Liceo de Cagayan University

R.N Pelaez Blvd. Carmen, Cagayan de Oro City

College of Nursing

Submitted by:
Kenneth Joy S. Egona
NCM501204

Submitted to:
Mr. Leonard U. Solima
Clinical Instructor

August 2009

1
TABLE OF CONTENTS

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

II. Health History

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

III. Developmental Data

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

V. Pathophysiology with Anatomy and Physiology

VI. Nursing Assessment (System Review & Nursing Assessment
II)
VII. Nursing Management
a. Ideal Nursing Management (NCP)
b. Actual Nursing Management (SOAPIE)

VIII. Referrals and Follow-up

IX. Evaluation and Implications
X. Bibliography

2
I. INTRODUCTION
In our field of study it is very important for us to be exposed to
different kinds of situations and cases, which can help us gain more
knowledge and is essential for us to be more effective in giving care towards
our patients.

A. Overview of the Case

B. Objective of the Study

The main reason and purpose why, I, as future nurse will conduct a study
and exposure in the intensive care unit is for me to be able to identify the
problems encountered by my patient. As a health care provider, it is indeed
my vocation to adjoined hands with the health care team for the promotion
of wellness of our clients.
My main goals for this study are the following:
• To establish rapport
• To identify chief complaints of clients to give its specific interventions
• To determine the family and personal history of the client that many
affect clients present condition
• To identify the cause and effect the main problem through the correct
analysis of the pathophysiology of the case
• To determine the medical management given through identifying
doctor’s order and its rationale
• To make nursing care plans for the different health problems
encountered by the client
• To evaluate the effectiveness of the actual nursing care plan that was
established

3
 • To give referrals and follow-up for the health promotion of the client

C. Scope and Limitation of the Study

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

II. HEALTH HISTORY

A. Profile of the Patient
Name: Mr. Panerio, Alijo Nacilla
Age: 74 years old
Sex: Male
Birth date: July 17, 1935
Religion: Roman Catholic
Civil Status: Married
Nationality: Filipino
Address: Zone-6 Baluarte, Tagoloan, Misamis Oriental
Occupation: Former Farmer
Date of Admission: October 19, 2009

4
Time of Admission: 10:00 pm
Admitting Diagnosis: AGE, with Severe Dehydration
A P: Dr. Karen G. Gonzales MD
Vital Signs Assessment
Temperature: 36.7c
Heart Rate: 68 bpm
Respiratory Rate: 18 cpm
Blood Pressure: 60/40 mmhg
Height: 5 ft. and 4 inches
Weight: 45 kgs.
Allergy: No known food and drug allergy

B. Family History and Personal Health History

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

5
 Patient was admitted to the said hospital last October 19, 2009 at 10:0
pm, his chief complaint prior to admission was LBM associated with
moderate fever.

III. DEVELOPMENTAL TASK

A. Erik Erikson’s Stages of Psychosocial Development Theory

Erikson describes eight developmental stages through which a healthily

developing human should pass from infancy to late adulthood. In each stage
the person confronts, and hopefully masters, new challenges. Each stage
builds on the successful completion of earlier stages. The challenges of
stages not successfully completed may be expected to reappear as problems
in the future. Each of Erikson's stages of psychosocial development are
marked by a conflict, for which successful resolution will result in a favorable
outcome and by an important event that this conflict resolves itself around.

In the Eriksons 8th stage of psychosocial Development theory which is

Senior: Integrity vs. Despair (65 years onwards). Integrity means moral
soundness, whole or completeness of a person, Despair means being
hopeless. When it comes to my patient he was loosing hope that his illness
will be cure, it is because he feels that he was really old and he don’t have
the capabilities of living the way it should be. But still, because of the
support of the family little by little he was trying to understand his situation
tried to think on positive side and for himr to live longer for his family that
still need him as a father, as a grandfather and as a husband.

B. Sigmund Freud’s Psychosexual Development Theory

According to Freud, people enter the world as unbridled pleasure

seekers. Specifically, people seek pleasure through from a series of
erogenous zones. These erogenous zones are only part of the story, as the

6
social relations learned when focused on each of the zones are also
important. Freud's theory of development has 2 primary ideas: One,
everything you become is determined by your first few years - indeed, the
adult is exclusively determined by the child's experiences, because whatever
actions occur in adulthood are based on a blueprint laid down in the earliest
years of life (childhood solutions to problems are perpetuated) Two, the story
of development is the story of how to handle anti-social impulses in socially
acceptable ways.

My patient belongs to the genital stage which begins at puberty

involves the development of the genitals, and libido begins to be used in its
sexual role. However, those feelings for the opposite sex are a source of
anxiety, because they are reminders of the feelings for the parents and the
trauma that resulted from all that.

C. Robert J. Havighurst’s Developmental Task Theory

Havighurst categorized the tasks, in first category are the tasks, which
has to be completed in certain period, and the second are the tasks that
continue for a long, sometimes for a lifetime.
So what happens if the task is not completed in that stage or
completed in a later date? Havighurst reply to that it is critical that the tasks
should be completed during the appropriate stage, otherwise result will be
the failure to achieve success in future tasks.

D. Jean Piaget’s Theory of Development

According to Piaget, development is driven by the process of
equilibration. Equilibration encompasses assimilation (i.e., people transform
incoming information so that it fits within their existing schemes or thought
patterns) and accommodation (i.e., people adapt their schemes to include
incoming information).

7
 My patient belongs to the formal operational stage. In this stage,
individuals move beyond concrete experiences and begin to think abstractly,
reason logically and draw conclusions from the information available, as well
as apply all these processes to hypothetical situations. The abstract quality
of the adolescent's thought at the formal operational level is evident in the
adolescent's verbal problem solving ability. The logical quality of the
adolescent's thought is when children are more likely to solve problems in a
trial-and-error fashion. Adolescents begin to think more as a scientist thinks,
devising plans to solve problems and systematically testing solutions. They
use hypothetical-deductive reasoning, which means that they develop
hypotheses or best guesses, and systematically deduce, or conclude, which
is the best path to follow in solving the problem.

IV. MEDICAL MANAGEMENT

• Doctor’s Order
DATE DOCTOR’S ORDER RATIONALE
October 19, 2009
4:10pm  Please admit to P1F2/A3T2
(ICCU)
BP: 80/60  Please secure conset to
HR:86\ care\
RR:20  DWI-AGE with severe
T:38C dehydration
 DAT\
 V/S Q4 reffer the FF: ➢ For proper
-BP >140/90 or admission and
90/60mmHg treatment
-HR >110 OR < 60BPM
-RR >30 OR < 12 ➢ To closely
monitor
patients’ vital
 Intake and output every signs
shift

 Labs: CBC with creatinine,

K,BUN, U/A, Chest xray, ➢ To know avoid

8
 ECG 12 leads + LII complications
 Start colysis PLR 1L Fd and to observe
now\ any problems
 IVF to follow PNSS 1L @
60gtts/min
 MEDICATIONS: ➢ To hydrate the
-Metronidazole, 500mg patient and to
IVTT q 8hours replace the
-Ciprofloxacin 200mg fluid and
every 12hours\ electrolyte
4:10pm -Paracertamol 500mg imbalances
Awake, coherent, 1TAB Q4
BM X 4 -Omeprazole 40mg cap ➢ To know any
BP 70/60 OD complications
and for and for
August 20,2009  Please chart frequency, examination
character, color, volume purposes
of stool and please record
in separate sheet.
 Refer if with sign of SOB,
chest pain, change of and
unsualities.

 IVF PLR 1L @ 30GTTS/MIN

To 80 gtts/min\
 Increase IVF

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

 Meds:

9
 ○ coversyl 5mg/80 I
tab OD/ngt
○ Dilantin 100g/cap

 iii caps q8h x 3doses/NGT

○ Omeprazole 40mg
1:45pm IVTT OD

 FBC attached to urobag in

placed – bloody urine
 I&O q shift
 Maintain head part @30-
40 degree
 Standby intubation set
 Monitor neurovitalsigns
q2h
 Pls inform AP once
admitted
July 10, 2009  Discussed plan w/ pt.
8:00am ○ transport to cebu
○ cerebral angio-
graphy
○ Possible coiling/
○ clipping of
○ aneurysm

 Pt seen and examined

-(+) HPN > 5yrs. w/ good
compliance of medication
to atenolol
- (-DM), (-) BA

 Oral care w/ bactidol

10:00am  IVF TF PNSS rate
20gtts/min
 Turn side to side q2h
 chest physiotherapy

 Nimodipine drip @ 5cc/hr

(Nimodipine 4 vials via
infusion pump)

10
  For chest x-ray
11:32am
 For UA

 Paracetamol I amp IVTT

now

2:40pm  Start nicardipine drip

10mg in 100ml D5W
solution in solution set
start at 20gtts/min
July 11, 2009
10:00am  Give captopril 50mg q6h
for SBp ≥ 140mmhg

1:20pm  Please do chest tapping q

after nebulization

5:50 pm  To consume nicardipine

drip

9:40pm  Same IVF to follow; PNSS

@ 15gtts/min

 May resume nicardipine

drip @ 10cc/hr, titrate q
15mins to keep SBp @
130-140mmhg

July 12, 2009  Hold vasalat

9:10am

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

11
 • Laboratory Results

Date Diagnostic Result Normal Interpretati

Ordered Exam Values on
Complete Blood Count
7/8/09 WBC 8,100 5,000- Normal
10,000/mm³
RBC 4.80 4.20-5.40mil Normal
Hemoglobin 14.4 12.0-16.0 g/dl Normal
Hematocrit 43.8 37.0-47.0% Normal
Platelet 233,000 174,000 – Normal
340,000
Differential Blood Count
Neutrophils 44 43.4-76.7% Normal
Lymphocytes 43 17.4-46.2% Normal
Monocytes 08 4.5-10.5% Normal
Eosinophils 05 0-2% %
Urinalysis
7/8/09 Color: Bloody
ph 6.5
Transparency: Hazy
Sugar Negative
Albumin Negative
Pus: +(0-21hpf)
RBC To numerous to count

12
 Epithelial Cells; Rare
Mucous Threads: Rare

• Drug study

Generic Name Dexamethasone

of ordered drug
Brand Name
Date Ordered
Classification Corticosteroid
Glucocorticoid
Hormone

Dose/Frequenc
y/Route
Mechanism of Enters target cells and binds to specific receptors, initiating many
complex reactions that are responsible for its anti-inflammatory and
Action immunosuppressive effects.

Specific Trichinosis with neurologic or myocardial involvement

Indication
Contraindicatio Contraindications and cautions
• Contraindicated with infections, especially tuberculosis, fungal
n infections, amebiasis, vaccinia and varicella, and antibiotic-
resistant infections, allergy to any component of the preparation
used.
• Use cautiously with renal or hepatic disease; hypothyroidism,
ulcerative colitis with impending perforation; diverticulitis;
active or latent peptic ulcer; inflammatory bowel disease; CHF,
hypertension, thromboembolic disorders; osteoporosis; seizure
disorders; diabetes mellitus; lactation.

Side • CNS: Seizures, vertigo, headaches, pseudotumor cerebri,

euphoria, insomnia, mood swings, depression, psychosis,
Effects/Toxic intracerebral hemorrhage, reversible cerebral atrophy in infants,

13
Effects cataracts, increased IOP, glaucoma
• CV: Hypertension, CHF, necrotizing angiitis
• Endocrine: Growth retardation, decreased carbohydrate
tolerance, diabetes mellitus, cushingoid state, secondary
adrenocortical and pituitary unresponsiveness
• GI: Peptic or esophageal ulcer, pancreatitis, abdominal
distention
• GU: Amenorrhea, irregular menses
• Hematologic: Fluid and electrolyte disturbances, negative
nitrogen balance, increased blood sugar, glycosuria, increased
serum cholesterol, decreased serum T3 and T4 levels
• Hypersensitivity: Anaphylactoid or hypersensitivity reactions
• Musculoskeletal: Muscle weakness, steroid myopathy, loss of
muscle mass, osteoporosis, spontaneous fractures
• Other: Impaired wound healing; petechiae; ecchymoses;
increased sweating; thin and fragile skin; acne;
immunosuppression and masking of signs of infection; activation
of latent infections, including TB, fungal, and viral eye
infections; pneumonia; abscess; septic infection; GI and GU
infections
Intra-articular
• Musculoskeletal: Osteonecrosis, tendon rupture, infection
Intralesional therapy
• CNS: Blindness (when used on face and head—rare)
Respiratory inhalant
• Endocrine: Suppression of HPA function due to systemic
absorption
• Respiratory: Oral, laryngeal, pharyngeal irritation
• Other: Fungal infections

Nursing • History for systemic administration: Active infections; renal

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

14
Generic Name of Chlonidine Hydrchloride
ordered drug

Brand Name Catapres

Date Ordered
Classification Antihypertensive
Sympatholytic (centrally acting)
Central analgesic
Dose/Frequency/R
oute
Mechanism of Stimulates CNS alpha2-adrenergic receptors, inhibits sympathetic
cardioaccelerator and vasoconstrictor centers, and decreases
Action sympathetic outflow from the CNS.

Specific Indication • Hypertension, used alone or as part of combination therapy

• Treatment of severe pain in cancer patients in combination
with opiates; epidural more effective with neuropathic pain
(Duraclon)

Contraindication • Contraindicated with hypersensitivity to clonidine or any

adhesive layer components of the transdermal system.
• Use cautiously with severe coronary insufficiency, recent
MI, cerebrovascular disease; chronic renal failure;
pregnancy, lactation.

Side Effects/Toxic Adverse effects

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

15
 • GI: Dry mouth, constipation, anorexia, malaise, nausea,
vomiting, parotid pain, parotitis, mild transient
abnormalities in LFTs
• GU: Impotence, decreased sexual activity, diminished
libido, nocturia, difficulty in micturition, urinary retention
• Other: Weight gain, transient elevation of blood glucose or
serum creatine phosphokinase, gynecomastia, weakness,
muscle or joint pain, cramps of the lower limbs, dryness of
the nasal mucosa, fever

Nursing Precaution Name confusion has been reported between clonidine

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

Generic Name of amlodipine besylate

ordered drug

Brand Name Norvasc

Date Ordered
Classification Calcium channel-blocker
Antianginal drug
Antihypertensive
Dose/Frequency/R
oute
Mechanism of Inhibits the movement of calcium ions across the membranes of
cardiac and arterial muscle cells; inhibits transmembrane calcium
Action flow, which results in the depression of impulse formation in
specialized cardiac pacemaker cells, slowing of the velocity of

16
 conduction of the cardiac impulse, depression of myocardial
contractility, and dilation of coronary arteries and arterioles and
peripheral arterioles; these effects lead to decreased cardiac work,
decreased cardiac oxygen consumption, and in patients with
vasospastic (Prinzmetal's) angina, increased delivery of oxygen to
cardiac cells.

Specific Indication • Angina pectoris due to coronary artery spasm (Prinzmetal's

variant angina)
• Chronic stable angina, alone or in combination with other
drugs
• Essential hypertension, alone or in combination with other
antihypertensives

Contraindication • Contraindicated with allergy to amlodipine, impaired

hepatic or renal function, sick sinus syndrome, heart block
(second or third degree), lactation.
• Use cautiously with CHF, pregnancy.

Side Effects/Toxic
Effects
Nursing Precaution

Generic Name of
phenytoin (diphenylhydantoin, phenytoin sodium)
ordered drug

Brand Name Dilantin

Date Ordered
Classification Antiepileptic
Antiarrhythmic, group 1b
Hydantoin

Dose/Frequency/R
oute
Mechanism of Has antiepileptic activity without causing general CNS depression;
stabilizes neuronal membranes and prevents hyperexcitability
Action caused by excessive stimulation; limits the spread of seizure

17
 activity from an active focus; also effective in treating cardiac
arrhythmias, especially those induced by digitalis; antiarrhythmic
properties are very similar to those of lidocaine; both are class IB
antiarrhythmics.

Specific Indication • Control of grand mal (tonic-clonic) and psychomotor

seizures
• Prevention and treatment of seizures occurring during or
following neurosurgery
• Parenteral administration: Control of status epilepticus of
the grand mal type
• Unlabeled uses: Antiarrhythmic, particularly in digitalis-
induced arrhythmias (IV preparations); treatment of
trigeminal neuralgia (tic douloureux)

Contraindication • Contraindicated with hypersensitivity to hydantoins, sinus

bradycardia, sinoatrial block, Stokes-Adams syndrome,
pregnancy (data suggest an association between
antiepileptic use and an elevated incidence of birth defects;
however, do not discontinue antiepileptic therapy in
pregnant women who are receiving such therapy to prevent
major seizures; this is likely to precipitate status epilepticus,
with attendant hypoxia and risk to both mother and fetus),
lactation.
• Use cautiously with acute intermittent porphyria,
hypotension, severe myocardial insufficiency, diabetes
mellitus, hyperglycemia.

Side Effects/Toxic • CNS: Nystagmus, ataxia, dysarthria, slurred speech,

mental confusion, dizziness, drowsiness, insomnia, transient
Effects nervousness, motor twitchings, fatigue, irritability,
depression, numbness, tremor, headache, photophobia,
diplopia, conjunctivitis
• CV: CV collapse, hypotension (when administered rapidly
IV; not to exceed 50 mg/min)
• Dermatologic: Dermatologic reactions, scarlatiniform,
morbilliform, maculopapular, urticarial and nonspecific
rashes; serious and sometimes fatal dermatologic reactions
—bullous, exfoliative, or purpuric dermatitis, lupus
erythematosus, and Stevens-Johnson syndrome, toxic
epidermal necrolysis, hirsutism, alopecia, coarsening of the
facial features, enlargement of the lips, Peyronie's disease
• GI: Nausea, vomiting, diarrhea, constipation, gingival
hyperplasia, toxic hepatitis, liver damage, sometimes fatal;
hypersensitivity reactions with hepatic involvement,
including hepatocellular degeneration and fatal
hepatocellular necrosis
• GU: Nephrosis

18
 • Hematologic: Hematopoietic complications, sometimes
fatal: thrombocytopenia, leukopenia, granulocytopenia,
agranulocytosis, pancytopenia; macrocytosis and
megaloblastic anemia that usually respond to folic acid
therapy; eosinophilia, monocytosis, leukocytosis, simple
anemia, hemolytic anemia, aplastic anemia, hyperglycemia
• IV use complications: Hypotension, transient hyperkinesia,
drowsiness, nystagmus, circumoral tingling, vertigo,
nausea, CV collapse, CNS depression
• Respiratory: Pulmonary fibrosis, acute pneumonitis
• Other: Lymph node hyperplasia, sometimes progressing to
frank malignant lymphoma, monoclonal gammopathy and
multiple myeloma (prolonged therapy), polyarthropathy,
osteomalacia, weight gain, chest pain, periarteritis nodosa,
hirsutism, alopecia

Nursing Precaution • History: Hypersensitivity to hydantoins; sinus bradycardia,

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

Generic Name of
ordered drug
Brand Name
Date Ordered
Classification
Dose/Frequency/R
oute
Mechanism of
Action
Specific Indication

19
Contraindication
Side Effects/Toxic
Effects
Nursing Precaution

IV. Anatomy and Physiology

20
The Brain

Three cavities, called the primary brain vesicles, form during the early
embryonic development of the brain. These are the forebrain
(prosencephalon), the midbrain (mesencephalon), and the hindbrain
(rhombencephalon).

During subsequent development, the three primary brain vesicles develop

into five secondary brain vesicles.

• The telencephalon generates the cerebrum (which contains the

cerebral cortex, white matter, and basal ganglia).

• The diencephalon generates the thalamus, hypothalamus, and pineal

gland.

• The mesencephalon generates the midbrain portion of the brain

stem.

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

• The myelencephalon generates the medulla oblongata portion of the

brain stem

21
22
• The cerebrum consists of two cerebral hemispheres connected by a
bundle of nerve fibers, the corpus callosum. The largest and most
visible part of the brain, the cerebrum, appears as folded ridges and
grooves, called convolutions. The following terms are used to
describe the convolutions:

• A gyrus (plural, gyri) is an elevated ridge among the

convolutions.

• A sulcus (plural, sulci) is a shallow groove among the

convolutions.

• A fissure is a deep groove among the convolutions.

The deeper fissures divide the cerebrum into five lobes (most named
after bordering skull bones)—the frontal lobe, the parietal love, the
temporal lobe, the occipital lobe, and the insula. All but the insula
are visible from the outside surface of the brain.

A cross section of the cerebrum shows three distinct layers of

nervous tissue:

• The cerebral cortex is a thin outer layer of gray matter. Such

activities as speech, evaluation of stimuli, conscious thinking,
and control of skeletal muscles occur here. These activities are
grouped into motor areas, sensory areas, and association areas.

• The cerebral white matter underlies the cerebral cortex. It

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

• Basal ganglia (basal nuclei) are several pockets of gray matter

located deep inside the cerebral white matter. The major

23
 regions in the basal ganglia—the caudate nuclei, the putamen,
and the globus pallidus—are involved in relaying and modifying
nerve impulses passing from the cerebral cortex to the spinal
cord. Arm swinging while walking, for example, is controlled
here.

• The diencephalon connects the cerebrum to the brain stem. It

consists of the following major regions:

• The thalamus is a relay station for sensory nerve impulses

traveling from the spinal cord to the cerebrum. Some nerve
impulses are sorted and grouped here before being transmitted
to the cerebrum. Certain sensations, such as pain, pressure, and
temperature, are evaluated here also.

• The epithalamus contains the pineal gland. The pineal gland

secretes melatonin, a hormone that helps regulate the
biological clock (sleep-wake cycles).

• The hypothalamus regulates numerous important body

activities. It controls the autonomic nervous system and
regulates emotion, behavior, hunger, thirst, body temperature,
and the biological clock. It also produces two hormones (ADH
and oxytocin) and various releasing hormones that control
hormone production in the anterior pituitary gland.

The following structures are either included or associated with the

hypothalamus.

• The mammillary bodies relay sensations of smell.

• The infundibulum connects the pituitary gland to the

hypothalamus.

• The optic chiasma passes between the hypothalamus and the

pituitary gland. Here, portions of the optic nerve from each eye

24
 cross over to the cerebral hemisphere on the opposite side of
the brain.

• The brain stem connects the diencephalon to the spinal cord. The
brain stem resembles the spinal cord in that both consist of white
matter fiber tracts surrounding a core of gray matter. The brain stem
consists of the following four regions, all of which provide
connections between various parts of the brain and between the
brain and the spinal cord. (Some prominent structures are illustrated
in Figure 2 ).

Figur Prominent structures of the

25
 e2 brain stem.

• The midbrain is the uppermost part of the brain stem.

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

• The medulla oblongata (medulla) is the lower portion of the

brain stem that merges with the spinal cord at the foramen
magnum.

• The reticular formation consists of small clusters of gray matter

interspersed within the white matter of the brain stem and
certain regions of the spinal cord, diencephalon, and
cerebellum. The reticular activation system (RAS), one
component of the reticular formation, is responsible for
maintaining wakefulness and alertness and for filtering out
unimportant sensory information. Other components of the
reticular formation are responsible for maintaining muscle tone
and regulating visceral motor muscles.

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

winglike lobes, the cerebellar hemispheres. Like that of the
cerebrum, the surface of the cerebellum is convoluted, but the gyri,
called folia, are parallel and give a pleated appearance. The
cerebellum evaluates and coordinates motor movements by
comparing actual skeletal movements to the movement that was
intended.

The limbic system is a network of neurons that extends over a wide

range of areas of the brain. The limbic system imposes an emotional
aspect to behaviors, experiences, and memories. Emotions such as
pleasure, fear, anger, sorrow, and affection are imparted to events and
experiences. The limbic system accomplishes this by a system of fiber
tracts (white matter) and gray matter that pervades the diencephalon and

26
encircles the inside border of the cerebrum. The following components are
included:

• The hippocampus (located in the cerebral hemisphere)

• The denate gyrus (located in cerebral hemisphere)

• The amygdala (amygdaloid body) (an almond-shaped body

associated with the caudate nucleus of the basal ganglia)

• The mammillary bodies (in the hypothalamus)

• The anterior thalamic nuclei (in the thalamus)

• The fornix (a bundle of fiber tracts that links components of the

limbic system)

Pathophysiology

Definition:

Cerebrovascular accident or stroke (also called brain attack) results

from sudden interruption of blood supply to the brain, which precipitates
neurological dysfunction lasting longer than 24 hrs. Hemorrhagic stroke is

27
the leakage of blood vessel causes compression of brain tissue and spasm of
adjacent vessels.

Predisposing Precipitating
Factor Factor
- Family - High fat
History diet
Fatty Dispostion in tunica Intimae sp.
Low density lipoprotein

Macropages will treat them as foreign

bodies

Will engulf fatty deposits in the tunica

Intima

Macrophage will become heavier

because of fatty deposits

Macrophages will be deposited

together with fats (foam cells)

Acumulate, becomes atherosclerotic

plaque

Hyperperfusion of vital organs

specially kidney
Juxtaglumerular cells of kidney will
secrete renin angiotensin 1

Angiotensin 1 converted to
angiotensin 2 by ACE

28
 Increase peripheral assistance

Increase Blood Pressure

Hypertension

Blood vessels become weak

Outpouching of brain
arteries(aneurysm)

Rupture of Blood vessels

CVA, Hemorrhagic

Accumulation of blood in the brain

s/sx:
- diplopia
Compression of brain organs De- - nausea
creased - nape pain
Brain - dizziness
Perfu
Increase Intracranial Pressure -sion

VI. NURSING ASSESSMENT

NURSING SYSTEM REVIEW CHART

Name:: Mrs. LML Date: July

Pulse: 94bpm Temp.: 36.7 c RR: 22 cpm BP: 160/100 mmhg Weight: 55 kgs.
Height: 5’4

EENT:

29
× impaired vision □ blind
□ Pain □ reddened □ drainage
□ gums □ hard of hearing □ deaf
□ burning □ edema □ lesion □ teeth __Diplopia____________
Assess eyes, ears, nose ___Eyepatch __________
Throat for abnormality □ no problem
_____________________
RESP: _____________________
□ Asymmetric □ tachypnea _____________________
□ apnea □ rales □ cough □ barrel chest _BP-
160/100mmhg_____
□ bradypnea □ shallow □ brochi
_____________________
□ sputum □ diminished □ dyspnea _____________________
□ orthopnea □ labored □ wheezing _Dry skin_____________
□ pain □ cyanotic _____________________
Assess resp, rate, rhythm, depth, pattern,
_____________________
breath sounds, comfort × no problem __IVF _site____________

CARDIO VASCULAR _____________________

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

30
□ wound □ rash □ skin color □ flushed _____________________
□ atrophy □ pain □ ecchymosis
_____________________
□ diaphoretic □ moist _____________________
Asses mobility, motion. Galt, alignment, joint function
_____________________
/skin color, texture, turgor, integrity □ no problem
_____________________
_____________________
_____________________

NURSING ASSESSMENT II

31
SUBJECTIVE OBJECTIVE

COMMUNICATION:
 Hearing Loss
× Visual Changes comment: “duha  Glasses  Languages
Denied man ang ako panan-  Contact Lens  Hearing Loss
aw mao gani gi  Speech Difficulties
butangan ko ani Pupils size: 3 mm
tanon sa ako mata. ” Reaction: Pupils
Equally round and
react to light and
accommodation

OXYGENATION: COMMENT: _”maayo Resp. × Regular Irregular

 Dyspnea raman pud akong Describe: Breathing pattern is regular.
 Smoking History pag-ginhawa, wala
× Cough man pud ko naglisod, R right lung is symmetrical to the left lung.
 Sputum usahay lang kay L left lung is symmetrical to the right lung.
 Denied mutukar ako ubo”

CIRCULATION: Heart Rhythm × Regular  Irregular

 Chest Pain COMMENT: “,wala Ankle edema: Presence of ankle edema
 Leg Pain man nuon sakit sa Pulse Car. Rad. DP Femoral*
 Numbness of ako tiil ug dughan, R ___+_______+______+______+____
Extremities kani raman ako liog” L ___+______ +______+____ _+_____
×Denied COMMENT: all pulses are present and palpable
* If applicable
NUTRITION:
Diet: Low salt, low fat Diet
 N □V COMMENT: “katong × Dentures  None
Character: miaging adlaw ga
×Recent change in suka ko, pero karon Full Partial W/ patient
weight, appetite wala naman, pero Upper  × 
 Swallowing Diff. wala lng ko gana
Denied mukaon.” Lower   

ELIMINATION: COMMENT: Bowel sounds:

Patient has a normal Normo active bowel
Usual bowel pattern: Urinary Frequency: bowel movement. sounds
1-2x daily_________ Her urine color is
 Constipation  Dysuria yellowish and Abdominal Distention:
remedies: ___  Hematuria aromatic in odor. Present
Date of last BM:  Incontinence  Yes × No
July 6, 2009  Polyuria Urine* Urine is
Diarrhea Character: × Foley in place yellowish in color
None_____________  Denied * If Foley is in place
Patients FBC to
Urobag is in place.

MGT. OF HEALTH AND ILLNESS: Briefly describe patient’s ability to follow

 Alcohol × Denied treatments for chronic health problems (if
(Amount, Frequency): present):
SBE: Last Pap Smear:__N/A____
LMP: ____N/A ________ Patient follows treatment regimen properly.

32
SUBJECTIVE OBJECTIVE

SKIN INTEGRITY:
×Dry COMMENT: “gamala ×Dry  Cold  Pale
Itching akong panit karon kay  Flushed  Warm
 Other dili man gud ko  Moist  Cyanotic
Denied galigo, tigulang rashes, ulcers, decubitus ulcers (describe size,
napud gud” location, drainage): none

ACTIVITY / SAFETY: LOC and Orientation: Patient is oriented to

 Convulsion COMMENT: “dili man time and space.
×Dizziness nako pa kaya
 Limited motion of magkatindog kay Gait:  Walker  Cane  Others
joints gakalipong ko” × Steady  Unsteady

Limitations in ability Sensory and motor losses in face or

to: extremities:
 Ambulate There is having diplopia.
× Bathe self
 Others ROM Limitations: The patient cannot bath by
 Denied itself appropriately and needs guidance when
doing it.

COMFORT / SLEEP / AWAKE:

 Pain (Location, COMMENT: “Maaayo  Facial Grimaces
Freq., Remedies) man hinuon ang ako  Guarding
 Nocturia pagkatulog”  Other signs of pain: none_
 Sleep Difficulties  side rail release from signed(60+years)
Denied None

COPING: Observed nonverbal behavior:

Patient follows instructions, cooperative, but

Occupation: Retired Teacher sometimes she easily get depressedof her
Mumbers of household: _3__ situation and she likes to talk things about her
Most supportive person:_husband______ life and family.

33
VII. NURSING MANAGEMENT

A.IDEAL NURSING INTERVENTIONS

Nursing Diagnosis: Ineffective cerebral tissue perfusion related to

hemorrhage

Interventions Rationale

Independent:
1. Determine factors related  Influences choice of
to individual situation/ interventions.
cause for coma/ cerebral
tissue perfusion and
potential increased in ICP.
2. Monitor or document  Assesses trends in level of
neurolohgical status consciousness and potential
frequently and compare increase in ICP and is useful in
with baseline. determining location, extent
and progression of the CNS
3. Monitor vital signs damage.
 Fluctuations in pressure may
occur because of cerebral
pressure/ injury in vasomotor
area of the brain. Change in
4. Position with head slightly rate of heart rhythm can occur
elevated and in neutral because of the brain damage.
position and maintain  Reduces arterial pressure by
bedrest. promoting venous drainage
and may improve cerebral
circulation or perfusion.

34
Dependent:
5. Administer prescribed  Reduces hypoxemia,
medications, supplemental increase of
oxygen,anticoagulants, ICP and may use to improve
antihypertensive drugs as cerebral blood flow.
ordered.

Nursing Diagnosis: Impaired physical mobility related to neuromuscular

involvement

Interventions Rationale

Independent:
1. Assess functional ability/  Identifies strengths/
extent of impairment deficiencies and may provide
initially and on a regular information regarding
basis. recovery.
2. Change position at least  Reduces risk of tissue
every 2hrs. and possibly ischemia/injury. Affected side
more often on the affected has poorer circulation and
side. reduced sensation and is more
3. Inspect skin regularly,
predisposed to skin
particularly over bony
breakdown/ decubitus.
prominences. Gently
 Pressure points over bony
massage any reddened
priminences are most at risk
areas and provide aids such
for decreased perfusion/
as sheepskin pads as
ischemia. Circulatory
4. Encourage
necessary. patient to assist
stimulstion and ,padding help
with the movement and
prevent ski breakdown and
exercisse using the
decubitus development.
unaffected extremity to
 May respond as if the affected
support or move weaker

35
 side. side is no linger part of the
body a nd needs
encouragement and active
training to reincorporate it as a
part of its own body.

Dependent:
5. Consult with the physical  Individualized program can
therapist regarding active develop to meet particular
resistive exercises and needs/ deal with deficits in
patient ambulation. balance, coordination and
strength.

Nursing Diagnosis: Disturbed Sensory perception related to altered

sensory receptor

Interventions Rationale

36
Independent:
1. Observe behavioral  Individual responses are
responses variable, but commonalities
such as emotional ability,
lowered frustration threshold,
apathy, and impulsiveness may
complicate care.
2. Eliminate extrenous noise/
stimuli as necessary.  Reduces anxiety and
exaggerated emotional
responses/ confusion
3. Speak in calm, quiet voice, associated with sensory
using short sentences. overload.
Maintain eye contact.
 Patient may have limited
attention span or problems
with comprehension. These
4. Ascertain/ validate patient’ measures can help the patient
perceptions. Reorient to attend to communication.
patient frequently to
environment , staff,  Assists patient to identify
procedures. inconsistencies in reception
and integration of stimuli and
5. Evaluate visual deficits. may reduce perceptual
Note loss of visual field, distortion of reality.
changes in depth
perception , presence of
diplopia(double vision)  Presence of visual disorders
can negatively affect patient’s
ability to perceive environment

37
 and relearn motor skills and
increases risk of accident/
injury.

B. ACTUAL NURSING INTERVENTION

o
A
P
I
E

38
B.
S
“ Kani man ang ako liog ang nag sakit ug pag – ayo, unya ga
doble na ang ako panan-aw”

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

A
Ineffective cerebral tissue perfusion related to hemorrhage.

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

I
Independent

1. Positioned with head slightly elevated.

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

39
 1. Maintained bed rest.
 Continual stimulation or activity ma increase
intracranial pressure.

1. Provided quiet environment.

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

1. Prevented straining at stool, holding breath.

 Valsava manuever increase ICP and potential risk of
rebleeding.

Dependent

1. Administer and stool softeners per doctor’s order.

 Prevent straining during bowel movement and
corresponds to increase ICP.

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

40
o
 Eye patch placed alternately q2h

A
Risk for injury related to visual disturbance.

P Long term:
At the end of 8 hours the patient with the help of
relatives and health care provider will be able to modify
environment as indicated to enhance safety and use
resources appropriately.

Short term:
At the end of 1 hour the patient will be able to identify
individual risk factors.

I  To know the extent of disturbance and further

interventions to be done.

2. Oriented patient on possible risk factors and on the

environment.
 To familiarize patient on her environment and identify
and avoid where danger is at its peak.

3. Adjust bed and keep side rails raised up, especially if

patient is at
rest.
 To prevent further injury from falls.

4. Placed unnecessary objects away from clients’ sight.

 To enhance safety appropriate use of necessary

41
 resources.

5. Administer medication as prescribe by the physician.

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

VIII. Referrals and Follow-up

Patient was transferred to Cebu as what was planned by the

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

42
 IX. Evaluation and Implication

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

43
to develop my knowledge as well as my skills and attitudes in applying the
prescribed procedure to improve the health status of the patient.
Moreover, this care study taught us to stand on our own by not depending
on others just to make this. This provides us, the students, a big learning
regarding on how well we take care of or patients in the real clinical setting.
Most of all, this study teaches the students to provide clients care more
efficiently and competently to achieve an effective and quality nursing care.

X. BIBLIOGRAPHY

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

44
  Lippincott Williams and Wilkins
Manual of Nursing Practice
7th Edition page 570-571
© 2001 by Lippincott Williams and Wilkins

 Robert Berhow M.D, et al

Home Edition, page 562
©1997 by Merck Co. Inc

 Microsoft ® Encarta ® Reference Library 2004

©1993-2003 Microsoft Corporation

WEB
 www.nursingcrib.com

 http://www.wisegeek.com/what-is-cva.htm

 http://en.wikipedia.org/wiki/cerebrovascularacciddent

 http://www.Emedicinehealth.com/cerebrovascularaccident/pages.em.ht
m

45
46