presence of infection. RBC is within normal level.

WBC

11,200

5.0-10.0

RBC

4.57

10^6/ L

4.2-5.4

oxygen carrying capacity of the blood. Usually done to a pt. with renal disease to determine if the kidneys ability to release erythropoietin factor is already affected Used to measure RBC number and volume. It is an integral part of the evaluation of anemic patients.

Hemoglobin

14.0

g/dL

12.0-16.0

Result is within the normal level, thus indicating enough oxygen carrying capacity of the blood

Result is within the normal range.

Hematocrit

44.1

37.0-47.0

Differential Count Determines any chronic bacterial infection or viral infection. Determines any acute bacterial infection. To determine any allergic reaction of the body. Used to help evaluate allergic, blood, neoplastic and infections caused by parasites. To diagnose and/or monitor bleeding and clotting disorders. Result is above normal level. Showing presence of infection Result is above normal. Indicating presence of bacterial infection. Result is within normal level. Result is above normal range which indicates presence of infections.

Lymphocyte

68.9

17.4-48.2

Monocyte

14.6

4.5-10.5

Eosinophils

1.5

1.0-3.0

Basophils

1.9

0.0-2.0

Platelet

320,000

10^3/ L

200-400

Result is within normal level.

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Clinical Chemistry August 8, 2011

Diagnostic/ Laboratory Procedure

Indication

Result

UNIT

Normal Values used by the hospital

Interpretation

Creatinine

This test was ordered in order to evaluate renal function.

0.59

mg/dL

0.59-1.21

Result is within the normal level indicating adequate renal function. The kidney can excrete nitrogenous waste product of protein leading to its accumulation in the blood.

Na+

To evaluate if sodium is properly excreted by the kidneys.

125.50

mmol/L

135-148

Result is below normal which means that sodium is excessively excreted by the kidneys.

K+

To evaluate if Potassium is properly excreted by the kidneys.

2.45

mEq/dl

3.5-5.3

Result is below normal, which indicates potassium is excessively excreted through the urine.

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BLOOD CHEMISTRY Test HDL Result 20.1 Unit mg/dL Reference 29-71

August 21, 2011 Interpretation

A decreased result may indicate altered transport of LDL to the liver causing high risk of developing cardiovascular disease. A high result may indicate risk for developing cardiovascular disease.

LDL

190

mg/dL

66-178

X-ray Report 2011 X-ray AP Hazed densities are seen in the right lower lung Heart is magnified in this view Aorta is tortuous and calcified Diaphragm and both costophrenia sulci are intact The rest of the visualized chest structures are unremarkable. Impression: Pneumonia, Right Lung CT scan Report

August 18,

Multiple sequential axial tomographic sections of the head from the skull base to the vertex which contrast reveals the following findings. Irregular in homogeneous hyperdense collection seen at the right frontal lobe with involvement of the corpus callosum genu extending partly into the left side frontal lobe. It measures around 5.0x4.5x5.3 cm with volume of approximately 64ml. there is surrounding edema with compression of the frontal horn of the lateral ventricles. Ventricles are mildly dilated. Minimal layering hyperdensities within the dependent portion of the lateral ventricles posterior horns demonstrating fluid level. Minimal subarachnoid hemorrhage seen. Patchy hypodensities involving both frontal parietal lateral periventricular white matter and subcortical white matter. Cerebellum and pons are intact. Included petromastoid and paranasal sinuses and orbits are intact.

Impression:
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Acute hemorrhage involving the right frontal lobe extending to corpus callosum

and partly to left side frontal lobe approximately 64ml, minimal subarachnoid hemorrhage.

VI. Nursing Care Plan

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Problem # 1 ASSESSMENT DATA Objective: Crackles noted upon auscultation at right lung. Non-productive cough noted with whitish sputum. RR: 25 cpm

NURSING DIAGNOSIS Ineffective airway clearance related to retained secretions on the bronchial airway secondary to pneumonia. GOALS AND OBJECTIVES At the end of 15 minutes of nursing care and intervention, patient will be able to: Maintain patent airway. Demonstrate absence /reduction of congestion with breath sounds clear and normal respiratory rate from 25cpm to 20 cpm. NURSING INTERVENTIONS Independent Place client in semi-fowlers position.

-To promote maximum lung expansion.

Change position of the client every 2 hours and as needed.

-To take advantage of gravity decreasing pressure on the diaphragm and

enhancing ventilation to different lung segments. Chest physiotherapy done.

- to mobilize bronchial secretion to larger airways.

Suction secretions as needed.

- to remove secretions in the bronchial airway to promote proper breathing.

Keep bedside clean and allergen free.

-to reduce irritant on airway.

Adjust activities within clients tolerance

- to avoid overexertion.
Dependent Administer Salbutamol 1 neb as prescribed.

-aids in reduction of bronchospam and mobilization of secretions.

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Collaborative Humidified with oxygen via nasal cannula at 3L/min.

-aid in mobilization of secretions.

EVALUATION Goals Met: Patient maintained patent airway and demonstrated reduction of congestion with breath sounds clear and normal respiratory rate of 20 cpm. Problem # 2 ASSESSMENT DATA Objective: Sick Sinus Syndrome (ECG result) Pallor Prolonged capillary refill (>4seconds) Increased Heart rate( 112 bpm) Elevated BP: 162/68mmHg NURSING DIAGNOSIS
Decrease cardiac output related to alterations in rate, rhythm and electrical

conduction of the heart as evidenced by ECG result. GOALS AND OBJECTIVES

Display hemodynamic stability with a normal heart rate from 122 bpm to 89 bpm

and a normal blood pressure from 162/68 mmHg to 120/70 mmHg.

Participate in activities that require decrease workload of the heart.

NURSING INTERVENTIONS Independent: Assess potential for/ type of developing shock states: hematogenic, septicimic, cardiogenic, vasogenic, and psychogenic

- to identify possible causative factors.

Monitored vital signs every hour

- to have baseline for comparison to follow trends and evaluate response to

interventions. Keep client on bed rest in positions of comfort.

- to decrease metabolic demand.

Provided good ventilation in the environment

- to prevent fatigue and good breathing pattern.

Dependent: Administer Amlodipine 25mg as prescribed

-to lower down blood pressure.

EVALUATION

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Goals Met: Patient displayed hemodynamic stability with a heart rate of 89bpm and a blood pressure of 120/80 mmHg.

Problem # 3 ASSESSMENT DATA Objective:

GCS= 12 (E-3;V-4;M-5) Constricted pupils, 2mm in size with sluggish reaction to light.

LOC: confused Orientation: drowsy NURSING DIAGNOSIS Ineffective cerebral tissue perfusion related to hemorrhage secondary to CVA. GOALS AND OBJECTIVES At the end of 8 hours of nursing interventions patient will be able to: Maintain usual/improved LOC, cognition and motor/sensory function. Demonstrate stable vital sign and absence of signs of increase ICP. Display no further deterioration /recurrence of deficits. NURSING INTERVENTIONS Independent: Assess neuro vital signs hourly.

- to closely monitor change in LOC.

Position with head elevated and in neutral position.

- to reduce arterial pressure by promoting venous drainage and may improve

cerebral circulation/perfusion. Maintain bed rest, provide quiet environment, provide rest periods between care activities, and limit duration of procedures.

-Continual stimulation/activity can increase ICP, absolute rest and quiet environment may be needed to prevent bleeding. Prevent straining at stool or holding breath. -Valsalva maneuver increases ICP potentiates risk for rebleeding.
Assess for nuchal rigidity, twitching, increase restlessness, irritability, onset of seizure activity.
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- Indicative of meningeal irritation, especially in hemorrhagic disorders. Seizures

may reflect increase ICP. Dependent: Administer peripheral vasodilators of Amlodipine 5mg.

- to protect brain by interrupting the destructive cascade of biochemical events.

Collaborative: Administer O2 inhalation via nasal cannula @ 3LPM.

- reduces hypoxemia which can cause cerebral vasodilation and increase

pressure/edema formation. EVALUATION: Goals met. Patient was able to maintain usual LOC, cognition and motor/sensory function, demonstrate stable vital sign and absence of signs of increase ICP and display no further deterioration. Problem # 4 ASSESSMENT DATA Objective: Impaired articulation, soft speech Inability to modulate speech Inability to comprehend spoken language, wernicks aphasia. NURSING DIAGNOSIS

Impaired verbal communication related to impaired cerebral circulation secondary to CVA. GOALS AND OBJECTIVES At the end of 8 hours of nursing intervention patient will be able to: Indicate an understanding of the communication problems. Established method in which needs can be expressed. INTERVENTIONS Independent: Provide alternative methods of communication NURSING

-provide for communication of needs/desire based on individual situation.

Anticipate and provide for clients needs.

-helpful in decreasing frustration when dependent on others and unable to

communicate desires. Talk directly to client, speaking slowly and distinctly. Use yes/no questions to begin with progressing in complexity as client responds.

-reduces confusion/anxiety to give time to process and respond on the information

given. Speak with normal volume of voice and avoid talking too fast. Give client ample of time to respond. Talk without pressuring for a response.

-Rising of voice may cause irritation or anger on the clients side.

Dependent: Administer Citicholine 1gm IVTT as prescribed.

-To enhance interneuronal function.

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EVALUATION: Goals not met: Patient wasnt able to indicate an understanding of the communication problems and established method of communication in which her need can be expressed.

Problem # 5

ASSESSMENT DATA Objective Limited range of motion Decrease muscle strength and control Generalized body weakness NURSING DIAGNOSIS Impaired physical mobility related to neuromuscular impairment secondary to cerebrovascular disease. GOALS AND OBJECTIVES At the end of 16 hours of nursing intervention patient will be able to : Long term: Maintain or increase strength and function of affected or compensatory body parts. Maintain skin integrity. Maintain optimal position of function AEB absence of contractures or foot drop. At the end of 4 hours of nursing intervention patient will be able to: Short term:
Perfom passive range of motion.

NURSING INTERVENTIONS Independent

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Assist client reposition client reposition self on regular schedule as dictated by individual situation

-to promote optimal level of functioning and prevent complications.

Schedule activities with adequate rest periods .Provide client with ample time to perform mobility related task.

-to reduce fatigue

Assisted patient in doing passive range of motion.

-to promote circulation and prevent contractures.

Encourage adequate intake of fluids/nutritious foods.

-promotes well-being and maximizes energy.

Dependent Consult with physical/ occupational therapist as indicated.

-to develop individual exercise/ mobility program and identify appropriate

adjunctive device. EVALUATION: Long term: Goals met: Patient maintained strength and function of affected and compensatory body parts, maintained skin integrity and maintained optimal position of function AEB absence of contractures or foot drop. Short term: Goals met: Participated in doing passive range motion. Problem # 6 ASSESSMENT DATA Objective Hypoactive bowel sounds 3clicks/min Decrease physical mobility 2 days of absent bowel movement Serum potassium level: 2.45 mEq/dl NURSING DIAGNOSIS Constipation related to insufficient physical mobility secondary to CVA. GOALS AND OBJECTIVES At the end of 16 hours of nursing intervention patient will be able to: Long term: Establish normal pattern of bowel functioning. Participate in bowel program as indicated. NURSING INTERVENTIONS Independent Auscultate abdomen for presence, location, characteristics of bowel sounds

-to determine bowel movements

Turn to sides every 2 hours

-to promote peristaltic movement

Placed patient into comfortable positions
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-to prevent fatigue

Perform passive range of motion

- to promote bowel functions.

Provide safety by assisting client during feeding by elevating head of the bed

-to prevent injury and aspiration.

Dependent Administer Senna concentrate 25mg as ordered.

-to promote bowel movement.

EVALUATION
Goals not met. Patient wasnt able to established normal pattern of bowel

functioning and participated in bowel program.

Problem # 7

ASSESSMENT DATA

Risk Factors Immobility Friction Senile skin turgor

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NURSING DIAGNOSIS Risk for Impaired skin integrity GOALS AND OBJECTIVES At the end of 16 hours of nursing intervention patient will be able to: Long term: Participate /demonstrate behavior/techniques to prevent skin breakdown such as regular change of bed position and passive range of motion. NURSING INTERVENTION Independent Change position in bed in a regular schedule such as turning to sides every 2 hours. Encourage participation with passive range of motion exercise

-To prevent skin breakdown

Massage bony prominences gently and avoid friction when moving client

-To improve circulation to the area and prevent skin breakdown

Keep bed clothes dry and keep bed free of wrinkles.

-To prevent vasoconstriction and shearing

Encourage /provide adequate nutritional/fluid intake

-to maintain general good health and skin turgor.

Provide information to client about the importance of regular observation and effective skin care in preventing problems

-to promote wellness.

EVALUATION
Goals met: Patient participated /demonstrated behavior/techniques to prevent

skin breakdown such as regular change of bed position and passive range of motion.

VII. DRUG STUDY

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Drug Order

Mechanism Of Action

Indication

Contraindication

Adverse Effects of the Drugs

Nursing Responsibility/Precautions

Generic name: amlodipine Brand name: Norvasc Classification: Calcium channel blockers Dosage: 25 mg Route: NGT Frequency : o.d

Inhibits the transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of subsequent contraction

Management of hype rtension

Hypersensitivity Blood pressure <90mmhg

CNS: headache, dizziness, fatigue CV: hypotension

Be alert for adverse reactions. Monitor vital signs closely especially the blood pressure. Monitor intake and output ratios and daily weight. Caution patient in changes in position slowly to prevent orthostatic hypotension.

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Drug Order Mechanism Of Action Indication Contraindication Adverse Effects of the Drugs Nursing Responsibility/Precautions

Generic name: levofloxacin Brand name: Levaquin Classification: anti-ineffective Dosage: 500mg Route: IV Frequency : o.d

Inhibit bacterial DNA synthesis by inhibiting DNA gyrase.

Treatment for Community acquired Pneumonia

Hypersensitivity

CNS: dizziness, headache,insomnia GI: diarrhea,nausea and abdominal pain

Be alert for adverse reaction Maintain a fluid intake of 1500-2000ml/day to prevent crystalluria. May cause dizziness and drowsiness, advise client avoid activities.

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Drug Order Mechanism Of Action Indication Contraindication Adverse Effects of the Drugs Nursing Responsibility/Precautions

Generic name: mannitol Brand name: Osmitrol Classification: Osmotic diuretic Dosage: 100 cc Route: IVTT Frequency : q6

Increase osmotic To reduce pressure of ICP glomerular filtrate, inhibiting reabsorption of water and electrolytes. This elevates blood osmolality, enhancing water and sodium to flow into extracellular fluid. Increase water excretion, decreases intracranial pressure.

hypersensitivity to the drug or any of its component, and those with anuria, severe pulmonary congestion, severe heart dehydration, metabolic edema, progressive renal disease or dysfunction

CNS: dizziness, headache,insomnia GI: diarrhea,nausea and abdominal pain

Assess patients condition before therapy and regularly thereafter to monitor the drug effectiveness. Be alert of adverse reaction and drug interaction. Monitor urine output.

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Drug Order Mechanism Of Action Indication Contraindication Adverse Effects of the Drugs Nursing Responsibility/Precautions

Generic name: potassium chloride Brand name: Kalium durule Classification: potassium supplement, mineral Dosage: 1tab Route: NGT Frequency : t.i.d.

Aids in transmitting nerve impulses, contracting cardiac and skeletal muscles, maintaining intracellular toxicity, cellular metabolism, acid-base balance and normal renal function

Use an electrolyte replenishes in the treatment of hypokalemia

Contraindicated with untreated Addison disease, adrenocotical insufficiency.

Flaccid paralysis, metal confusion, weakness, paresthasia of the limbs. Arrhythmias, cardiac arrest, ECG changes Abdominal pain, diarrhea, Nausea, vomiting

Be alert of adverse reaction and drug interactions. During therapy, monitor ECG, renal function, fluid intake and output, serum potassium level. Give potassium with or after meals with full glass of water for GI distress

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Drug Order Mechanism Of Action Indication Contraindication Adverse Effects of the Drugs Nursing Responsibility/Precautions

Generic name: Captopril Brand name: captopril Classification: Antihypertensives Dosage: 25 mg, 1 tab Route: P.O./NGT Frequency : q 6

Inhibits ACE,

preventing convertion of angiotensin I to angiotensin II, a potent vasoconstrictor. Reduced formation of angiotensin II decreases peripheral arterial resistance, thus decreasing aldosterone secretion. This reduces sodium and water retention and lowers blood pressure.

Hypertension

Use cautiously in patients with impaired renal functions or serious auto-immune disease (particularly systemic lupus erythematous) or in patients who have been exposed to other drugs known to affect WBC counts or immune response.

CNS: dizziness, fainting CV: tachycardia, hypotension, angina pectoris CHF: pericarditis. GI: anorexia, dysgeusia GU: proteinuria, nephritic syndrome, membranous glomerulopathy, renal failure.

Monitor the patients blood

pressure and pulse rate frequently.

Monitor the patients WBC

and differential counts before starting treatment, every 2 weeks for the first 3 months of therapy, and periodically thereafter.
Elderly patients may be

more sensitive to the drugs hypotensive effects.

Instruct patients to take

this medication 1 hour before meals, food in the GI may reduce absorption.

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Drug Order Mechanism Of Action Indication Contraindication Adverse Effects of the Drugs Nursing Responsibility/Precautions

Generic name: Citicholine Brand name: Somazine amp Classification: Neuroenhanccer Dosage: 1000 g Route: IVTT Frequency : q 12h

Citicoline is an

CVD in acute &

interneuronal communication enhancer. It increases the neurotransmissi on levels because it favors the synthesis and production speed of dopamine in the striatum, acting then as a dopaminergic agonist thru the inhibition of tyrosinehydroxylase.

recovery phase, symptoms & signs of cerebral insufficiency (dizziness, memory loss, poor concentration, disorientation, recent cranial trauma & their sequelae.)

Contraindicated in

patients with Parasympathetic hypertonia

GI: dyspepsia, Somazine must not be abdominal pain, administered along with nausea, constipation, medicaments containing diarrhea. meclophenoxate

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Drug Order Mechanism Of Action Indication Contraindication Adverse Effects of the Drugs Nursing Responsibility/Precautions

Generic name: Simvastatin Brand name: Lipex Classification: Antihyperlipidemic Dosage: 20 mg Route: NGT Frequency : hs

Inhibits HMG-CoA To reduce total reductase. This cholesterol and LDL enzymes is early levels in patients with (and rate-limiting) homozygous familial step in synthetic hypercholesterolemia pathway of cholesterol Lowers LDL and Total cholesterol level

Hypersensitive to the drug or any of its components

CNS: asthenia, headache GI: abdominal pain, constipation, diarrhea, flatulence, nausea Hepatic: hepatitis, cirrhosis Musculoskeletal: Myalgia

Obtain liver function test result before starting therapy. Be alert for adverse reaction and drug interaction. Assess patients dietary fat intake Assess patiens and familys knowledge Give drug with evening meal for enhanced effectiveness

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Drug Order Mechanism Of Action Indication Contraindication Adverse Effects of the Drugs Nursing Responsibility/Precautions

Generic name: Ipatropium bromide Brand name: Atrovent Classification: Bronchodilator Dosage: 1 neb Route: inhalation Frequency : q 8h

Inhibits vagally mediated reflexes by antagonizing acetylcholine Relieves bronchospasms and symptoms of seasonal allergic rhinitis

Bronchospasm

Hypersensitive to CNS: dizziness, the drug or any of headache, nervousness its components CV: chest pain, palpitations EENT: blurred vision, burning eyes, epistaxis GI: constipation, dry mouth, GI distress, nausea Respiratory: bronchitis, cough, upper respiratory tract infection Skin: rash

Be alert for adverse reaction and drug interaction Assess patients and familys knowledge Give drug on time to ensure maximal effect

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VIII. DISCHARGE PLAN
MEDICATIONS Explain to the patient and family members the importance of taking medicines. Discuss to the patient and family the dosage, frequency, and adverse effects of the drugs. The patient will be able to take medications as what had been prescribed by the physician religiously and be able to follow directions as instructed by the nurse. ECONOMIC STATUS Explain to significant others that the rehabilitation may be prolonged to be able for the family to prepare financial needs. Have occupational therapist to help re- learn everyday activities or ADL. Inform the patient to avail to some government programs such as philhealth.

TREATMENT Physical Therapy Rehabilitation can be explained as the planned withdrawal of support in order to enable the patient to become as independent as possible. This is achieved by an interdisciplinary team of professionals, one member of which is the physical therapist. Physical therapists work with patients to help them regain motor control, strength, physical conditioning, and mobility and to help them return to independent living. Occupational Therapy Occupational therapists specialize in retraining patients to perform activities of daily living. They teach and develop strategies for the patient and rehabilitation team to enhance patient success in independence. This may include the use of adaptive equipment or compensatory strategies or the redevelopment of skills that were lost because of motor function, perception, and cognitive deficits. HEALTH TEACHINGS Inform client and instruct Deep Breathing Exercise to promote mobilization of secretion. Safety precaution should be maintained to prevent injury. Encouraged in active range of motion exercises to promote circulation. Importance of proper hygiene for comfort and decrease susceptibility to infection. Adjustment of activities to avoid over exertion and fatigue, allow rest periods.
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OUT-PATIENT DIET Eat five or more servings of vegetables and fruit daily. Increase bulk in the diet to allow defecation. Intake of fluids 8-10 glasses a day to avoid constipation and to maintain skin turgor. Instruct patient to eat low sodium intake with zero transatrated fat that will help the preventing the worsening of her condition as ordered by the physician. The patient could avail her medication from government hospitals in which she could get some benefits. She will also be able to avail the services offered by the barangay health center and and at the Botikang barangay. Instruct patient to seek regular medical check-up

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IX.PROGNOSIS The outcome varies with the extent of disease and brain damage at the time of treatment and other chronic underlying medical complications. The individual who was healthy and had no neurologic symptoms before suffering a mild stroke may completely recover and lead a normal life after following the prescribed treatment. The individual who has suffered a massive stroke may be permanently paralyzed on one side of the body and no longer be able to speak. The individual who has suffered more than one stroke may be completely paralyzed and may have his or her life shortened considerably. Recovery of any movement may be very limited. If carotid endarterectomy is performed, the individual may avoid a stroke. Recovery from this surgery should be complete within 6 weeks, and the individual may be able to return to his or her normal activities, including work. Disability affects 75% of stroke survivors enough to decrease their employability. 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), and 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. 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. 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. Patient X still has not loss her ability to speak although patient didnt recognize her condition and was unaware of it. As a family provider patient may suffer an emotional problems. In General Patient X still has not manifested the worst course of the disease process, hence patient X may still be classified as having good prognosis.

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X.LEARNING EXPERIENCE

Our experiences speak of what we have learned. It had improved us as an individual. Likewise just as we are unique, we also have unique experiences individually. Having our duty at CUMC ICU is quite a great experience for us. We've encountered different people and learn to deal with them, to attend to their different needs and most especially to the emotions that they have. We've learned to be more passionate in the profession that we have chosen, Weve learned to be patient in dealing towards our patients especially with the kind of conditions that they have. To manage our time effectively and to work efficiently with the help of everyone (our group mates) and most especially the guidance of our C.I. Weve learned to be more helpful towards our group mates, to be respectful to everyone and to be more careful in everything that we do. It was quite frustrating because we only had 3 days of duty in the ICU, we were expecting more challenges from the area in this rotation but because of some instances we have to accept the fact that we will not totally experience everything what the area (ICU) could offer. Hence in this point, we will never be as effective as we are right now if without our ever loving C.I Mr. Dennis Medalle who had helped us in becoming one of the effective and efficient future nurses. For being a great disciplinarian and for being understanding, bound with skills and knowledge and the heart to teach. For being a role model of how an ideal nurse should be. Attending all our questions and enhancing our skills in the care of these clients. To the members of group 3 for being very helpful and very jolly to be with, there is a lot of learning from each of you, for the mistakes that we have committed and for the remarkable things they have done for their patients. Theyve been so cooperative and are always willing to help.

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XI.REFERENCE Books Black,Joyce(2010).Medical Surgical Nursing Deglin,Judith(2010).Drug guide for nurses Doenges, Marilyn (2004).Nurses Pocket Guide Moorehouse, Mary Frances (2004). Nurses Pocket Guide Internet Sources http://emedicine.com http://wikipedia.com http://www.google.com http://www.righthealth.com http://www.yahoo.com

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