Opd Case Pres

Far Eastern University
Institute of Nursing
CASE
PRESENTATION
Concept: INP
Cerebral Vascular Accident (CVA)
Submitted By:
Dulay,CarlaJaneena
Pangilinan, Brylle Jae
Reyes, Kristine Irish
Sallan, ShermaneCriszen
Sernande, Marlon Nikko
Subijano, Aljonlexter
Taguiam,Marvin Gardner
Tria, Juris Ezra
BSN504 Group 16
Submitted To:
Clinical Instructor
Date Submitted:
March 3, 2015
I. Demographic Data
Name: E.D.J.
Address: 23 E. Castillo St. Barangay Commonwealth Q.C.
Current Address: 23 E. Castillo St. Barangay Commonwealth Q.C.
Age: 63
Birth Date: August 5, 1951
Birth Place:
Educational Attainment:
Occupation before Admission: Security Guard
Marital Status: married
Religion: Catholic
Chief Complaint: double vision
Impression Diagnosis: C.V.A
II. Past Health History
The patient has no history of hypertension. He has a type 2 diabetes mellitus. He has a
complete immunization whenhe was still a child. No know allergies in any drugs or foods.
III. Present Health History
Patient come in referral from internal medicine with a diagnosis of R/O reinfarction, S/P CVA in
2002 and 2009 with the complaint of having a double vision but no pain in the eye and no
blurring of vision.
III. Family History
Patient has a family history of hypertension and diabetes mellitus but no history of cancer
III. Gordons Assessment

Gordons
Assessment
Health
Perception and
Management
Nutritional
Pattern
Before Admission
During Admission
Analysis
Interpretation
When asked about

his perceptions
about being
healthy, he stated,
Pagmalusogangis
angtao,
kumakainnggulay
at nag eexercise.
He also said that
he rates his health
5/10 because he
believes that being
healthy is not only
seen in physical
aspects. He thinks
he is mentally,
emotionally and
spiritually healthy.
Hindi ako masyado

makalad kasi nanghihina
yung kanang paa ko.
Hindi ko na magawa
yung normal na Gawain
ko simula nung Friday
noong dinala ako ditto
dahil nga doble na
nakikita ko, as
verbalized by the client.
Health perceptions (or

perceived health
status) are subjective
ratings by the affected
individual of his or her
health status6. Some
people perceive
themselves as healthy
despite suffering from
one or more chronic
diseases.
Normal
The client also said

that whenever he
has problems
about health he
always consult his
doctor.
The client prefer
eating vegetables
,fruits and fish only.
He likes food with
sabaw like
sinigang. He
seldom eat meats
especially if it is
fried.
He said that he
drinks plenty of
water in a day. He
drinks 7-8 glasses
of water in a day.
He also said that he

rates his health 5/10
because he believes that
being healthy is not only
seen in physical aspects.
He thinks he is mentally,
emotionally and
spiritually healthy.
The client has changes

in appetite. He was
having a difficulty in
swallowing and he thinks
that it is because of his
cough and his mouth is
deviated to the right side.
Reference: American
Thoracis Society,
2007)..
The middle aged adult

should continue to eat
a healthy diet,
following the
recommended
portions of the food
groups, with special
attention to protein,
calcium and limiting
cholesterol and caloric
intake. Two or three
litters of fluid\should
be included in the
diet. (Kozier&Erbs,
Fundamentals of
Nursing 8th Edition
Vol. 2 page 1243).
Although the
nutritional content of
food is an important
consideration when
Deviation from
normal
Gordons
Assessment
Before Admission
During Admission
Analysis
Interpretation
planning a diet, an
individuals food
preferences and
habits are major factor
affecting actual food
intake. (Kozier&Erbs,
Fundamentals of
Nursing 8th Edition
Vol. 2 page 1237).
Elimination
Pattern
Activity and
Exercise pattern
The client usually

defecates once or
twice a day he
doesnt have any
difficulty letting it
out. The client
urinates 5-7 times
a day because he
drinks a lot of water
everyday. When he
feels the urge to
urinate, hes going
to the bathroom
immediately to
urinate and he
stated that he
doesnt feel any
difficulty when
urinating.
Since the client
experience CVA
before, he is
religiously doing
his exercise
everyday for 15 to
30 minutes. His
form of exercise
are walking, wall
push ups and
stationary biking.
When he has
nothing to do he
takes nap at noon
time or sometimes
watching TV.
The client usually

defecates once or twice
a day he doesnt have
any difficulty letting it out.
The client urinates 5-7
times a day because he
drinks a lot of water
everyday. When he feels
the urge to urinate, hes
going to the bathroom
immediately to urinate
and he stated that he
doesnt feel any difficulty
when urinating.
The frequency of
defecation is highly
individual, varying
from several times per
day totwo or three
times per week.
Even though the client is

experiencing weakness
on his right foot he still
do his stationary biking
as his daily exercise .
According to
researchers at
Harvards School of
Public Health (HSPH),
a regular physical
activity is the best
form of health
promotion and
maintenance.
(Kozier&Erbs,
Fundamentals of
Nursing 8th Edition
Vol. 2 page 1105).
Normal
(Kozier&Erbs,
Fundamentals of
Nursing 8th Edition
Vol. 2 page 1325 and
1284).
Normal
Gordons
Assessment
Sleep rest
pattern
Cognitive
Perceptual
Pattern
. Self-perception
Self-concept
Pattern
Before Admission
During Admission
Analysis
Interpretation
The client usually

sleep at around 10
in the evening and
wakes up at 6 in
the morning. He
describes his sleep
as deep and has
interuptions only if
he has to go to the
bathroom.
The daughter said that

the client is having
difficulty in sleeping
lately because of his
cough.
Normal
When asked about

the changes that
he observed while
aging, he stated,
Lumabo mata ko
pero nagsimula
yun matagal tagal
na, reading glass
lang.
When asked about the

changes that he
observed while aging, he
stated, Lumabo mata
ko pero nagsimula yun
matagal tagal na,
reading glass lang.
Most adults need 7 to

9 hours of sleep a
night. However, there
is individual variation
as some adults may
be able to function
well with 6 hours
sleep and others may
need 10 hours to
function optimally.
(Kozier&Erbs,
Fundamentals of
Nursing 8th Edition
Vol. 2 page 1168).
Any alteration in
peoples sensory
functions can affect
their ability to function
within the
environment. A
number of factors
affect amount and
quality of sensory
including a persons
developmental stage.
When asked about if

there were situations that
When asked about he experienced having
if there were
difficulty recalling things,
situations that he
he said, Hindi pa naman
experienced having masyado, nakakaalala
difficulty recalling
pa naman ako, lalo na
things, he said,
yung mga matatagal na
Hindi pa naman
mga bagay na, di pa
masyado,
naman ako malilimutin
nakakaalala pa
ngayon.
naman ako, lalo na
yung mga
matatagal na mga
bagay na, di pa
naman ako
malilimutin
ngayon.
The client
The client describes his
describes his self
self as a happy person.
as a happy person.
He said that he feels
He said that he
satisfied about his self
feels satisfied
even though he has
about his self even
health problems. He
though he has
feels happy and
health problems.
satisfied with his life. He
He feels happy and
gets along easily with
Deviation from
normal
(Kozier&Erbs,
Fundamentals of
Nursing 8th Edition
Vol. 2 page981-982).
A positive self concept

is essential to a
persons mental and
physical health.
Individuals with
positive self concept
are better able to
develop and maintain
interpersonal
Normal
Gordons
Assessment
Role
Relationship
Pattern
Before Admission
During Admission
Analysis
satisfied with his

life. He gets along
easily with other
people and look on
things positively.
other people and look on

things positively.
relationships and
resist psychological
and physical illness.
An individual
possessing a strong
self concept should be
better able to accept
or adapt to changes
that may occur over
the life span. How one
views one self affects
ones interaction with
others.
The client is happy

and proud that he
has a happy family
and that he was
able to provide the
needs of his family.
He said that he is
happy that he has
his family
especially his wife
and daughter that
is always their
supporting him
and taking care of
him during his first
stroke attack and
up until now.
The client is happy and

proud that he has a
happy family and that he
was able to provide the
needs of his family. He
said that he is happy that
he has his family
especially his wife and
daughter that is always
their supporting him and
taking care of him during
his first stroke attack and
up until now.
(Kozier&Erbs,
Fundamentals of
Nursing 8th Edition
Vol. 2 page 1003).
Generativity versus
stagnation is the
seventh stage of Erik
Eriksons theory
ofpsychosocial
development. This
stage takes place
during middle
adulthood between
the ages of
approximately 40 and
65. During this time,
adults strive to create
or nurture things that
will outlast them; often
by having children or
contributing to positive
changes that benefits
other people.
Reference: The
Seventh Stage of
Psychosocial
Development by
Kendra Cherry
Interpretation
Normal
Gordons
Assessment
Coping Stress
Tolerance Pattern
Before Admission
During Admission
Analysis
The client said that

whenever he is
facing problems,
he just dont want
to think about it. He
doesnt want to
stress to much. But
when he needs
someone to vent it
out, he said that he
talks to his wife or
his eldest daughter.

whenever he is facing
problems, he just dont
want to think about it. He
doesnt want to stress to
much. But when he
needs someone to vent it
out, he said that he talks
to his wife or his eldest
daughter.
Coping may be
described as dealing
with changesuccessfully or
unsuccessfully. A
coping strategy or
coping mechanism is a
natural or learned way
of responding to a
changing environment
or specific problem or
situation. Coping
strategies vary among
individuals and are
often related to the
individuals perception
of the stressful event.
He said that he is
very thankful
because he has his
family taking care
of him.
Value Belief
Pattern

he and his family
always go to
church. He said
that his daughters
were very active in
their church before.
They were once
member of the
choir. As a family,
they always pray
the Holy Rosary
daily.
The daughter said
that her parents
taught them to be
God fearing and
respectful to other
people.
He said that he is very

thankful because he has
his family taking care of
him.
The clients daughter

said that their faith
became more stronger
when they learned that
their father had CVA.
(Fundamentals of
Nursing Kozier and
Erbs Fundamentals of
Nursing Volume 2,
pp.1068).
A persons value-belief
system is the core of
his or her existence
and
interconnectedness
with his or her spiritual
side as well as with his
or her environment.
Reference: Muhammad
Iqbal, Value- Belief
Pattern: Advanced
Concept in Nursing)
Interpretation
Normal
Normal
III. Physical Assessment

VITAL SIGNS: BP:
Temp:
PR:
RR:
O2 saturation:
Assessment of Head to Toe

Areas assessed
( or Test
Performed)
I. Skull
Technique
Used
Inspection
Palpation
II. Hair and

Scalp
Hair
III. Face
IV. Eye
Structures and
Visual Acuity
a. Eyebrows
b. Eyelashes
Inspection
Inspection
Inspection
Inspection
Inspection
Analysis
Rounded (normocephalic and
symmetric, with frontal, parietal,
and occipital prominence) ; smooth
skull contour
[Krozier&Erbs Fundamentals of
Nursing, 8th Edition].
Smooth, uniform consistency;
absence of nodules or masses
Scalp is clean and dry. Sparse
dandruff may be visible
[Weber & Kelly, Health Assessment
in Nursing, 3rd Edition]
Evenly distributed, thick, silky and
resilient hair, no infection or
infestation
Symmetric or slightly asymmetric
facial features; palpebral fissures
equal in size; symmetric nasolabial
folds; symmetric facial movements
Hair evenly distributed; skin intact;
eyebrows symmetrically aligned;
equal movement
Equally distributed; curled slightly
outward
Actual
Findings
Rounded and
symmetric
No nodules
and masses
Interpretation
Normal
Normal
Scalp has
dandruff and
dirty
Deviations from
Normal
- Self-care
deficit
Hair is dirty
and oily.
Minimal loss of
hair.
Deviation from normal

- Self-care
deficit
- Age 63 years
old
The clients
right facial
muscle is
paralyzed
Deviation
from normal
The client is
status post
CVA
The clients
eyebrows are
evenly
distributed
Normal
The clients
eyelashes are
short, thin and
sparse but are
evenly
distributed over
Normal
c. Eyelids
Inspection
Skin intact; no discharge ; no

discoloration; lids close
symmetrically
Approximately 15 to 20 involuntary
blinks per minute
When lids open, no visible sclera
above corneas, and upper and
lower borders of cornea are slightly
covered
d. Bulbar
conjunctiva
Inspection
Transparent; capillaries sometimes
evident; sclera appears white
(darker or yellowish and with small
brown macules in dark-skinned
clients)
e. Palpebral
conjunctiva
Inspection
f. Lacrimal
gland
Inspection
Shiny, smooth, and pink or red
No edema
Palpation
No tenderness over lacrimal gland
Inspection
No edema
Palpation
No tearing
g. Lacrimal sac
and
nasolacrimal
duct
h. Cornea
Inspection
Nursing, 8thEdition].
Transparent, shiny, and smooth;
details of the iris are visible
In older people, a thin, grayish
white ring around the margin, called
arcussenilis, may be evident
Client blinks when the cornea is
the eyelids and

are curved
outward along
the lid margins.
The clients
eyelids skin is
intact and able
to blink 15-20
per min
Normal
No opportunity
to assess
No opportunity to
assess
No opportunity
to assess
No opportunity to
assess
The clients
lacrimal gland
has no edema
Normal
No tenderness
over lacrimal
gland
Normal
No Edema
Normal
No tearing in
the eye when
palpated
The clients
cornea has
grayish white
ring around the
margin and
thin.
Normal
Normal
touched, indicating that the

trigeminal nerve is intact
i. Anterior
chamber
j. Pupils
Inspection
Inspection
Transparent
No shadows of light on iris; Depth
of about 3 mm
Black in color; equal in size;
normally 3 to 7 mm in diameter;
round, smooth border, iris flat and
round
Pupils constrict when looking at

near object; pupils dilate when
looking at far object; pupils
converge when near object is
moved toward nose
k. Peripheral
visual fields
(retina and
neuronal visual
pathways)
l. Six ocular
movements
Inspection
(Neurologic
Assessment)
Inspection
(Neurologic
Assessment)
m. Near vision
Inspection
n. Distance
vision
Inspection
V. Ears and
hearing
a. Auricles
Inspection
Palpation
When looking straight ahead, client
can see objects in the periphery
Both eyes coordinated, move in
unison, with parallel alignment
[Krozier&ErbsFundamentals of
Able to read newsprint
20/20 vision on Snellen output
Color same as facial skin;
symmetrical; auricle aligned with
outer canthus of eye, about 10
from vertical
Mobile, firm, and not tender; pinna
recoils after it is folded
The client can

see object in
periphery
Normal
No opportunity
to assess
No opportunity to
assess
No opportunity
to assess
No opportunity to
assess
No opportunity
to assess
No opportunity to
assess
The color of
the clients
auricles is
same as the
clients facial
skin.
Normal
The clients
pinna recoils
Normal
after it is folded
b. Normal voice
tone
c. Watch tick
test
Inspection
Normal voice tones audible
Inspection
Able to hear in both ears
d. Webers test
e. Rinnes test
VI. Nose and

Sinuses
a. External nose
b. Patency of
nasal cavities
c. Nasal cavities
d. Nasal septum
e. Maxillary and
Inspection
Inspection
Inspection
Inspection &
palpation
Inspection
Inspection
Palpation
Sound is heard in both ears or is

localized at the center of the head
(Weber negative)
The clients
voice tone is
audible.
Normal
The client can

hear from both
ears and able
to respond in
questions.
Normal
No opportunity
to assess
Air-conducted(AC) is greater than
bone-conducted (BC) hearing, i.e.,
AC>BC (Rinne positive)
Symmetric and straight
No discharge or flaring
Uniform color
Air moves freely as the client
breathes through the nares
The nasal mucosa is dark pink,
moist and free of exudates
No opportunity to
assess
Presence of
discharge from
nares
The client
breathes
through the
nares freely
Deviations from
Normal
- Impaired
tissue
perfusion
-
Normal

in Nursing, 3rd Edition].
The nasal septum is intact and free
of ulcers or perforations
No opportunity
to assess
No opportunity to
assess

in Nursing, 3rd Edition]; nasal
septum is in midline [Krozier&Erbs
Fundamentals of Nursing, 8th
Edition].
Not tender
No opportunity
No opportunity to
frontal sinuses
to assess
assess
The lips are

pale and
chopped.

- Impaired
tissue
perfusion
No opportunity
to assess
No opportunity to
assess
No opportunity
to assess
No opportunity to
assess
No opportunity
to assess
No opportunity to
assess
No opportunity
to assess
No opportunity to
assess
VII. Mouth and
Oropharynx
a. Outer lips
b. Inner lips and

buccal mucosa
c. Teeth and
gums
d. Tongue
Inspection
Inspection &
Palpation
Inspection
Inspection
Uniform pink color (darker e.g.

bluish hue in Mediterranean people
and dark-skinned people)
Soft, moist, smooth texture
Symmetry of contour
Ability to purse lips
Uniform pink color (freckled brown
pigmentation in dark clients)
Moist, smooth, soft, glistening,
elastic texture (drier oral mucosa in
elderly due to decreased salivation
32 adult teeth
Smooth, white, shiny tooth enamel
Pink gums (bluish or brown patches
in dark-skinned clients)
Moist, firm texture to gums
No retraction of gums (pulling away
from the teeth)
Central position
Pink color (in dark clients, with
brown pigmentation on tongue
borders); moist, slightly rough; thin
whitish coating
Smooth, lateral margins; no lesions
Raised papillae(taste buds)
Moves freely; no tenderness
Smooth with no palpable nodules
Palpation
Smooth with no palpable nodules
e. Hard and soft

palate
Inspection
Light pink, smooth soft palate
Lighter pink hard palate, more
irregular in texture
Inspection
Positioned in midline of soft palate
g. Oropharynx
Inspection
Pink and smooth posterior wall
h. Tonsils
Inspection
f. Uvula
i. Gag reflex
Inspection
Pink and smooth

No discharge
Of normal size or not visible
Present
No opportunity
to assess
No opportunity to
assess
No opportunity
to assess
No opportunity to
assess
No opportunity
to assess
No opportunity
to assess
No opportunity to
assess
No opportunity to
assess
No opportunity
to assess
No opportunity to
assess
VIII. Neck and
Lymph Nodes
a. Neck muscles
Inspection
Muscles equal in size; head

centered
IX. Lymph
Nodes
Neck
X. Trachea
Palpation
Not palpable
Palpation
Central placement in midline of
neck; spaces are equal on both
sides
The client can

move his neck
but most of the
time it is on
right side
Deviation
from normal
No opportunity
to assess
No opportunity to
assess
No opportunity
to assess
No opportunity to
assess
No opportunity
to assess
No opportunity to
assess
No opportunity
to assess
No opportunity to
assess
XI. Thyroid
Gland
Thyroid gland
Inspection
Palpation
Not visible on inspection

Glands ascend during swallowing
but is not visible
Lobes may not be palpated
If palpated, lobes are small,
smooth, centrally located, painless

and rise freely with swallowing
XII. Posterior
Thorax
a. Posterior
Thorax
b. Spinal
alignment
c. Posterior
Thorax
Inspection
Inspection
Palpation
Anteroposterior to transverse
diameter in ratio of 1:2
Chest symmetric
Spine vertically aligned;
Spinal column is straight, right and
left shoulders and hips are at same
height
Skin intact, uniform temperature
Chest wall intact; no tenderness no
masses
No opportunity
to assess
No opportunity to
assess
No opportunity
to assess
No opportunity to
assess
No opportunity
to assess
No opportunity to
assess
No opportunity
to assess
No opportunity to
assess
No opportunity
to assess
No opportunity to
assess
Nursing, 8thEdition].
d. Posterior
chest
Palpation
Symmetrical chest expansion

Bilateral symmetry of vocal fremitus
Fremitus is heard most clearly at
the apex of the lungs
f. Posterior
Thorax
Percussion
Percussion notes resonate, except
over scapula
Lowest point of resonance is at the
diaphragm
Percussion on a rib normally elicits
dullness
Excursion is 3-5 cm (1 to 2 in.)
bilaterally in women and 5-6 inch (2
to 3 in.) in men
Diaphragm is usually slightly higher
on the right side
h. Chest
Auscultation
Vesicular and
bronchovesicularbreathsounds
XIII. Anterior
Thorax
a. Anterior
Thorax
Inspection
Breathing patterns are quiet,

rhythmic, and effortless respirations
Costal angle is less than 90, and
the ribs insert into the spine at
approximately a 45 angle
Palpation
Symmetrical chest expansion
Positive
crackles. The
client has
cough
Breathing
patterns are
effortless
respirations
Normal
No opportunity
to assess
No opportunity to
assess
No opportunity
to assess
No opportunity to
assess
No opportunity
to assess
No opportunity to
assess
No opportunity
to assess
No opportunity to
assess
No opportunity
to assess
No opportunity to
assess
Full symmetric excursion; thumbs

normally separate 3-5 cm (1 to 2
in.)
b. Anterior
chest
Palpation
Percussion
c. Trachea
d. Anterior
chest
Auscultation
Auscultation
Bilateral symmetry of vocal fremitus
Fremitus is normally decreased
over heart and breast tissue
Percussion notes resonate down to
the sixth rib at the level of the
diaphragm but are flat over areas of
heavy muscle and bone, dull on
areas over the heart and liver, and
tympanic over the underlying
stomach
Bronchial/tubular breath sounds
Bronchovesicular and vesicular
breath sounds
Equal strength on each body side
Musculoskeletal
Inspection
+5 - full ROM, full strength

+4 - full ROM, less than normal
strength
+3 - can raise extremity but not
against resistance
+2 - can move extremity but not
lift it
+1 - slight movement
0 - no movement
3 Grade of
muscle
strength
50 % of
normal
strength;
normal
movement
against
gravity,
can stand
with
support
Deviations from
normal
- Activity
intolerance
IV. Laboratory and Diagnostic Examinations Results

August 9, 2014
HEMATOLOGY
TEST NAME
RESULT
UNIT
CBC + DIFF
Complete Blood Count
WBC Count
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
RBC Count
Hemoglobin (Hgb)
Hematocrit (Hct)
MCV
MCH
MCHC
RDW CV
RDW SD
Platelet Count
MPV
PDW
7.51
0.613
0.290
0.060
0.029
0.008
4.33
131
0.396
91.5
30.3
331
12.4
41.9
267
8.8
8.7
x109/L
x1012/L
g/L
L/L
fL
pg
g/L
%
fL
x109/L
fL
fL
REFERENCE
RANGE
INTERPRETATION
5.00 10.00
0.550 0.650
0.250 - 0.350
0.020 0.060
0.030 0.050
0.000 0.010
5.50 6.50
140 160
0.420 0.520
80.0 100.0
27.0 34.0
320 380
11.0 16.0
35.0 56.0
160 380
6.5 12.0
9.0 17.0
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Low
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
August 5, 2014
BLOOD CHEMISTRY
TEST
BUN
Creatinine
Total Bilirubin
Direct Bilirubin
Indirect Bilirubin
Albumin
SGOT/AST
SGPT/ALT
Sodium
Potassium
ALP
REFERENCE RANGE
2.5 7.2 mmol/L
50.40 98.0 umol/L
3.4 20.5 umol/L
0.00 8.6 umol/L
3.4 11.90 umol/L
35 50 g/L
0 55 U/L
0 55 U/L
136 145 mmol/L
3.5 5.10 mmol/L
32-92 U/L
RESULT
INTERPRETATION
80.00
Normal
15.00
135.80
4.40
Normal
Low
Normal
ESR
August 5, 2014
URINALYSIS
PARAMETER
Color
Character
Blood
Bilirubin
Urobilinogen
Ketone
Protein
Nitrite
Glucose
pH
Specific gravity
Leukocytes
FINDINGS
Yellow
Hazy
Negative
Negative
Normal
(-)
(-)
(-)
+1
6.0
1.015
(-)
MICROSOCPIC
Cast
Crystals
Pus Cells
Red Blood Cells
Epithelial Cells
A. Urates/Phosphates
Bacteria
None
None
0-1 /hpf
0-1 /hpf
Few
Occasional
Occasional
CBG
Reference Range
70 180 mg/dl
8/5/2014
6pm - 150
8/6/2014
5am 117
11am 170
5pm - 94
8/7/2014
5am - 103
Gram stain of sputum

Smear shows plenty gram positive cocci seen in singly, pairs, chains, and clusters. Few
epithelial cells with 50-60 pus cells/hpf
August 8, 2014
Sputum Culture and Sensitivity Report
Light growth of Pseudomonas putida after growth in 24 hours of incubation.
August 5, 2014
ELECTROCARDIOGRAPHIC REPORT
RHYTHM:
RATES:
AURICULAR:
VENTRICULAR:
SINUS
P-R Interval:
0.14 SEC.
83/MIN
83/MIN
QRS Interval: 0.08 SEC.

Q-T Interval: 0.36 SEC.
QRS AXIS:
N
ELECTRICAL
POSITION:
ECG INTERPRETATION
Within Normal Limits
August 5, 2014
ROENTGENOGRAPHIC REPORT
CHEST:
No active lung infiltrate seen. Pulmonary vascular markings are within normal limits.
Heart is not enlarged. Diaphragm and bony thorax are unremarkable.
IMPRESSION:
Unremarkable chest
August 9, 2014
ROENTGENOGRAPHIC REPORT
CHEST#2:
Follow up film since Aug. 5, 2014 shows interval development of ill-defined densities in
both lung bases suggestive of interstitial pneumonia. Heart remains unenlarged. The
rest of the chest findings are unchanged including atheromatous aorta and
osteodegenerative changes.
V. Overview of Disease/Anatomy and Physiology
Strokes are a heterogeneous group of disorders involving sudden, focal interruption of cerebral
blood flow that causes neurologic deficit. Strokes can be ischemic (80%), typically resulting from
thrombosis or embolism, or hemorrhagic (20%), resulting from vascular rupture (eg,
subarachnoid or intracerebralhemorrhage). Transient stroke symptoms (typically lasting< 1 h)
without evidence of acute cerebral infarction (based on diffusion-weighted MRI) are termed a
transient ischemic attack (TIA). In the US, stroke is the 4th most common cause of death and
the most common cause of neurologic disability in adults.
Strokes involve the arteries of the brain either the anterior circulation (branches of the internal
carotid artery) or the posterior circulation (branches of the vertebral and basilar arteries).
According to the latest WHO data published in April 2011 Stroke Deaths in Philippines reached
40,245 or 9.55% of total deaths. The age adjusted Death Rate is 82.77 per 100,000 of
population ranks Philippines #106 in the world. Review other causes of death by clicking the
links below or choose the full health profile.
A stroke can be caused by an artery to the brain may be blocked by a clot (thrombosis) which
typically occurs in a blood vessel that has previously been narrowed due to atherosclerosis
("hardening of the artery"). When a blood clot or a piece of an atherosclerotic plaque (a
cholesterol and calcium deposit on the wall of the artery) breaks loose, it can travel through the
circulation and lodge in an artery of the brain, plugging it up and stopping the flow of blood; this
is referred to as an embolic stroke. A blood clot can form in a chamber of the heart when the
heart beats irregularly, as in atrial fibrillation; such clots usually stay attached to the inner lining
of the heart but they may break off, travel through the blood stream, form a plug (embolus) in a
brain artery and cause a stroke. A cerebral hemorrhage (bleeding in the brain), as from an
aneurysm (a widening and weakening) of a blood vessel in the brain, also causes stroke.
Initial symptoms occur suddenly. Generally, they include numbness, weakness, or paralysis of
the contralateral limbs and the face; aphasia; confusion; visual disturbances in one or both eyes
(eg, transient monocular blindness); dizziness or loss of balance and coordination; and
headache.
Neurologic deficits reflect the area of brain. Anterior circulation stroke typically causes unilateral
symptoms. Posterior circulation stroke can cause unilateral or bilateral deficits and is more likely
to affect consciousness, especially when the basilar artery is involved.
Risk factors include: Hypertension, Cigarette smoking, Dyslipidemia, DiabetesAbdominal
obesity, Alcoholism, Lack of physical activity, High-risk diet (eg, high in saturated fats, trans fats,
and calories), Psychosocial stress (eg, depression), Heart disorders (particularly disorders that
predispose to emboli, such as acute MI, infective endocarditis, and atrial fibrillation),
Hypercoagulability (thrombotic stroke only), Intracranial aneurysms (subarachnoid hemorrhage
only), Use of certain drugs (eg, cocaine, amphetamines), Vasculitis.Unmodifiable risk factors
include the following:Prior stroke, older age, Family history of stroke, Male sex.
When a stroke is severe, the brain swells, increasing pressure within the skull. Increased
pressure can damage the brain directly or indirectly by forcing the brain downward in the skull.
The brain may be forced through the rigid structures that separate the brain into compartments,
resulting in a serious problem called herniation
Computed tomography or magnetic resonance imaging of the brain is done. These tests can
detect most hemorrhagic strokes, except for some subarachnoid hemorrhages. If needed to
confirm the diagnosis, a specialized type of MRI, called diffusion-weighted MRI, can show areas
of brain tissue that are deprived of blood. The blood sugar level is measured immediately
because a low blood sugar level (hypoglycemia) can cause symptoms similar to those of stroke.
Doctors evaluate people who have had a stroke for problems that can contribute to or cause a
stroke, such as infection, a low blood oxygen level, and dehydration. The ability to swallow is
evaluated, sometimes with x-rays taken after a radiopaque dye such as barium is swallowed.
Depending on the type of stroke, more tests are done to identify the cause.
Treatments used during the first hours depend on the type of stroke. These treatments include
drugs (such as antiplatelet drugs, anticoagulants, drugs to break up clots, and drugs to control
high blood pressure) and surgery to remove blood that has accumulated. Later and ongoing
treatments focus on preventing subsequent strokes, treating and preventing problems that
strokes can cause, and helping people regain as much function as possible (rehabilitation).
VI. Ecologic Model
Predisposing factors:
I.
Host
a. Gender: Male
b. Age: 63 years old
c. Family History: Hypertension
II.
Agent
a. Diet
b. Lifestyle
III.
Environment
Living condition
Analysis:
The model used was a wheel. The model shows that there are different contributing
factors that affect the client and leads to his CVA Infarctions. These risks factors aggravate the
already present disease of the client like hisfamily history of Hypertension which contributes to
bloodflow to different parts of the body. CVA Infarctions occurs when there is an occlusion to a
blood vessel that leads to the brain, this diminishes the blood supplied to the brain and causes
infarction resulting to damage to nerves and other cells. Age, diet and gender are also some of
the contributing factors wherein in the patients case this is the enabling factors for his condition,
his diet consists mostly of fastfoods and salty food, with his age and gender rendering his more
susceptible to the disease.
VIII. Problem Prioritization

PROBLEMS IDENTIFIED
Impaired
physical
mobility related to
neuromuscular
impairment secondary to
CVA
RANK
1
JUSTIFICATION
This problem is highly
prioritized because it is an
actual problem and gives
the patient discomfort.
This is moderately
prioritized because it can
only prevented if other
underlying aspect can be
reduced or treated.
This is moderately
prioritized because it can
only prevented if other
underlying aspect can be
reduced or treated.
SUBJECTIVE:
medyo Nahihirapan Siyang
Igalaw ung kanang parte ng
katawan
niya as verbalized
by clients daughter.
OBJECTIVES:
-limited range
of motion
-uncoordinated
movements
-slowed movement
Activity intolerance related
to body weakness
secondary to CVA
Subjective
nahihirapan ako
maglakad
Objective
Verbal report of fatigue or
weakness
Inability to begin or perform
Activity
Abnormal heart rate or
blood pressure (BP)
response to activity
Risk for Impaired
Swallowing r/t
Neuromuscular
Impairment
Subjective:
As verbalizes by the client
pag kumakain ako
nahihirapan akong
lumunok.

Opd Case Pres

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Far Eastern University

III. Gordons Assessment

When asked about

Hindi ako masyado

Health perceptions (or

The client also said

He also said that he

The client has changes

The middle aged adult

The client usually

The client usually

Even though the client is

The client usually

The daughter said that

When asked about

When asked about the

Most adults need 7 to

When asked about if

A positive self concept

satisfied with his

other people and look on

The client is happy

The client is happy and

The client said that

The client said that

The client said that

He said that he is very

The clients daughter

III. Physical Assessment

Assessment of Head to Toe

II. Hair and

Deviation from normal

Skin intact; no discharge ; no

the eyelids and

touched, indicating that the

Pupils constrict when looking at

The client can

VI. Nose and

Sound is heard in both ears or is

The client can

[Weber & Kelly, Health Assessment

[Weber & Kelly, Health Assessment

The lips are

Deviation from normal

b. Inner lips and

Uniform pink color (darker e.g.

Smooth with no palpable nodules

e. Hard and soft

Pink and smooth

Muscles equal in size; head

The client can

Not visible on inspection

smooth, centrally located, painless

Symmetrical chest expansion

Breathing patterns are quiet,

Deviation from normal

Full symmetric excursion; thumbs

Equal strength on each body side

+5 - full ROM, full strength

IV. Laboratory and Diagnostic Examinations Results

Gram stain of sputum

Light growth of Pseudomonas putida after growth in 24 hours of incubation.

QRS Interval: 0.08 SEC.

Within Normal Limits