DE LA SALLE HEALTH SCIENCES INSTITUTE COLLEGE OF NURSING AND MIDWIFERY NURSING CASE STUDY

Cerebrovascular Accident
Presented By: APALISOK, Germaine CALIS, Elaine Sarah R. CRUZATE, Justine Antoniette M. DOMINGUEZ, Sherry Mae T. GATBONTON, Imari Jean L. MAGPANTAY, Ivan Leo MASCAREAS, Raffy ONG, Mark Joshua RIVERA, Angeli SOLOMON, Shane VALENZUELA, Deana JonnMariz M.

3/14/2011 AY: 2010-2011

BSN 36
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ADMISSION and FINAL DIAGNOSIS Cerebrovascular Accident

I.

HEALTH HISTORY DOA:December 20, 2010 10:52 am

A. DEMOGRAPHIC (BIOGRAPHICAL DATA) 1. Clients Initial: M.D.J. 2. Gender: Male 3. Age: 62 years old Bithdate: November 19, 1949

Birthplace: Dasmarias, Cavite 4. Marital (Civil Status): Married 5. Race and Nationality: Filipino 6. Religion: Catholic 7. Address:L* PH* Burol 1 Dasmarias, Cavite Telephone Number: ***-**-**

8. Educational Background: Highschool graduate 9. Occupation (usual and present):None 10. Usual Source of Medical Care:Hospital

B. SOURCE AND RELIABILITY OF INFORMATION Clients wife, E.M., who seems reliable Patients chart

C. REASONS FOR SEEKING CARE OR CHIEF COMPLAINTS Numbness of legs for 2 days Slurring of speech for 2 days Loss of consciousness Vomiting

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D. HISTORY OF PRESENT ILLNESS/ OR PRESENT HEALTH

The pt was apparently well until 2 days PTA, pt have experienced numbness of lower extremities after he had a drinking session with friends of one bottle of Gin. As he went home right after symptom ceased, there had been an associated slurring of speech, with again, numbness of the lower extremities. However, no loss of consciousness, headache, dizziness or vomiting was observed. Pt. did not seek for consultation andno medications were taken. 1 day PTA, pts symptoms persisted. No medications were taken. Pts activities of daily living were affected due to the symptoms. Pt. stayed in bed. 1 hour PTA, pt. was observed outside the house, and neighbor found the pt. unconscious, lying on the floor, with drooling of saliva, right arm flexed. He was immediately brought to DLS-UMC. 30 minutes PTA, he had one episode of non-bolus, non-bloody vomiting and eye opening but is unable to speak hence, immediately admitted.

E. PAST MEDICAL HISTORY OR PAST HEALTH During the clients childhood, he had occasional coughs and colds twice or thrice a year. No major illness was noted. Later on in life, the client was experiencing dizziness and has elevated blood pressure which is indicative of having Hypertension. The client has not experienced any accidents in his life. The client may have injuries such as scratches and bruises but these were only considered as minor and were treated with pain-reliever medications or pain-relieving measures such as rest, and compression. Thiswas the clients first hospitalization, and client he hasnt undergone any surgery before. No known allergies in food, environment and medications were noted. The client has no maintenance on medication.
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F. FAMILY HISTORY

K. J., 78 (Old-age)

B. J., 77 (Old-age)

T. D., 75 (Old-age)

P. D., 76 (Old-age)

M. J., 80 (Old-age) HPN

H. D., 82

M. D. J., 62 Cerebrovascular Accident

Based on the genogram, there isa history of HPN running in the family. They are certain that the grandmothers and grandfathers of the pt. on both sides died because of old-age as well as his father. History of HPN was present on the mother side. Thus, the pt. has a probability of acquiring this disease. Unfortunately, the patient does have hypertension which contributed to his health status now.

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G. SOCIO-ECONOMIC The clients son is the one who is providing for their needs especially all the medical and financial expenses. The wife does also ask for the support coming from the PCSO since they are in the service ICU.

H. DEVELOPMENTAL HISTORY The client is 62 years old which falls on the Ego Integrity vs. Despair stage of Erik Eriksons Theory of Psychosocial Development. In this stage, the older adult recognizes changes present as a result of aging, in relationships and activities, maintains relationships with children, grandchildren and other relatives and completes transition from retirement at work to satisfying alternative activities. The older adult also maintains a maximum level of physical functioning through diet, exercise and personal care, integrates philosophical or religious values into understanding of self to promote comfort and he also reviews accomplishment as and recognizes meaningful contributions he or she has made to community and relatives. In this stage of development, it is said that the person achieves ego integrity if he maintains a maximum level of physical functioning which in this case is not seen in the client wherein he had developed Hypertension coming from different factors. These factors can be controlled if the client had a better view of his health, preventing the aggravation of his illness. Some behaviors relating to the achievement of ego integrity cannot be assessed since the client is not conscious at the time of gathering the data.

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I. REVIEW OF SYSTEM AND PHYSICAL EXAMINATION

1. ROS AND PE Examination performed: January 19, 2011

ROS a. General/overall health status Inspection

PE

Received

patient

lying

on

bed,

awake,incoherent, and with poor eye contact.

(+) stupor: awakens to vigorous shake or painful stimuli, but returns to

unresponsive sleep.

(+) general weakness (-) chills (+) inability to speak (+) inability to ingest food (+) dry mucosa Vital Signs: Temperature: 36.4C Pulse Rate: 81bpm Resp. Rate: 20cpm BP: 120/80 mmHg

BM: with diaper Urine:325ml

b. Integument

SKIN: Inspection:

Skin color is consistent all throughout the body

(-) pruritus
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(-) unusual hair growth

Palpation:

(-) lumps (-) tenderness No swelling or edema on the skin Rough and dry skin Skin is warm to touch with a temperature of 36.4oC

Good skin turgor

HAIR: Inspection:

Thin oily hair Dark colored hair Equally distributed on parts of the body

SCALP: Inspection:

No presence of lesions symmetrical (-) dandruff (-) lice/parasites

Palpation:

Smooth and firm scalp

NAILS: Inspection: Nail plate is attached @ the nail bed

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 Round nails (-) clubbing Nail extends to the end of the fingers (+) pale nail beds Nail is round, hard and immobile Palpation: Good capillary bed refill c. Head Inspection:

Symmetrically rounded (-) head injury (-) lesion (-) scars and masses Face: facial features are symmetrical, centered head position

(-) stiffness Unequal movement of the

Temporomanidubular joint, Right side cannot move in synchrony with the Left side d. Eyes Inspection:

Eyes are equal in size and shape bilaterally

Right eye is smaller than the left Symmetrical eyebrows eyelids, eyelashes and

Lid margins are moist and pink Lashes are short, evenly spaced and curled outward

Blinking: symmetrical, complete closure

involuntary with

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(-) cataract (-) use of eye glasses or contact lenses Pupils converge as object moves in toward the nose

PERRLA

e. Ears

Inspection The ears are of equal size and similar in appearance Skin is smooth without nodules Palpation Non-tender auricle and tragus Temperature is warm

f. Nose and Sinuses

Inspection

Symmetric and on the midline, proportion to other body structure

Skin color is consistent with color of the skin on the face

External

nose:

solid

placement,

no

nodules, masses or pain reported

Nasal septum: midline without bleeding, no inflammation on skin lesions.

Palpation (-) nodules/masses Non-tender sinuses g. Mouth and throat Inspection:

Lips dry and in pinkish light color uvula found on the midline tongue in the midline (-) lesions on tonsils and uvula

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(-) bleeding gums (-) abnormal discharges (-) inflammation (-) oral thrush No unusual foul odor

(+) accumulation of saliva in the mouth Palpation (+) dry lips h. Neck Inspection

Neck is symmetrical with other parts of the body

(-) visible pulsations (Neck Vein Engorgement)

Trachea is symmetrical and located at midline.

Palpation Adams apple is palpable (-)non tender and enlarged lymph nodes (-) pain sensation elicited during palpation i. Breast and Axillary Inspection (-) gynecomastia (+) dark brown areolae color of the breast is same with the rest of the body (-) discharge No swelling, ulcerations and nodules Palpation Non-tender breast and axillary nodes upon palpation j. Respiratory Inspection:

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Chest symmetry is equal No use of accessory muscles of respiration No nasal flaring, RR = 20 cpm Scapulae are symmetrical Sternum is level with ribs (+) productive cough: phlegm greenish, viscous, and about 30cc in amount

Intercostal space: even and relaxed

Palpation: (+) tactile thoracic fremitus Auscultation: (-) crackles (+) wheezes on bilateral lung fields Percussion: (+) resonance upon percussion of both lung fields k. Cardiovascular Inspection Pulse Rate: 81bpm Blood Pressure: 120/80 mmHg Palpation No vibrations or pulsations are palpated in aortic, pulmonic, or tricuspid area Upper extremities are warm Bilateral pulses are strong and equal Auscultation Regular heart rate: 86bpm Normal heart sounds l. Urinary Urine Frequency: 325ml
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Inspection >yellowish urine color >continuous stream >no blood traces seen Palpation (-) pain in the flank or low back m. Genitalia Inspection (-) discharge in the penis (-) lesions or ulcerations n. Musculoskeletal Inspection (+) symmetrical structure and

development of the muscles Bilaterally symmetrical and equal bone structure and bony landmarks of the lower extremities

(+) body malaise (+) numbness on the right part

Muscle strength: Right upper extremities = 0 Right lower extremities = 0 Left upper extremities = 1 Left lower extremities = 1 Palpation Non-tender shoulders Non-tender and warm hips Percussion: Tympany over large muscular areas o. Neurologic Inspection

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 Cranial Nerve I (olfactory nerve): (+)ability to identify the smell between the alcohol and cologne Cranial nerve II (Optic nerve):Unable to test, client has impaired verbal

communication Cranial nerve III(oculomotor nerve), Cranial nerve IV(Trochlear nerve), Cranial nerve VI (Abducens nerve): PERRLA (+) constriction of pupils when light was introduced, right eye has difficulty to move through the 6 ocular fields of vision able to see and identify objects using the peripheral vision Cranial Nerve V(trigeminal nerve): (+) blinking reflex able to feel light touches in mandibular and maxillary regions Muscles contract bilaterally on clenching teeth Cranial Nerve VII(Facial nerve): unsymmetrical facial expression but able to blink, frown, smirk, wink and smile without difficulty Cranial nerve VIII(acoustic nerve): (+) response to whispering of patients name approximately 5 meters away Cranial nerve IX(glossopharyngeal nerve): (+) gag reflex
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 Cranial nerve (vagus nerve)X: Uvula in midline, moves upward when saying Ah (+) Gag reflex Cranial Nerve XI (Accessory nerve):
The pt. was not able to shrug his

shoulders but able to turn his head only on left side.There is contraction of muscle on side

sternocleidomastoid

opposite the turned face Cranial nerve XII (Hypoglossal nerve): Tongue movement is symmetric and smooth and bilateral strength is apparent. p. Gastrointestinal Inspection BM: with diaper (+) soft, dark colored stools Palpation (-) masses in the abdomen Nontender abdomen Auscultation (+) regular bowel sounds at 7 per minute No bruits, no venous hums heard in the abdomen q. Hematologic Inspection (-) bruises (-) bleeding r. Endocrine Inspection (-) abnormal hair distribution (-) excessive sweating

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2. LABORATORY STUDIES/ DIAGNOSTICS Procedure and Date Indication Normal Values/ Findings Actual Findings Nursing Responsibilties/Implications (PRE, INTRA, POST) Hematology January 4, 2011 Hct 0.36-0.45 5-10 x 109/L 0.42 Hgb 123-153 g/L 139 g/L Pre: Check the Doctors order. Identify the pt. Check the VS. Ensure pts. and their family is provided with written

WBC Differential Count Segmenters

8.7 x 10g/L

0.36-0.66

0.43

statements of their "Rights and Responsibilities". Decrease pts anxiety by

Lymphocytes

0.22-0.40

0.51 Implication: Increased lymphocytes may indicate presence of viral infection.

explaining the procedure and why it is performed. Ensure that pts. are aware of, understands and is involved in the procedure. Gathers information from

relatives who accompany the pt. to hospital. Acknowledge questions

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Eosinophils Monocytes

0.01-0.04 0.04-0.08

0.03 0.03 Implication: Decreased monocytes may indicate

overwhelming infections, dietary deficiencies, and some drug toxicities

regarding the safety of the procedure. Intra: Maintain a constant safe

environment for the pt. based on the Risk Assessment. Maintain a safe and

operational environment of all the Provide resources in the

Laboratory. ongoing monitoring

and reporting of pts. mental and hemodynamic state. If the test is to be done at bedside, remain with the pt. Post: Ensure the procedures are completed. Check the site for bleeding, cyanosis, or swelling. Check VS for any changes.

Identify the number of blood components. Can also tell if there is an infection

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 Provide an explanation of and ensure pts. understanding of rights and responsibilities. Document the data (attach to the chart). Liaise with the other Health Team members for other

collaborative interventions. Blood Chemistries January 2, 2011 Sodium 137-145 mmol/L 136mmol/L Implication: Decreased sodium may be an indication of hyponatremia due to excess water or Serum Creatinine 58-110umol/L 59umol/L PRE: The nurse should explain the purpose and the procedure of the BUN and Creatinine test. INTRA: The nurse should facilitate with the extraction of blood from a vein and practice sterile technique at the time of the procedure. The extracted blood is then passed onto the laboratory for Potassium 3.505.10mmol/L 3.30 mmol/L the interpretation of the

fluid in the body

results.
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Implication:Decre ased potassium may be an indication of hypokalemia due to certain medications and may also indicate health condition such as: injury to tissue and infection BUN creatinine are done and tests to

POST: The nurse should facilitate in getting the result of the exam and coordinating with the

doctor regarding the result of the exam.

monitor

kidney

function. If blood levels of these substances high, are

kidney

disease may be present. Test

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results can also be used to other

diagnose medical conditions. Potassium

Test

is used to detect concentrations that are too high (hyperkalemia) or too low

(hypokalemia). Blood sodium

testing is used to detect hyponatremia or hypernatremia associated dehydration, edema, variety diseases. and a of with

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PT/ PTT December 2010 30,

PT time

10-14 seconds

12 seconds

PRE: Check the medications that

Prothrombin time (PT) blood test measures long it is a that how takes

the client is actually taking because many medicines can change the results of this test. Explain the procedure to client INTRA: Wrap an elastic band around the upper arm to stop the flow of blood. This makes the veins below the band larger so it is easier to put a needle into the vein. Clean the needle site with alcohol. Put the needle into the vein. Attach a tube to the needle to fill it with blood. Remove the band from your arm when enough blood is collected.

blood to clot. A prothrombin time test can be used to check for

bleeding problems. PT is also check medicine prevent used to

whether to blood

clots is working.

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POST: Put a gauze pad or cotton ball over the needle site as the needle is removed Put pressure to the site and then a bandage. Inform the client regarding the test results Urinalysis January 3, 2011 Color Character Specific Gravity Ph Albumin Sugar WBC RBC Amorphous urates Epithelial Cells Group of manual and/or automated qualitative and semi-quantitative tests performed on a urine Yellow-Amber Clear 1.002-1.030 4.5-7.7 0 - 8 mg/dl negative 0-5/ HPF 0-2/HPF Few Yellow Clear 1.010 5.0 Negative Negative 0-2/HPF 0-2/HPF Few Rare PRE: Check the medications that the client is actually taking because many medicines can change the results of this test. Explain the procedure to client INTRA: Wrap an elastic band around the upper arm to stop the flow of blood. This makes the veins below the band larger so it is easier to put a needle into the vein. Clean the needle site with
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sample. Performed for general health screening to detect renal and metabolic diseases, diagnosis of diseases or disorders of the kidneys or urinary tract, monitoring of patients with diabetes.

alcohol. Put the needle into the vein. Attach a tube to the needle to fill it with blood. Remove the band from your arm when enough blood is collected. POST: Put a gauze pad or cotton ball over the needle site as the needle is removed Put pressure to the site and then a bandage. Inform the client regarding the test results

CT Scan of the Brain December 2010 28,

CT scan is used to define normal and abnormal structures in the body and/or assist in procedures by

The brain and blood vessels and bones of the skull and face are normal in

Plain CT scan of PRE: the brain was The nurse should explain the performed. indication and the procedure Examination was for the client. studied with 1.25 Instruct client that fluids and mm thick section food may be restricted for at 1.25 mm intervals. All of the several hours prior to the sections are
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helping to accurately guide the placement of instruments or treatments.

size, shape, and position. No foreign objects or growths are present. No bleeding

parallelat the orbito-meatal line. There is hypodensity seen in both frontal peroventricular regions.

examination Tell the client that the actual procedure can take from a half an hour to an hour and a half. INTRA: Tell the patient that all metallic materials and certain clothing around the body are removed because they can interfere with the clarity of the images. It is important during the CT scan procedure that the patient minimizes any body movement by remaining as still and quiet as is possible. The CT scan technologist tells the patient when to breathe or hold his/her breathe during scans of the chest and abdomen.

The brainstem as or collections well as the cerebellum is of fluid are unremarkable. present. The ventricular systems are dilated with prominent cortical sulci There is no shift of midline structures nor there is evidence of subdural or epidural hematoma formation. The cerebellopintinean

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gle, sella, orbits and bony calvarium are unremarkable. There is sclerosis of the left mastoid air cells.

POST: The nurse should facilitate in getting the result of the exam and coordinating with the doctor regarding the result of the exam.

Impression: Chronic small vessel ischemia both frontal periventricular regions. Central and

peripheral cerebral atrophy mastoiditis, left.

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3. OTHER ASSESSMENT TOOLS

Date(S) Taken

Comprehensive Actual Content Legend

Actual Results

Muscle strength 0 = No muscle movement (Oxford Scale) 1 = Capable of spontaneous January 19, 2011 muscle twitching 2 = muscle strong enough to perform its designated joint movement 3 = muscle strong enough to perform the joint action to the full range against gravity but with no resistance applied 4 = muscle can move the joint through the full movement both against gravity and against some resistance such as body weight 5 = muscle can move through the joint in normal power and against most resistances Glasgow Coma Scale January 19, 2011 Eye Response: 1. No eye opening 2. Eye opening to pain 3. Eye opening to verbal command 4. Eyes open spontaneously Verbal Response: 1. No verbal response 2. Incomprehensible sounds

Right side: Grade 0 Left side: Grade 1

E3V2M4 = GCS 9

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3. Inappropriate words 4. Confused 5. Oriented Motor Response: 1. 2. 3. 4. 5. 6. No motor response Extension to pain Flexion to pain Withdrawal from pain Localizing pain Obeys commands

J. FUNCTIONAL ASSESSMENT Date of interview: January 18, 2011

1. Health Perception/ Health Management Pattern Clients wife said that one factor that may have caused his illness is the genetic predisposition of the client to inheritable diseases. His use of alcohol and smoking habits may have triggered his illness. Whenever the client experiences discomforts or for any health problem, they go directly to the hospital for consultation and check-ups. The pt is in a more stable condition since he was admitted to the hospital, his mechanical ventilator was already removed, he doesnt have any contraptions, and he can now somehow feel if somebody touches his arms. 2. Self Esteem, self-concept/ Self Perception Pattern Self-Esteem, self-concept and self-perception pattern is purely subjective in nature and it should be answered by the client. Since the client was not conscious at the time, this aspect cannot be assessed. 3. Activity-Exercise Pattern The client does not have regular exercise but according to his wife, his ADL includes walking every day in their subdivision 10-20 minutes. As the wife narrates his husband experience stress in his office and relieves these by eating adequate food and having sufficient rest and relaxation. When the client is in their house, he usually rest, watch TV or just play with their pet dogs. With the clients present condition (stupor), he cannot perform activities such as feeding, bathing, toiling, dressing, grooming, cooking,
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general mobility and home maintenance. He requires full assistance and is dependent on the other members of the family for these activities.

Before hospitalization, his perceived ability for different activities is: Feeding Bathing Toileting Bed Mobility Dressing Grooming General Mobility Now that he is hospitalized, his perceived ability for different activities is: Feeding Bathing Toileting Bed Mobility Dressing Grooming General Mobility 3 3 3 3 3 3 3 0 0 0 0 0 0 0

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Legend: Legend Level 0 Level 1 Level 2 Level 3 Functional Level Code Full self-care Requires use of equipments or device Requires assistance or supervision from another person Requires assistance or supervision from another person or device

4. Sleep-Rest Pattern The client usually has different times of sleep depending on his activities for the day. If he had done stressful and strenuous activities during the day, he doesnt find it difficult to sleep during the night and still manages to have 7-8 hours of sleep and even if he doesnt do anything during the day, even though sometimes he comes home late. Before sleeping, he eats midnight snack or just watch TV. He also takes nap during noontime. When he was admitted to the hospital, his wife said that her husband somehow experiences difficulty in sleeping because of the doctors and nurses in his room. 5. Nutritional/Elimination Before hospitalization, the client takes in about 1 cup or rice or a small piece of meat, fish or vegetables and loves to eat fatty foods. During hospitalization, the client experiences difficulty in chewing and swallowing food because of his altered level of consciousness. An NGT tube is inserted to facilitate the ingestion of food to meet the nutritional requirements of the client having 1400kcal diluted in 1000cc of water given in 6 equal feeding. Before hospitalization, the client usually defecates once a day and the stool has a brown and normal consistency.But during hospitalization, the client cannot defecate so laxative was prescribed soften the stools and facilitate defecation. He is currently experiencing constipation, because of prolonged immobilization.

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6. Sexuality/ Reproductive Pattern Patient has three children two boys and a girl all of them have their own family, and is currently living in Bicol. 7. Interpersonal Relationships/Resources Before the clients hospitalization, he has a harmonious relationship with his family and friends, he also make it a point that somehow they have communication with his children even though they are living far from him. He is also the prime decision maker for the family regarding financial, personal and social aspects. But regarding his condition, his family feels sad because they cant even talk to him and he barely recognizes his family members. 8. Coping and Stress Management/ Tolerance Pattern Before the clients hospitalization, the client usually releases his stress and problems through the use of alcohol and smoking while having a conversation with his friends. He usually takes in 5-6 glasses of alcohol sometimesand usually smokes a lot having 1 pack per day to divert his attention and forget all his problems. 9. Personal Habits The client smoke whenever his with friends or having problems, so that he will feel better, he also drinks alcohol sometimes amounting to about 5-6 glasses of beer and liquors per day. 10. Environmental Hazards The location of their house and their neighborhood is considered safe but little bit crowded, according to the clients wife. He lives with his family and it was said that he has harmonious relationship with their neighbors because some were there family friends. They were a resident of their place for quite long and they have already have adapted to their environment. Their place was not far enough from the commercial area and markets so it was very convenient on their part. There is adequacy of utilities and accessibility to transportation. They have good clinics near them and there was DLSUMC Hospital which served as sources of their medical care.

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II. PROBLEMS IDENTIFIED

A. Actual or Active Problem No. Problem Date Identified 1/19/11 Date Resolved/Remarks

Ineffective Airway Clearance

01/19/11 Goal met. Client manifested clear breath sounds.

Impaired physical mobility

01/18/11

01/18/11 Goal met. Client maintained optimal position of function as evidenced by absence of contractures and foot drop.

Impaired Verbal Communication

01/18/11

01/18/11 Goal met. Client used eye response/movement as method of communication.

Constipation

01/18/11

01/18/11 Goal not met. Client was not able to defecate during the shift.

B. High Risk or Potential Problem No. 1 Problem Risk for infection Date Identified January 18, 2011

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III.

IMPLEMENTED NURSING CARE PLAN

CUES NURSING DIAGNOSIS LONG TERM SHORT TERM INTERVENTIONS RATIONALE EVALUATION

OBJECTIVE (+) productive cough: greenish thick phlegm, about 30 cc (-) nasal flaring (+) pursed -lip breathing (+)general ized weakness (+) wheezes on bilateral lung fields (-) Use of accessory Ineffective Airway Clearance r/t Accumulation of thick, tenacious, tracheobronchi al secretions The client will be able to facilitate the maintenanc e of a supply of oxygen After 8 Independent: hours of nursing Auscultated breath intervention sounds. Note s, the adventitious breath patient will sounds; wheezes, be able stridor manifest clear breath sounds Some degrees of bronchospas m are present with obstructions in airway and may/may not be manifested in adventitious breath sounds; absent breath sounds in severe asthma. Tachypnea is usually present to some degree and may be pronounced
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Goal met. Pt. was able to manifest clear breath sounds.

Assessed/monitored respiratory rate. Note inspiratory/ expiratory ratio.

muscles (+) tactile thoracic fremitus RR: 20 cpm

on admission or during stress/concu rrent acute infectious process. Respirations may be shallow and rapid, with prolonged expiration in comparison to inspiration. Noted presence/degree of dyspnea; reports of air hunger, restlessness, anxiety, respiratory distress, use of accessory muscles. Respiratory dysfunction is variable depending on the underlying process; e.g. infection, allergic reaction and the stage of chronicity in a client with established COPD.

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 Assisted client to assume position of comfort; e.g. elevate head of bed

To facilitate respiratory function by use of gravity; however, client in severe distress will seek the position that most eases breathing. Supporting arms/legs with table, pillows and so on helps reduce muscle fatigue and can aid chest expansion. Precipitators of allergic type of respiratory reactions that can trigger/
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Kept environmental pollution to a minimum (e.g. dust, smoke and feather pillows). According to individual situation.

exacerbate onset of acute episode. Assisted with abdominal or pursedlip breathing exercises. To provides client with some means to cope with/control dyspnea and reduce airtrapping. Cough can be persistent but ineffective, especially if client is elderly, acutely ill or debilitated. Coughing is most effective in an upright or in a headdown position after chest
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Observed characteristics of cough; e.g. persistent, hacking, moist. Assist with measures to improve effectiveness of cough effort.

percussion.

Collaborative: Suctioned tracheobronchial secretions To remove excess tracheobronchial secretions

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CUES Objective: (+) Body weakness

Limited range of motion on the right side

NURSING DIAGNOSIS Impaired physical mobility related to decrease strength and endurance secondary to Cerebrovascular Accident

LONG TERM The client will be able to maintain good body mechanics and prevent or correct deformity.

SHORT INTERVENTION TERM Within the Independent: shift, the Observed client will affected side increase for color, strength and edema or function of other signs of affected body compromised part and circulation. maintain optimal position of function. Inspected skin regularly, particularly over bony prominence.

RATIONALE

EVALUATION Goal met. Client maintained optimal position of function as evidenced by absence of contracture s and foot drop.

Edematous tissue is more easily traumatized and heals more slowly.

Pressure points over bony prominences are most at risk for decreased perfusion.

To reduce Changed risk of tissue positions at injury. least every 2 hours (supine, side lying)
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and more often if placed on affected side.

Positioned in prone once or twice a day if client can tolerate.

To help maintain functional hip extension

Used footboard during the period of flaccid paralysis. Maintained neutral position of

To prevent contractures / footdrop. Flaccid paralysis may interfere with ability to support head.

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head.

Gently massaged any reddened areas.

Circulatory stimulation helps prevent skin breakdown decubitus ulcer development .

Began passive range of motion exercises to all extremities

To minimize muscle atrophy, promotes circulation and helps prevent contractures.

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 Encouraged adequate fluids and right diet as necessary to the client.

To increase energy production.

Provided rest periods between activities. Assisted to develop sitting balance (e.g., raise head of bed; increase sitting time)

To reduce fatigue and oxygen demand. To aid in retraining neuronal pathways, enhancing proprioceptio n and motor response.

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Collaborative: Administer muscle relaxants, antispasmodi cs as indicated.

To relieve spasticity in affected extremities

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CUES OBJECTIVE: (+) Dysarthria (+) Body weakness

NURSING DIAGNOSIS Impaired verbal communication r/t impaired cerebral circulation; neuromuscular impairment loss of facial/oral muscle tone/control 2oCVA

LONG TERM To facilitate the maintenance of effective verbal and nonverbal communicatio n.

SHORT INTERVENTION RATIONALE TERM Within the Independent: shift, the Assessed To help client will type / degree determine demonstrate of area and understandin dysfunction: degree of g of e.g., receptive brain treatment aphasia. involvement and establish and difficulty an alternative client has method of with any or communicati all steps of on in which the needs can be communicati expressed. on process.

EVALUATION Goal met. Client used eye response/ movement as method of communica tion.

Provided To provide alternative for methods of communicati communicatio on of needs / n (e.g., writing desires or felt board, based on pictures). individual Provided situation / visual clues underlying (gestures,
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pictures, demonstration ).

deficit.

Anticipated and provide for clients needs.

Helpful in decreasing frustration when dependent on others and unable to communicat e desires.

Talked directly to client, speaking slowly and distinctly.

To reduce confusion / anxiety at having to process and respond to large amount of information
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at one time.

Used yes / no Advancing questions to complexity of begin with, communicati progressing in on complexity as stimulates client memory and responds. further enhances word / idea association.

Spoke with normal volume and avoid talking too fast.

Client is not necessarily hearing impaired and raising voice may irritate or anger client.

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 Gave client ample time to respond. Talked without pressing for a response.

Forcing responses can result in frustration and may cause client to resort to automatic speech (e.g., garbled speech, obscenities).

Respected clients preinjury capabilities; avoided speaking down to client or making patronizing remarks.

To enable client to feel esteemed because intellectual abilities often remain intact.

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Collaborative: Referred to speech therapist To assess individual verbal capabilities and sensory, motor and cognitive functioning to identify deficits / therapy needs.

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CUES Objective (-) bowel movement (+) immobility

NURSING DIAGNOSIS Constipation r/t defective nerve stimulation, weak pelvic floor muscles, and immobility 2 to Cerebrovascular Accident

LONG TERM The client will be able to maintain good hygiene and physical comfort.

SHORT TERM Within the shift, the client will be able to defecate.

INTERVENTION Independent: Identified previous bowel habits and encourage increase in activity by performing passive ROM and assisted in sitting position.

RATIONALE Independent: To assist in development of retraining program and to aid in preventing constipation and impaction.

EVALUATION Goal not met. Pt. was not able to defecate within the shift.

(+) constipation

Collaborative: Administered stool softeners. May be necessary at first to aid in establishing regular bowel function.

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CUES OBJECTIVE

(+) productive cough: phlegm greenish, viscous, and in moderate amount

NURSING DIAGNOSIS Risk for infection r/t compromised host defenses 2o increased length of hospital stay.

LONG TERM To promote safety through prevention of accident, injury, or other trauma, and through the prevention of the spread of infection.

(+) wheezes on right unilateral lung field

VS as follows: 36.7oC 82bpm, 19cpm, 140/100mmHg

SHORT INTERVENTION RATIONALE EVALUATION TERM Within the Independent: Goal shift the pt. met.pt. was Provided First-line of will be able to able to meticulous/as defense understand understand eptic care, against together with together maintain good nosocomial his family the with his handwashing infection ways to family the techniques. prevent ways how acquiring and to prevent transmitting infection. Early Observed infection. identification areas of of impaired skin developing integrity infection permits prompt intervention and prevention of further complication s.

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 Providedperin eal care.

To reduce potential for bacterial growth/asce nding infection.

Collaborative: Obtained specimen such as sputum as indicated. Culture/sensi tivity, Grams stain may be done to verify presence of infection and identify causative organism and appropriate treatment choices.

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 Suctioned patient as indicated

To remove increased secretions that may lead to a secondary illness.

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IV. ANATOMY AND PHYSIOLOGY THE NERVOUS SYSTEM Nervous system is made up of two principal types of cells: (1) neurons (nerve cells) transmit nerve impulses; and (2) neuroglia supports and nourishes neurons.

Nervous system has three specific functions:

Sensory input. Sensory receptors present in skin and organs respond to external and internal stimuli by generating nerve impulses that travel to the brain and spinal cord.

Integration. Brain and spinal cord sum up the data received from all over the body and send out nerve impulses.

Motor output. Nerve impulses from the brain and spinal cord go to the effectors, which are muscles and glands. Muscle contractions and gland secretions are responses to stimuli received by sensory receptors.

Neuron Structure: Neurons vary in appearance, but all of them have just three parts: a cell body, dendrite(s), and an axon. Cell body contains the nucleus as well as other organelles. At dendrites, signals can result in nerve impulses that are then conducted by an axon. The axon is the portion of a neuron that conducts nerve impulses. Any long axon is also called a nerve fiber. Long axons are covered by a white myelin sheath formed from the membranes spiraled neuroglia. In peripheral nervous system, a of neuroglial cell tightly called

a neurolemmocyte (Schwann cell) performs this function, leaving gaps called

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neurofibril nodes (nodes of Ranvier). Another type of neuroglial cell performs a similar function in the central nervous system. Synapse. The junction between a nerve cell and another cell is called a synapse. Messages travel within the neuron as an electrical action potential. The space between two cells is known as the synaptic cleft. To cross the synaptic cleft requires the actions of neurotransmitters. Neurotransmitters are

stored in small synaptic vesicles clustered at the tip of the axon.

The nervous system is composed of all nerve tissues in the body. The functions of nerve tissue are to receive stimuli, transmit stimuli to nervous centers, and to initiate response. The central nervous system consists of the brain and spinal cord and serves as the collection point of nerve impulses. The peripheral nervous

system includes all nerves not in the brain or spinal cord and connects all parts of the body to the central nervous system. The peripheral (sensory) nervous system

receives stimuli, the central nervous system interprets them, and then the peripheral (motor) nervous system initiates responses. The somatic functions that nervous are system controls under conscious

voluntary control such as skeletal muscles and sensory neurons of the skin. The autonomic nervous system, mostly motor nerves, controls functions of

involuntary

smooth

muscles,

cardiac
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muscles, and glands. The autonomic nervous system provides almost every organ with a double set of nerves - the sympathetic and parasympathetic. These systems generally but not always work in opposition to each other. The sympathetic system activates and prepares the body for vigorous muscular activity, stress, and emergencies. While the parasympathetic system lowers activity, operates during normal situations, permits digestion, and conservation of energy. Division of the Nervous System (Simplified)

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CENTRAL NERVOUS SYSTEM The Central Nervous System (CNS) is composed of the brain and spinal cord. The CNS is surrounded by bone-skull and vertebrae. Fluid and tissue also insulate the brain and spinal cord. Brain

Brain has cerebrum, diencephalon, cerebellum, and brain stem. The brains four ventricles are called, in turn, the two lateral ventricles, the third ventricle, and the fourth ventricle.

Cerebrum: Cerebrum is largest portion of brain in humans. Cerebrum is

last center to receive sensory input and carry out integration before commanding voluntary motor responses. It communicates with and coordinates the activities of other parts of the brain.

Diencephalon: Hypothalamus and thalamus are in diencephalon, a

region that encircles third ventricle. Hypothalamus is an integrating center that helps maintain homeostasis by regulating hunger, sleep, thirst, body

temperature, and water balance. Thalamus is on the receiving end for all sensory input except smell. Visual, auditory, and somatosensory information arrives at thalamus via cranial nerves and tracts from spinal cord. Thalamus integrates this information and sends it on to appropriate portions of cerebrum.
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Cerebellum: It is the third part of the hindbrain, but it is not considered

part of the brain stem. Functions of the cerebellum include fine motor coordination and body movement, posture, and balance

Brain Stem: Brain stem contains midbrain, pons, and medulla oblongata.

The midbrain acts as a relay station for tracts passing between the cerebrum and spinal cord or cerebellum. It also has reflex centers for visual, auditory, and tactile responses. Pons contains bundles of axons traveling between cerebellum and rest of CNS. Pons functions with the medulla oblongata to regulate breathing rate and has reflex centers concerned with head movements in response to visual and auditory stimuli.

Spinal Cord Spinal cord is a cylinder of nervous tissue that begins at base of brain and extends through a large opening in skull called the foramen magnum. The spinal cord is protected by vertebral column, which is composed of individual vertebrae. The gray matter of the spinal cord consists mostly of and dendrites. cell The

bodies

surrounding white matter is made up of bundles of interneuronal axons (tracts). Some tracts are ascending (carrying messages to the brain), others are descending (carrying messages from the brain). The spinal cord is also involved in reflexes that do not immediately involve the brain.

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PERIPHERAL NERVOUS SYSTEM The Peripheral Nervous System (PNS)contains only nerves and connects the brain and spinal cord (CNS) to the rest of the body. The axons and dendrites are surrounded by a white myelin sheath. Cell bodies are in the central nervous system (CNS) or ganglia.

Ganglia are collections of nerve cell bodies. Cranial nerves in the PNS take impulses to and from Spinal

the brain (CNS).

nerves take impulses to and away from the spinal cord. There are two of the major PNS the the

subdivisions motor somatic autonomic.

pathways: and

Somatic system serves the skin, skeletal muscles, and tendons. It includes nerves that take sensory information from external sensory receptors to the CNS and motor commands away from the CNS to the skeletal muscles. Autonomic system regulates activity of cardiac and smooth muscles and glands.

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Two main components of the PNS: 1. CNS. 2. Motor (efferent) pathways that carry signals to muscles and glands Sensory (afferent) pathways that provide input from the body into the

(effectors). Most sensory input carried in the PNS remains below the level of conscious awareness. Input that does reach the conscious level contributes to perception of our external environment. Nervous System Homeostasis Nervous system detects, interprets, and responds to changes in internal and external conditions to keep internal environment relatively constant. Together with endocrine system, it coordinates and regulates functioning of other systems in the body to maintain homeostasis. Everyday regulation of internal organs that maintains composition of blood and tissue fluid usually takes place below level of consciousness. Subconscious control is dependent on reflex actions that involve the hypothalamus and medulla oblongata. Hypothalamus and medulla oblongata act through autonomic nervous system to control such important parameters as the heart rate, the constriction of the blood vessels, and the breathing rate. Because nervous system stimulates skeletal muscles to contract, it controls major movements of body. When we are in a fight-or-flight mode, nervous system stimulates the adrenal glands and voluntarily controls skeletal muscles to keep us from danger.

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V. PATHOPHYSIOLOGY
Modifiable Non-Modifiable

Legend: Risk factors Lab S/Sx Process Sequence -

Hypertension Age (more than 55) Smoking Hereditary Diabetes Mellitus Sex (male) Heart disease Previous stroke/attacks Poor diet Obesity Alcohol abuse Elevated cholesterol level Atherosclerosis

Vomiting, Seizures, Fever, Confusion, Labored or irregular respiration, Apneic period, Increased BP,Bowel and bladder incontinence,Dysarthria, Apraxia

Occlusion by major vessels Structural integrity loss of brain tissue and blood vessels

Vascular wall becomes weakened and fragile

Leaking of blood
Sudden weakness, Numbness, Paralysis in faces, arm, leg typically on one side,Slurred speech/ difficulty understanding other, sudden blindness in one or both eyes/ double vision, Dizziness, lack of balance/ coordination, Loss of consciousness

Rupture of brain aneurysm

Cerebral hemorrhage

Breakdown of the protective Blood Brain barrier

Mass of blood forms and grows Vascular Congestion

Cerebral Hypoperfusion

Impaired distribution of oxygen and glucose

Tissue hypoxia and cellular starvation

Hematology, UA, CT Scan, Blood Chemistries, PT/PTT

Compression of tissue Increased Intracranial

CEREBROVASCULAR ACCIDENT

Impaired perfusion and function 57 | P a g e

Synthesis

Modifiable risk factors for CVA include: Hypertension, smoking, diabetes mellitus, heart diseases, poor diet, obesity, alcohol abuse, and elevated cholesterol level while the non-modifiable risk factors include: Age (more than 55), heredity, sex (male), and previous stroke/attacks. The brain is very sensitive to a loss of blood supply. Hypoxia can cause cerebral ischemia because unlike other body tissues, such as muscle, the brain cannot use anaerobic metabolism in the absence of oxygen and glucose. The brain is perfused at the expense of other less vital organs to preserve cerebral metabolism. If blood flow is not restored, brain tissue sustains irreversible damage or infarction within minutes. The extent of infarction depends on the location and size of the occluded artery and the adequacy of collateral circulation to the area it supplies. The clients baseline oxygen level and ability to compensate determine how quickly irreversible changes occur. Blood flow can be altered by localized perfusion problems, such as stroke, or by generalized perfusion problems, such as hypotension or cardiac arrest. Cerebral perfusion must fall to two thirds of normal before the brain receives adequate blood flow. A client who has lost compensatory auto regulation experiences manifestations of neurologic deficit sooner. Decreased cerebral perfusion is usually caused by occlusion of a cerebral artery or intracerebral hemorrhage. Occlusion produces ischemia in the brain tissue supplied by the affected artery and edema in the surrounding tissue. Cells in the center of the stroke area, of the core, die almost immediately after stroke onset; this is referred to as primary neuronal injury. A zone of hypoperfusion also exists around the infarcted core; this zone is called the penumbra. The size of this zone depends on the amount of collateral circulation present. Collateral circulation describes the vessels that augment the major circulatory vessels of the brain. Differences in the size and number of collateral vessels help to explain variations in the severity of manifestations experienced by clients with strokes in the same anatomic area.

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A cascade of biochemical process occurs within minutes of cerebral ischemia. Neurotoxins, including oxygen free radicals, nitric oxide, and glutamate, are released. Local acidosis develops. Membrane depolarization occurs. This results in an influx of calcium and sodium. Cytotoxic edema and cell death are a result; this is secondary neuronal injury. Penumbral neurons are highly susceptible to the effects of ischemic cascade. The area of edema after ischemia may lead to temporary neurologic deficits. Edema may subside in a few hours or sometimes in several days, and the client may regain some function.

VI. MEDICAL-SURGICAL MANAGEMENT

1. Procedures Procedure Date Osteorized Feeding (Gavage) Date: January 18, 19, 25, 2011 Indication For patients who dont have the ability to take food via oral route. To promote rest of stomach Nursing Responsibilities (PRE, INTRA, POST) Pre: Prepare the food. Divide the total amount of food to the required amount of food to be taken by the patient. Take it with medications Medications should be crushed well. Check patency of your NGT. Check VS. Intra: Flush first through the use of water. After flushing, start the feeding right away. Administer flushing every after feeding since there
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are medications included in the food. Check signs of aspirations Stop is necessary. Post: After feeding, flash again using water.

Procedure Date Suctioning Date: January 19, 2011

Indication Patient's inability to adequately clear the airway by cough

Nursing Responsibilities (PRE, INTRA, POST) Pre: Review the patient's chart for physician order, and note any indications, contraindications, or potential side effects of therapy ordered. Review the patient's history, physical diagnosis, progress notes, CXR, lab reports (including PFT's and ABG'S) and medications before performing the procedure. Identify patient to those on the physicians orders for therapy. Examine and auscultate patient. Assemble Equipment Attach connective tubing to suction regulator/equipment and inlet of suction container. Connect suction machine
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to vacuum wall outlet. Turn vacuum on, and occlude tip of connective tubing. If no suction is demonstrated on gauge, tighten all connections. If still no suction occurs increase vacuum. If still no suction occurs, label machine "defective" obtain another suction machine, reassemble and retest Identify patient by verification of name by verbal questioning. Identify yourself. Inform the patient/family of the procedure and its purpose. Be prepared to answer any questions about the procedure that the patient may have.

Intra: Wash hands and apply personal protective equipment as indicated (gloves and submicron masks mandated, gowns, eye protection if splashing is likely to occur.) Position the patient by extending the neck slightly to facilitate entrance into the trachea (especially for nasotracheal auctioning) Open suction catheter exposing only the connector, attach to connective tubing and
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maintain sterility of catheter. Fill sterile box with sterile water, and place a dab of water-soluble lubricant on sterile envelope if nasotrachealauctioning is to be performed. Check heart rate before, during and after procedure. If tachycardia or bradycardia occurs discontinue the procedure until it resolves. Place sterile gloves on both hands. Remove suction catheter from envelope maintaining sterile technique. Insert the catheter through the nose or endotracheal tube to the point of restriction without applying suction again. After the restriction has been passed, slowly advance catheter. Ask patient to take deep breaths or watch for inspiration. Pass catheter into trachea. Once catheter has been placed in trachea, slowly withdraw while applying intermittent suction and rotating catheter. Remember: Suction should not be applied for more than 10-15 seconds.

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Post: Instruct patient to take several slow, deep breaths Clear suction tubing with sterile saline Discard suction catheter inside glove. Auscultate patient's lungs bilaterally and takes vital signs. (Respirations should be quiet and occur with less effort.) Wash hands with antimicrobial soap. Documents the following information on the patient's record: frequency of suctioning amount, color, consistency, odor of secretions, and respiratory status. Patient's tolerance to suctioning procedure. any complications and nursing actions taken

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2. Pharmacotherapeutics/ Medicines GN (BN) Classification Stock Citicoline (Cholinerv) CNS Stimulants/ Neurotonics 500 mg For acute and recovery phase of cerebral infarction, cognitive dysfunction due to cerebral insufficiency 500 mg1 tab taken twice a day Indication (Client-Specific) Dosage and Frequency Nursing Responsibilities/ Implications (PRE, INTRA, POST) PRE: Verify the doctors order first. Assess allergy for warfarin. Explain the purpose of the drug. Assess any history pt allergy with Citicoline Medication should be administered at least 6 hours before bed time to minimizesleep disturbances. Make sure that the contents of other medication to be administered doesntcontainmeclofenoxat e. INTRA Administer drug per orem Tell the pt that he/she may experience the following side effects: trouble sleeping (insomnia), headache, diarr hea, low or high blood pressure, nausea, blurred vision, and chest pains Tell the patient to take the medication with a full glass of water. POST Monitor the adverse
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reaction. Watch out for hypotensive effects. Document the procedure. Telmisartan(Pritor) Antihypertensive; Angiotensin II receptor antagonist 40 mg Treatment of hypertension, alone or in combination with other antihypertensive 40 mg 1 tab OD PRE Verify the doctors order first Assess hypersensitivity with the drug Tell the purpose for taking this drug INTRA Take drug without regard to meals. Tell patient that he/she may experience these side effects: headache, worsening of symptoms , fever, chills POST Assess for adverse reaction Instruct pt. to report headache, worsening of symptoms, fever, chills. Metoprolol(Lopressor) Antihypertensive; Beta selective Adrenergic Blocker 50 mg Treatment of HPN alone PRE or w/ combination with Verify doctors order first other drugs or diuretics. Ask patient if he/she has hypersensitivity with the 50 mg; BID drug Tell the purpose for taking this drug INTRA Take with meals if upset stomach occurs. Tell pt that he/she may
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experience these side effects Nausea, vomiting (eat frequent small meals) headache. POST Instruct pt. to report headache, worsening of symptoms , fever, chills Amlodipine(Norvasc) Anti Anginal; Antihypertensive; Calcium Channel Blocker 10 mg Angina Pectoris due to coronary artery spasm; Chronic stable, angina alone or in combination with other drugs 10 mg 1 tab OD PRE Verify doctors order first Assess any history of allergy with Metoprolol Tell the purpose for taking this drug INTRA Give drug with food. Tell patient the side effects of the drug POST Continue therapy for 2 days after signs and symptoms of infection are gone. Monitor for clinical response occurs, if no improvement is seen or a relapse occurs, repeat culture and sensitivity. Encourage pt to complete full course of therapy. Lactulose(Duphalac) Laxative 10g/15ml solution syrup, Treatment constipation, of PRE

prevention Assess condition and treatment of portalbefore therapy and reassess regularly systemic encephalopathy thereafter to monitor
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 PRN

drugs effectiveness. Explain the purpose of the medication given. Ask the patient if he has eaten his meals already. Do not administer if patient has already pass out stool especially if stool is liquid. Give medication hours before sleeping.

INTRA Tell the patient to take the medication with a full glass of water. POST Assess for adverse reaction. Mefenamic acid(Dolfenal) Antiinflammatory; Analgesic ; Antipyretic 500 mg Relief of moderate pain PRE when therapy will not exceed 1wk; Treatment of Verify doctors order first Assess hypersensitivity with primary dysmenorrheal the drug 500 mg; Q8 Tell the purpose for taking this drug INTRA Take drug with food take only the prescribed dosage; do not take the drug longer than 1wk Discontinue drug and consult your health care provider if rash diarrhea or digestive problems occur. Tell patient the he/she may experience these side effects: headache, worsening of symptoms ,
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fever, chills POST Instruct pt. to report headache, worsening of symptoms , fever, chills PNSS An aqueous solution of Used to replace fluids in dehydration deprivation Pre: Check the Doctors order. Identify the pt. Check the VS. Ensure pts. and their family is provided with written

0.9% NaCl, isotonic with Salt and water blood and tissue fluid, used in medicine, chiefly 1L x 31-32 gtts/min for 8 for bathing tissue and, in sterile form, as a solvent for drugs that are to be administered parenterally to replace body fluids. hrs.

statements of their "Rights and Responsibilities". Decrease pts anxiety by explaining the procedure and why it is performed. Ensure that pts. are aware of, understands and is

involved in their treatment plan. Acknowledge questions

regarding the safety of the procedure. Intra: Maintain a constant safe

environment for the pt. based on the Risk Assessment. Maintain a safe and

operational environment of

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all

the

resources

in

the

Laboratory. Monitor for any s/sx of infxn, specifically: swelling,

discharge, redness on the puncture site, and fever. Check for the IV lines. Monitor the time infusion and level. Provide ongoing monitoring and reporting of pts. mental and hemodynamic state. Post: Ensure treatments and

procedures are completed. Check the site for bleeding, cyanosis, or swelling. Check VS for any changes. Provide an explanation of and ensure pts.

understanding of rights and responsibilities. Document the data (attach to the chart). Liaise with the other Health Team members regarding discharge planning.

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VII. PROGRESS NOTES Received patient awake, stuporous in semi fowlers position with an intravenous fluid of #6 of PNSS 1L x 8 hours inserted @ right metacarpal vein, received at the level of 150 cc level, infusing well. He is wearing a diaper, Color and quality of urine was observed. Limited ROM or a decreased in his movements was observed. He has a baseline vital sign of PR = (radial pulse) 81 bpm RR= 20cpm, BP = 120/80 mm Hg, and T = (axillary) 36.4oC. Morning care and bed side care done, bed linens changed. Drugs within the shift were given on time. Ensured the patients safety by putting up side rails. Provided a conducive environment for sleep and rest. Instructed patient and relatives about his current diet which is OF of 1400kcal diluted in 1000cc of water. Frequently monitored and checked vital signs especially in his blood pressure to ensure whether there are possible deviations from normal. He is experiencing sudden changes in blood pressure so it is important to note his vital signs. Diaper is changed frequently to prevent infection and to checked his urine output, Intake and Output was strictly monitored. Received patient on semi-fowlers position, stuporous, His IV fluid was removed. Same procedures were done like morning care and change of bed linens and patients diaper. Medications within the shift were given on time with pre-assessment of the patients current condition. Possible adverse effects of drugs given were also advised to him and were monitored. Vital signs were stable though there are slight changes in the result of his blood pressure. Assisted in performing passive ROM and assessment of his movements. Received patient awake, on semi-fowlers position, obtunded, and was apparently in a better condition compared to that of previous week. Same procedures were done like morning care and change of bed linens and pts diaper. Medications within the shift were given on time, vital signs were stable. Assisted in performing passive ROM exercises.

Day #1 (January 18th 2011)

Day #2 (January19th, 2011)

Day #3 (January 25th, 2011)

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VIII. DISCHARGE HEALTH TEACHING PLANS Content 1. Compliance Medication The family together with the patient will continue the prescribed medications with proper dosage and frequency in order to maintain glucose levels of the client. Reminding and reviewing the family members about the drugs in order to make the familiar with the treatment. Informing the family members about the prescribed medications and its importance regarding the condition of the patient. Strategy

Advise the family members to avoid using any non-prescription drug unless use is approved by the physician.

Encouraging the family members to administer medications exactly as

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prescribed by the physician.

Encouraging the family members to follow the diet and fluid intake recommended by the physician for the patient.

Diet

Prepare foods that are high in sugar content. The client should also avoid foods which contains fats. Also, the family members will know and follow the patients restrictions in foods and proper eating of healthy foods.

Educating the family members to follow the diet and fluid intake recommended by the physician for the patient.

Educating the family members as well as the patient about foods that are healthy yet appropriate for the diet of the patient.

Exercise

The patient will be engaged on doing simple range of motion exercises in order to

Teaching the relatives about how to assist patient do simple range of motion exercises like

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maintain muscle and bones integrity as well as maintaining a good body circulation.

flexion of upper and lower extremities or walking for a short distance.

Educating the relatives about the importance of exercise in the body and its benefits to ones health.

Activity/ Lifestyle Changes

The patient will be encouraged to adjust in the modification of her activities and diet in order to hasten recovery and improve coping.

Encourage the family members to help the patient to adjust in the modification of her activities and diet. Educate the patients relatives about the importance of having a regular check-up after hospitalization.

2. Follow up/ Check-up The patients relatives will know the importance of having regular checkups to maintain the patients well-being.

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IX. SUMMARY OF CLIENTS STATUS OR CONDITION AS OF LAST DAY OF CONTACT January 25, 2011 At the last day of contact with the client, he was observed to be in a more stable condition. He was able to smile and respond to painful stimuli. Client was also able to defecate after about 2 weeks of absent bowel movement.Also, level of consciousness showed improvement, client was assessed to be obtunded at the last day of contact. He has moderate reduction in alertness or clouding of consciousness. Client still had impaired physical mobility and impaired verbal communication though. However, he was able to respond, still by his eyes responses.

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CALIS, Elaine Sarah R.

CRUZATE, Justine

DOMINGUEZ, Sherry Mae

GATBONTON, Imari Jean L.

MAGPANTAY, Ivan Leo

MASCAREAS, Raffy

ONG, Mark Joshua

RIVERA, Angeli

SOLOMON, Shane

VALENZUELA, Deana JonnMariz SN12

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