Far Eastern University Institute of Nursing

I. Biographic Data

Name: Mr. MO Address: 1229 Algeciras St., Sampaloc Manila Educational Attainment: High School Graduate Occupation: Taxi Driver Gender: Male Civil Status: Married Religion: Catholic Date of Birth: August 12, 1949 Age: 59 years old Birthplace: Cagayan Nationality: Filipino Admission Date and Time: June 15, 2009, 10:25pm Physician: Dr. Jesus Bartolome and Dra. Luna Chief Complaint: Patient refused to eat Diagnosis: s/p Cardiovascular Accident, decubitus ulcer G3 sacral area

II. Nursing History

A. Past Health History

1.

Childhood Illness

The clients wife is not aware of any childhood illness that the client had.

2.

Immunization

The client received complete immunizations.

3.

Allergies

According to the patients wife, he doesnt have any known allergies.

4.

Accidents

Mr. MO doesnt have any previous accident.

5.

Hospitalization

His first hospitalization was this 15th of June, 2009 when his relatives complained that he has lost appetite in eating

6.

Medications currently taken

Vitamin B Complex 1 capsule BID Multivitamins 1 tablet once a day Imidapril 10 mg/cap once a day Citicholine 500 mc/cap every 6 hours Fenofibrate 200 mcg 1 tab OD Aspirin 80 mg 1 tab OD Allopurinol 200 mg 1 tab OD Clonidine (Catapres) 75 mcg PRN for BP 180/100 Metronidazole 500 mg 1 tab TID

7.

Foreign Travels

The client didnt have any foreign travels in the past.

B. Comprehensive Nursing History of Present Illness (as told by the patients wife)

The patient was a taxi driver and was the breadwinner of the family. In the year 2006, he complained of difficulty in speaking and body weakness. He had a stroke attack that made his right limbs disabled temporarily. His family brought him to a clinic where the doctor is a specialist of stroke. The doctor prescribed Neobloc and Doxaril then he underwent physical therapy. After a few months, he was able to recover but a lot of his activities are already restricted. He wasnt able to drive a taxi anymore so he just stayed home playing with his grandchildren. 2007 came and he had another stroke. What the family does whenever a stroke attack comes is that they pinch his radial pulse very tight and pours very cold water over him. These instructions just came from a manghihilot and the wife said that it was effective for the patient. Came 2008 and he had another stroke attack and they did the same procedure as they had done during 2007. On the same year, he had his fourth stroke that made him disabled that he developed bed sores at home. His family experienced difficulty when it comes to his activities of daily living because unlike before, they now do everything for him including his bath and hygienic needs. In the present year, his relatives noticed that he has lost appetite in eating for two days because he doesnt want to open his mouth when his family members are feeding him. This led him to be hospitalized for the first time in Ospital ng Sampaloc.

C. Family History

FO

MO

EO

JO

MaO

MarO (patient )

DO

ManO

FOjr

LO

AO

Legend: Male Female Deceased Has/Had CVA (male) Has CVA (female) Died in a car accident

III. Patterns of Functioning a. Psychological Health

1. Coping Pattern According to the wife of the client, the clients strategy when it comes to problems before he had CVA was to drink alcohol but now he cant show his coping strategy because he can no longer speak. When he got admitted to the hospital, the healthcare givers tried to clean his pressure ulcer. His blood pressure hightened and he was rushed to the operating room. The wife also verbalized, Hindi na siya makapagsalita dahil kahit nung una pa nga lang nagkastroke bulol na siya at di na maintindihan pero nakikita mo sa kanyang malungkot siya. Analysis: Aphasia is a deficit in the ability to communicate. Aphasia may involve any or all aspects of communication, including speaking, reading, writing and understanding spoken language. The primary language center is usually located in the left cerebral hemisphere and is affected by stroke in the left middle cerebral artery. Brocas (expressive or motor) aphasia affects speech production in the frontal lobe of the brain. (Medical-Surgical Nursing by Black, page 1847) Interpretation: Since the client cannot talk, he cannot show his emotion to his family members and even non verbal communication is difficult for him that is why he cannot express his coping mechanisms for any stressors. 2. Interaction Pattern The client doesnt interact well with the people around him, Pagkinakausap mo siya tititigan ka lang niya, wala siyang reaksiyon kahit ano pa ang sinasabi mo o ginagawa mo sa kanya, his wife added. Unlike before, the client is a friendly person although when he is drunk, he yells at everyone and always demands something. Analysis: Aphasia is a deficit in the ability to communicate. Aphasia may involve any or all aspects of communication, including speaking, reading, writing and understanding spoken language. The primary language center is usually located in the left cerebral hemisphere and is affected by stroke in the left middle cerebral artery. (Medical Surgical by Black, p. 1847)

Lack of mobility can also diminish an individuals opportunities to interact socially and deprive that person of normal support systems. (Fundamentals of Nursing 8th edition, p.1119) Interpretation: The client have a deficit in communication including speaking, reading, writing and spoken language because the primary language center is located to left cerebral hemisphere that is being affected by stroke.

3. Cognitive Pattern The client is only a high school graduate. His past time leisure was reading news paper during free time but after the stroke incident the client cannot comprehend the essence of the news paper. In his last stroke, he can no longer talk and remember anything. Analysis: Sensory or fluent aphasia involve loss of ability to comprehend written, printed, or spoken words. The client can hear the sounds of speech but the parts of the brain that give meaning to this sounds are damaged. They hear sounds but cannot make sense of it because they cannot understand the symbolic communication with the sounds. (Medical Surgical by Black, p.1847) Interpretation: since the client had the stroke incidence he cannot comprehend the written, printed, or spoken words because of damaged parts of the brain that gives meaning to the sounds, written symbols and visual objects. 4. Self-Concept Pattern The cllient views his self as siga before but everyone in their place respect him.The client cant express any concept about himself. Analysis: After a stroke, the client may experience grief over lost mobility, inability to communicate, alterations in sensation and vision and loss of roles within society. Stroke clients express feelings of profound suffering related to the sudden, devastating changes that accompany stroke. Loss of independence is of particular concern for the stroke client. (Medical Surgical, p.1865) When a person can no longer move the body purposefully and needs to depend on someone else for assistance with simple self-care activities, the persons sense of self is often threatened. (Fundamentals of Nursing 8th edition, p.1119)

Skeletal deformities can influence body image; an inability to meet role expectations can decrease self-concept; and a prolonged period of lying dependent in bed can lead to feeling of worthlessness and diminished self-esteem. (Fundamentals of Nursing 8th edition, p.1119) Interpretation:The client can express his own self-concept incidence before the CVA incidence but due to his condition that causes immobility, inability to express himself his self concept declines. 5. Emotional Pattern Before hospitalization the client express his emotion to his wife but he does not also share his problems with his friends instead he drinks together with his friends. During hospitalization, the client cant express his emotion to his family and to other people. His wife verbalized, Wala na siyang reaksiyon ano man nangyayari sa paligid niya, nung kinuhaan nga siya ng dugo di man lang siya nasaktan. Analysis: Various portions of the brain assist with control of behavior anf emotion the cerebral cortex interprets stimuli. The temporal and limbic areas modulates emotional responses to stimuli.the brain can be seen as a modulator of emotions and when the brain is not fully functional emotional reaction and responses lack this modulation. Behavioral changes after stroke are common. People with stroke in the left cerebral, or dominant, hemisphere are frequently slow, cautious, and disorganize. (Medical Surgical, p.1850-1851) Immobility can produce exaggerated emotional responses to the stresses of everyday living. Patients can become apathetic, possibly because of decreased sensory stimulation and develop altered thought processes. (Fundamentals of Nursing 8th edition, p.1119) Interpretation: Given that condition, that the left cerebral hemisphere is not fully functioning well resulting to lack of emotional reactions. 6. Sexuality Pattern Before the patient acquired his condition, he freely expresses his sexual needs to his wife. According to the wife of the client, ever since he had his first attack of CVA, he already stopped attaining his sexual needs and even expressing his manhood is restricted.

Analysis: Libido diminishes with general ill health and chronic diseases that cause debility or pain. (Fundamentals of Nursing by Kozier page 336) Interpretation: Increasing age of the client and the degree of severity of the disease lessen the desire for sexual activities. 7. Family Coping Pattern The client and his wife was already separated with their two children. Their eldest son already had a family and his daughter works far from home. His youngest son is the only one living with them. Because of that, they cant talk about the existing problems in the family, but their children are very supportive with the current situation of the client especially with the financial support because it is the major problem they are facing now. Analysis: At times the stroke client may not be able to tolerate the intensive therapy of a rehabilitation setting and placement in an extended care facility may be necessary. This is usually very stressful for the client and family, particularly an older spouse. Emotional support must be provided to both the client and family members. Education in how to choose a facility and how to monitor care can be helpful. (Medical Surgical, p.1867) Interpretation: Even though their children support them financially they lack in emotional support in evidenced by not talking the existing problem with in the family. b. Socio-cultural Patterns

1. Cultural Patterns The client celebrates Christmas, birthdays and anniversaries. They always attend mass especially on Christmas and Lenten season. They believe in superstitious beliefs and in other unnatural creatures. But at present the client cannot celebrate fully the occassion or any cultural activity as Mr. MO is in capable of doing cultural practices due to weakness and difficulty in interaction caused by the disease. Analysis: Hemiparesis (weakness) or hemiplegia (paralysis) of one side of the body may occur after stroke. Apraxia is a condition that affect complex motor integration and therefore can result from a stroke in several areas in the brain. A client with apraxia amy be able to conceived or conceptualized the content of messsages to send to muscles. The motor patterns or schemia necessary to convet the impulse message cannot be reconstructed, however. Thus accurate instruction do not

reach the limb from the brain and the desire action does not happen.(Mediacl Surgiacl by Black, pp.1846 and 1849) Interpretation: The manifestations of the disease present to the client supports the findings that he cannot fully participates in the cultural activies he had done before due to immobilization and impaired interaction. 2. Significant Relationship The client has a close relationship with his family especially to his grandchildren. And until now his wife perceives that this close relationships did not change even though he had this condition that Mr. MO cannot show his feelings to significant others verbally.The clients wife verbalized Naaawa ako sa kanya pero kahit ganito na siya hindi nabawasan pagmamahal ko sa kanya, kakayanin kong alagaan siya kahit mahirap. Analysis: Deficit to ability to communicate involving all the aspects of communication that includes speaking, writing and understanding spoken language. Disturbance in the ability to recognize familiar objects . (Medical Surgical by Black pp.1847 and 1849) Interpretation: inability to express emotions and show love to significant others are the result of his condition. 3. Recreation Pattern The clients recreational activities before he was admitted to the hospital are watching TV and playing with his grandchildren that visited them every weekends. Because of his hot temper, he sometimes makes his grandchildren cry. But since now he has no recreational activities, he just stares at one direction until he fell asleep. Analysis: Hemiparesis (weakness) or hemiplegia (paralysis) of one side of the body may occur after stroke. Apraxia is a condition that affect complex motor integration and therefore can result from a stroke in several areas in the brain. A client with apraxia amy be able to conceived or conceptualized the content of messsages to send to muscles. The motor patterns or schemia necessary to convet the impulse message cannot be reconstructed, however. Thus accurate instruction do not reach the limb from the brain and the desire action does not happen.(Mediacl Surgiacl by Black, pp.1846 and 1849) Interpretation: Immobility caused by weakness and paralysis are mainly the reasons why he cannot perform his leisure activities.

4. Environmental Pattern The client together with his wife and youngest son live in Sampaloc, Manila. But they used to live in Trece Martires in Cavite before they were relocated. Because of the clients recent attack of CVA, they decided to sell their house in Cavite and bought a small house in Sampaloc, Manila and even if it only has one window, they still bought it just to be able to suffice for the clients medical needs. They are contented with their environment even if it is congested for as long as they have a home to stay in. Analysis: The environment has many influences on health and illness. Housing, sanitation, climate and pollution of air, food and water are elements in the environmental dimension. (Fundamentals of Nursing 5th edition, p. 66) Interpretation: The prognosis of the clients condition will be attain if the environment is conducive to clients situation but their low socio-economic status and seeking for near medical facilities affect in optimizing the proper environment. 5. Economic Patterns The family of the client has a financial problem. They cant handle the situation because of lack of resources to buy the medications of the client and some of their family needs. The client only depends on his eldest son and daughter but it is not enough. They only have 2 thousand pesos per month. Analysis: Another effect of illness is the financial burden it places on clients and their families. Even people with health insurance may find it does not cover all costs. In addition, many lose income during the illness. (Fundamentals of Nursing 5th edition, p. 257) Interpretation: The family has a lack of financial resources to provide adequate medical and other necessities to have a better condition.

c. Spiritual Patterns

1. Religious Beliefs and Practices Their family always attends mass especially on Christmas and Lenten season. His wife always prays the rosary beside the client. They celebrate fiestas.

Analysis: Many people seek support from their religious faith during times of stress. This is often vital to the acceptance of an illness, especially if the illness brings with it a prolonged period of convalescence or indicates a questionable outcome. Prayer, devotional reading and other religious practices often do for the person spiritually what protective exercises do for the body physically. (Fundamentals of Nursing 6th edition, p. 1100) Interpretation: The client has a difficulty in practicing this religous belief since there barriers to consider. 2. Values and Valuing The client is very serious about the way they guide their children growing up until the time they build their own family. Even the client had been suffering from CVA still he is trying to guide his children to be responsible persons and for that, his children are indeed valuing his guidance. But now that he can no longer speak and move by himself, he cannot do the things he value the most in life. Analysis: Various portions of the brain assist with control of behavior anf emotion the cerebral cortex interprets stimuli. The temporal and limbic areas modulates emotional responses to stimuli. The brain can be seen as a modulator of emotions and when the brain is not fully functional emotional reaction and responses lack this modulation. Behavioral changes after stroke are common. People with stroke in the left cerebral, or dominant, hemisphere are frequently slow, cautious, and disorganize. (Medical Surgical, p.1850-1851) Interpretation: Mr. MO still values giving importance and guidance to the family but expressing his emotions to show to his family that he still values it are not functional due to lack of modulation.

IV. Activities of Daily living

PATTERN 1. NUTRITION BEFORE HOSPITALIZATIO N The client usually eats 1 cup of rice every meal(breakfast,lun ch and dinner). He eats vegetables,fish,me at and chicken and reported no allergies on any DURING HOSPITALIZATIO N The client is on NGT with osteorize feeding of 1500 kcal into 6 equal feedings . The client already given fresh egg osteorized with his feeding for protein supplement. The ANALYSIS AND INTERPRETATION Analysis: Weakness and loss of coordination of the swallowing muscles may impair swallowing (dysphasia), and allow food to enter the lower airway. This may lead to aspiration pneumonia, another common cause

kind of food. His favorite viand is Diningding and he loves eating salty foods. The client eats any kind of bread on his merienda, sometimes with 8 ounces of RC cola, 1 cup of coffee and 1 glass of water. The client drinks water 5 glassess a day.

client has IVF of D5LR 1 liter.

of death shortly after a stroke. Because of the difficulty swallowing, the person who has suffered a stroke may need a temporary or permanent feeding tube inserted into the stomach to ensure adequate nutrition. Such tubes can be either nasogastric, a thin tube that is inserted through the nose, into the esophagus, and then into the stomach, or a gastric one, which is a wider-lumen tube surgically implanted into the stomach. (Medical-Surgical by Black, p.1856) Interpretation: The client had CVA and for that reason he develops impaired ability to swallow or Dysphasia. Nasogastric tube is inserted to the client to make sure he gets enough nutrition.

2. ELIMINATION

The client defecates 2x a week. The color of the stool is black and the consistency of the stool is semiformed and with foul odor. He urinates 3-4x a day. The color of his urine is amber yellow and aromatic with moderate amount.

The client has difficulty in defecating. According to his wife he defecate the other day(June 27, 2009), Ang tae niya parang tae ng kambing na maliliit pero mamasamasa, she added. It has less odor. The client has indwelling foley catheter. His urine output is 380 cc. The odor is aromatic and the color is amber yellow.

Analysis: Stroke may cause bowel and bladder dysfunction. One type of neurogenic bladder, an unihibited bladder, sometimes occurs after stroke. Nerves send the message of bladder filling to the brain, but the brain does not correctly interpret the message and does not transmit the message not to urinate to the bladder. This results in frequency, urgency, and incontinence. Sometimes clients with a type of neurogenic bowel seem fixated on having a bowel movementOther causes of incontinence may be

memory lapses, inattention, emotional factors, inability to communicate, impaired physical mobility and infection. (Medical-Surgical Black, p.1851) by

3. EXERCISE

The client can mobilized half of his body. The only exercise he is doing is to move a part of his body to sit and stand with assistance by his significant others.

Interpretation: The failure to transmit messages to the bladder and bowel the client experienced inability to urinates and to have fixated bowel movement. The client is lying Analysis: on bed. The client Hemiparesis can not move (weakness) or independently.The hemiplegia (paralysis) of significant others one side of the body of the client may occur after a excercise the stroke. (Medical-Surgical lower and upper by Black, p.1846) extremeties by strenching the Apraxia is a condition limbs. They also reposition the that affects complex client side to side motor integration and every 2 hours. His therefore can result wife massage the from a stroke in several clients extremities areas in the brain. by means of Clients who have sponge bath. apraxia cannot carry our skilled act such as dressing even when they are not paralyzed. A client with apraxia may be able to conceive or conceptualize the content of messages to send to muscles. (Medical-Surgical Black, p. 1849) by

4. HYGEINE

The client takes a

Interpretation: The client can not perform any kind of exercise independently. He needs someone to assist him in turning, stretching or any range of motion exercises. The client only has Analysis:

bath 2x a day and perineal care done by his wife. He brushes his teeth 3x a day. The client uses deodorant, lotion and powder. The wife trims the clients nails once a week. He washes his face every morning when he woke up.

sponge bath done by his wife. His wife applies powder to the clients face,chest,back and perineal area. His teeth are not brushed since he was admitted to the hospital. His nails are not trimmed.

Initially a client who has had a stroke may need considerable help with all self-care activities, including washing, eating and grooming. (Medical-Surgical Black, p.1862) by

5. SUBSTANCE USE

The client is a smoker. He consumes 1 pack cigarrettes a day. He drinks alcohol every night about 1-2 bottles of small Gin. But since he had CVA on 2006 he stopped his vices.

Interpretation: He can no longer do proper hygiene by himslef. The clients wife is the one doing his personal hygiene needs. The client does not Analysis: use any substance. Modifiable risk factors for stroke include hyerlipidemia, cigarette smoking, heavy alcohol consumption, cocaine use, and obesity. Current researchsuggest that although heavy alcohol consumption increases ones risk of a stroke, light or moderate alcohol consumption can protect against ischemic stroke. Primary prevention of stroke includes the following maintaining ideal body weight, maintaining safe cholesterol level, smoking cessation, reducing heavy alcohol consumption. (Medical Surgical Black p. 1845) Interpretation: Identifying the risk factors that contribute to the disease made the client realize that he should avoid consuming alcohol and smoking. by

6. SLEEP & REST

The client is disturbed in sleeping and does not have a

The client sleeps Analysis: all the time. He is Cerebral perfusion of less disturbed in the cerebrum is critical sleeping and sleep for survival and long

complete sleep and rest. He has irregular sleeping pattern. His wife estimated his sleeping hours, according to her his husband sleeps up to 6 hours at night and 2 hours of naps in the afternoon.

all day long. His wife verbalized, Kahit nga kinuhaan ng BP tulog pa rin. The client wakes up when there is a strong stimuli and after 10 minutes he sleeps again.

term outcome. Altered perfusion decreases level of consciousness. (Medical-Surgical Nursing by Black, page 1863) Interpretation: Continuous sleep is a result of an altered level of consciousness caused by the disease that damaged the neurologic function.

V. Physical Assessment

GENERAL APPEARANCE

NORMAL FINDINGS

ACTUAL FINDINGS

ANALYSIS INTERPRETATION

Body built

Proportionate, varies with lifestyle (Fundamentals of Nursing by Kozier, 5th ed., page 531)

The clients body built is unproportional. He is very thin and shows body weakness.

Problems in the muscuskeletal or nervous system can have a negative influence from body alightment and movement. Similarly, illness or trauma involving other systems may interfere the movement because of either the underlying pathology or the treatment regimen. (Fundamentals of Nursing by Taylor, page 1109) Interpretation: The clients body built is unproportional because of illness. Diseases or injury may reduce a persons ability to perform hygiene measures or motivation to follow usual hygiene habits. (Fundamentals of Nursing by Taylor, page 1128) Interpretation: The client cannot perform overall hygiene because of immobility A dry odorous mouth may be the result of fluid volume deficit or of mouth breathing. (Fundamentals of Nursing by Taylor page 1690) Interpretation: The client has a foul odor because of illness. Problems in the musculoskeletal or nervous systems can have a negative influence on body alignment and movement. Similarly, illness or trauma involving other body systems may interfere with movement because of either the underlying pathology or the treatment regimen. (Fundamentals of Nursing by Taylor, page 1269) Interpretation: The client shows weakness because of his illness. Behavioral changes after a stroke are common. People with stroke in the left cerebral or dominant hemisphere are frequently slow, cautious and disorganized. (Medical-Surgical Nursing by Black p. 1850) Interpretation: The client cannot respond to any stimuli because of being paralyzed. The patient with head injury may develop deficits such as anosmia, eye movement abnormalities, aphasia, memory deficits, and posttraumatic seizures or epilepsy.

Overall hygiene

Clean, neat (Fundamentals of Nursing by Kozier, 5th ed., page 531)

The client hasnt taken a bath for two weeks due to activity restriction in the hospital

Body and breath odor

No body odor or minor odor relative to work or exercise; no breath odor (Fundamentals of Nursing by Kozier, 5th ed., page 531)

The client have foul breath odor

Signs of health or illness

Healthy appearance (Fundamentals of Nursing by Kozier, 5th ed., page 531)

The client shows signs of total body weakness

Attitude

Cooperative (Fundamentals of Nursing by Kozier, 5th ed., page 531)

The client does not respond to any stimuli

Quantity and quality of speech

Understandable, moderate pace; exhibits thought association (Fundamentals of Nursing by Kozier, 5th ed., page 531)

The client cannot speak anymore

GENERAL APPEARANCE BODY PARTS INTEGUMENTARY Body built EXAMINATION: Skin color

NORMAL FINDINGS NORMAL FINDINGS

ACTUAL FINDINGS ACTUAL FINDINGS

ANALYSIS INTERPRETATION ANALYSIS AND INTERPRETATION

Overall hygiene Uniformity of skin color

Edema Body and breath odor

Signs of health or illness Skin lesions

Skin moisture Attitude

Skin temperature Skin turgor Quantity and quality of speech

NAILS Fingernail and toenail bed color

Proportionate, varies with lifestyle The clients body built is unproportional. Problems in the muscuskeletal or nervous system can (Fundamentals of Nursing by Kozier, 5th He is very thin and shows body have a negative influence from body alightment and The the Normal blood circulation lies on muscle ed., page Varies from light to deep brown; from 531) weakness. color of the skin of the skin of movement. Similarly, illness or trauma involving other ruddy pink; from yellow overtones to olive client is pale brown activity. Immobility impedes circulation and systems may interfere the movement because of either (Fundamentals of Nursing by Kozier, 5th diminishes the or the of nutrients to specific the underlying pathology supplytreatment regimen. ed., page 538) areas.(Fundamentals of Nursing 1109) (Fundamentals of Nursing by Taylor, page by kozier,p897) Interpretation: Interpretation: The clients body built is unproportional because of illness. The client skin color changes to pale brown because of immobility that hindered Clean, neat The client hasnt taken a bath for two Diseases or injury may reduce a persons ability to th circulation of blood (Fundamentals of Nursing by Kozier, 5 weeks due to activity restriction in the perform hygiene measures or motivation to follow usual Generally uniform except in areas exposed The skin color is uniform Normal ed., page 531) hospital hygiene habits. (Fundamentals of Nursing by Taylor, to the sun; areas of lighter pigmentation page 1128) (palms, lips, nail beds) dark- skinned tone (Fundamentals of Nursing by Kozier, 5th Interpretation: ed., page 538) The client cannot perform overall hygiene because of No edema Edema is present on his right hand immobility and Infiltration occurs when an IV fluid (Fundamentals of Nursing to 5th arm accidentally enters the result of fluid volume No body odor or minor odor relativeby Kozier, The client have foul breath odor A dry odorous mouth may be the surrounding tissue ed., page 538) rather than the vein. It is characterized by work or exercise; no breath odor deficit or of mouth breathing. (Fundamentals of Nursing coolness and (Fundamentals of Nursing by Kozier, 5th by Taylor page 1690) pallor to the skin as well as local edema. ed., page 531) (Medical-Surgical by Brunner,p.199) Interpretation: The client have folu breath because of lack of oral hygiene Interpretation: The client has presence of edema because of infiltration. Healthy appearance The client shows signs of total body Problems in the musculoskeletal or nervous systems can Freckles,Nursing by Kozier, 5th flat and some birthmark, some He has a pressure ulcer on his sacral area negative influence on body alignment and at risk The patient who has had stroke may be (Fundamentals of weakness have a for skin and tissue breakdown because other ed., page raised nevi; no abrasions or other lesions 531) movement. Similarly, illness or trauma involving of (Fundamentals of Nursing by Kozier, 5th altered interfere with movement because of body systems maysensation and inability to respond to ed., page 538) pressure and discomfort by treatment either the underlying pathology or the turning and moving.(Medical-Surgical by Brunner,p.2221) regimen. (Fundamentals of Nursing by Taylor, page 1269) Interpretation: The client has a pressure ulcer on his Interpretation: sacral area because of inability of The client turningweakness because of musculoskeletal shows Moisture in skin folds and the axillae His skin is dry In disfunction patient that is unhygienic will cause the (varies with environmental temperature and Cooperative The client does not respond to any Behavioralskin to beafter a (Fundamentals of Nursing by changes dry. stroke are common. People humidity; body temperature, and Taylor,p612) (Fundamentals of Nursing by Kozier, 5th activity) stimuli with stroke in the left cerebral or dominant hemisphere ed., page (Fundamentals of Nursing by Kozier, 5th 531) are frequently slow, cautious and disorganized. ed., page 539) Interpretation: The Black skin is (Medical-Surgical Nursing byclientsp. 1850)dry because of inability to perform it due to immobilization. Interpretation: Uniform; within normal range The skin temperature is uniform The client Normalrespond to any stimuli because of loss cannot proprioception(ability to turgor is associated with a fluid When pinched, skin springs back to Skin flattened more slowly after being Decrease skin perceive position and motion of body partsvolume deficit. (Fundamentals of Nursing, by as well as difficulty in interpreting visual, previous state release and remain elevated tactile and Kozier, page 1083) auditory stimuli) (Fundamentals of Nursing by Kozier, 5th Understandable, moderate pace; exhibits The client cannot speak anymore The patient with head injury may develop deficits such ed., page 539) thought association as anosmia, eye movement abnormalities, aphasia,more Interpretation: The client skin flattened (Fundamentals of Nursing by Kozier, 5th memory deficits, and posttraumatic seizures or epilepsy. slowly because of dehydration. ed., page 531) (Medical- Surgical Nursing, by Brunner, page 998) Highly vascular and pink in light skinned Its fingernail and toenail bed color is pale A pallor may reflect poor arterial circulation

VI. Laboratory and Diagnostic Examination Results

CT Scan June 16, 2009

Clinical History: Re Stroke; left sided weakness

Findings: Wedge shaped corticomedullary hyperdensity is noted in the left temporoparietooccipital lobes. Theres is effacement of the overlying cortical sulci Poorly defined penventricular law attenuation densities are noted bilaterally with no associated mass effect Midline structures are not effaced Ventricles are prominent Both internal carotid arteries are calcified

Impression -acute non-hemorrhagic infarct, left posterior cerebral artery branch territory -moderate chronic small vessel ischemic changes of the cerebral white matter with cerebral atrophy -atherosclerotic internal carotid arteries

Interpretation: The client had ischemic stroke which was caused by atherosclerosis on the posterior part of his cerebrum. Degeneration is already noted.

Urinalysis June 24, 2009 Exam taken Color Normal Values Pale yellow, straw Actual Findings Yellow Analysis/Interpret ation Normal

colored or amber depending on its concentration Transparency

Clear

Turbid

Analysis: Normal urine is transparent. Turbid (cloudy) urine may be caused by either normal or abnormal processes. Normal conditions giving rise to turbid urine include precipitation of crystals, mucus, or vaginal discharge. Abnormal causes of turbidity include the presence of blood cells, yeast, and bacteria. Interpretation: The clients urines transparency is turbid and may indicate presence of organisms.

Pus Cell

None

1-3 hpf

Analysis: Normally negative. Leukocytes are the white blood cells (or pus cells). This looks for white blood cells by reacting with an enzyme in the white cells. White blood cells in the urine suggests a urinary tract infection. Interpretation: Pus cell is present in the clients urine

which may indicate the presence of recent infection in the clients body.
Red Cell

02 per high power field

Few 0-5 LPF

0-2 hpf

Normal

Epithelial Cell Cast: hyaline cast

Few 3-5 LPF

Normal Normal

Hematology June 17, 2009

Exam Taken Hemoglobin Hematocrit WBC Count Lymphocyte Eosinophil

Normal Values Male: 14-16 mg/dl 0.40-0.57 4.8-10.8 x 10 30-40% 1-3%

Actual findings 15.9 mg/dl 0.48 10.6 20% 100%

Analysis/Interpret ation Normal Normal Normal Normal Analysis: An increased eosinophil indicates parasites, cancer, allergies or thrombophlebitis Interpretation: The clients increased eosinophil is triggered by the presence of thrombophlebitis in his body.

Platelet count: 158

131-400 x 10

158

Normal

Laboratory Chemistry June 19, 2009

Exam Taken Potassium

Normal Values 3.50-5.30 mmol/L

Actual findings <3.32 mmol/L

Analysis/Interpre tation Analysis: Decreased potassium levels can cause muscle weakness and dehydration Interpretation: The client manifests signs of muscle weakness. His skin is dry due to lack of taking a bath.

Sodium

135-148 mmol/L

145.40 mmol/L

Normal

Blood Chemistry

Exam Taken FBS Creatinine

Normal Values 4.2 6.4 mmol/L 44 120 umol/L

Actual findings 5.99 mmol/L 184.61 umol/L

Analysis/Interpre tation Normal

Analysis: Increased creatinine levels in the blood suggest diseases or conditions that affect kidney function. Interpretation: The client has a problem with the functions of his kidney because he has increased creatinin levels.

Cholesterol Triglyceride

3.8 6.7 mmol/L 0.68 1.9 mmol/L

5.01 mmol/L 2.19 mmol/L

Normal

Analysis: Triglyceride is an indication of the

bodys ability to metabolize fats; increased triglycerides and cholesterol indicate high risk of atherosclerosis. Interpretation: The client has increased triglyceride which indicates that he has a presence of atherosclerosis in his cardiovascular system.
Uric acid Male: 206 -416 umol/L 720 umol/L

Analysis: Uric acid is produced by breakdown of ingested purines in food and nucleic acids; it is elevated in kidney disease, gout, and leukemia. Interpretation: The client has an increased uric acid level in his blood which indicates kidney disease.

SGOT SGPT

Male up to 37 U/L Male up to 42 U/L

31.41 U/L 37.34 U/L

Normal Normal

Radiology Report

Chest PA: Lungs are clear Heart is not enlarged Aorta is tortuous Diaphragm sulci are intact

Impression: atheromatous aorta

Interpretation: Presence of plaque in the heart

Reference: Community Health Nursing Book by Reyala J.P. et al 9th edition Medicine Blue Book by Willie Ong 3rd Edition Harrisons Principles of Internal Medicine 13th Edition Berry and Kohns Operating Room Technique 10th edition by Nancymarie Phillips

VII.
Generic Vitamin B Complex

Medications taken
Classificati on Vitamin and minerals Indication Treatment for neuritis, neuralgia, shoulder-arm syndrome, facial paresis, pregnancy neuritis, druginduced & alcoholic neuropathy, diabetic neuropathy, sciatica, lumbagolumbalgia, intercostal neuralgia, trigeminal neuralgia, herpes zoster, optic neuritis, numbness of the extremities, rheumatic pain, cardiac disorder, Contraindicatio n Caution patients with liver dysfunction Side Effects Possible side effects include skin problems. medicines. Nursing Responsibilitie s Those on medication for high blood pressure Any person with a chronic health condition, or taking other medications should be advised to seek the advice of a health professional before beginning any program of supplementatio n.

Dosage/ Frequency 1 capsule BID

Multivitami ns

1 tablet/once a day

Vitamins &/or Minerals

Imidapril

10 mg/cap once a day

ACE Inhibitors

hyperemesis gravidarum, vit B deficiency, CVA. Dietary supplement for the treatment and prevention of dietary deficiencies. These vitamins ar necessary for normal growth and development. Many acts as conenzymes or catalysts in numerous metabolic processes. Hypertension

None

None

May be taken with or without food (May be taken w/ meals for better absorption or if GI discomfort occurs.). Teach the patient that a well balanced diet is the best source of vitamins.

None

None

Caution: Potentially Fatal: Excessive hypotension, which could result in MI or stroke in patients with ischaemic heart disease or cerebrovascular disease. Should be taken on an empty stomach. (Take 15 mins before meals. However, when initiating therapy, 1st dose should be given at bedtime.) Caution: Potentially Fatal: Marked hypotension with diuretics, other antihypertensiv es, alcohol, other agents that lower BP. Assess for Hepatic impairment, aortic stenosis, hypertrophic cardiomyopathy , psoriasis. Surgery. Haemodialysis or apheresis with high-flux

membranes. Citicholine 500 mg /cap every 6 hours Neurotonics Supplement used to improve thinking, learning and memory in older people, such as in alzheimers disease None None Take medication as prescribed Take medication on time Monitor patient neurologic status Note if there are signs of slurring of speech Note for adverse reaction Fenofibrate 200 mcg 1 tab OD Dyslipidaemi c Agents Hyperlipidemias None None Caution: Increased risk of cholelithiasis, pancreatitis, skeletal muscle effects. Withdraw treatment if no adequate response after 2 months of treatment at maximum recommended dose. For patient with swallowingg difficulties, crush nonentericcoated aspirin and dissolve in soft food or liquid. Administer liquid immediately after mixing because drug will break rapidly Monitor elderly patients closely because they may be more susceptible to aspirins toxic effects Monitor patient for hypersensitivity reactions such as anaphylaxis or asthma.

Aspirin (Acetylsalic ylic acid)

80 mg 1 tab OD

Nonnarcotic analgesics and antipyretics

Reduction of risk of MI in patients with previous MI or unstable angina

None

None

Allopurinol

300 mg 1 tab OD

Antigout drugs

Prevention of acute gout attacks

None

None

Monitor fluid intake and output Dont restart drug if the patient experienced a severe reaction

Clonidine (Catapres)

75 mcg PRN for BP 180/100

Antihyperten sives

Essential and renal hypertension

Contraindicated in patients hypersensitive to drug.

CNS: weakness, malaise, depression, GI: Constipation , dry mouth,

Monitor blood pressure and pulse rate frequently Instruct patient to take drug exactly as prescribed Observe patient for tolerance to drugs therapeutic effects, which may require increased dosage Observe patient for edema Tell patient that metallic taste and dark or redbrown urine may occur

Metronidaz ole

500 mg 1 tab TID

Amebicides and antiprotozoal s

Bacterial infections caused by anaerobic microorganisms Prevention of postoperative infection

None

CNS: incoordinati on, irritability, depression, weakness, CV: edema, flushing GI: constipation , dry mouth

Lactulose

30 cc OD before bedtime

Laxative

Constipation

Contraindicated in patients on a low-galactose diet

None

Instruct patients about adverse reactions and tell him to notify prescriber if reactions become bothersome or if diarrhea occurs Instruct patient not to take other laxatives during lactulose therapy Be prepared to replace fluid loss

Cefuroxime sodium (Kefurox)

500 mg/tab BID

Cephalospori ns

Serious infections of lower respiratory and

None

None Cefuroxime tablets may be crushed for

urinary tracts, skin and skinstructure infections, bone and joint infections, septicemia, meningitis, gonorrhea, and perioperative prophylaxis

patients who cant swallow tablets If large doses are given, therapy is prolonged, or patients at high risk, monitor patient for signs and symptoms of superinfection Notify prescriber about stools or diarrhea

VIII.

Anatomy

The Cerebral Arterial Circle (Cilrcle of Willis) The blood supply to the brain is carried and vertebral arteries. The vertebral arteries join to form the basilar artery. Branches of the internal carotid arteries and basilar artery supply blood to the brain and complete a circle of arteries around the pituitary gland and the base of the brain called the cerebral arteries circle (Circle of Willis) (Essentials of Anatomy and Physiology by Seeley et al page 363)

IX. Pathogenesis
Precipitating Factors: Alcohol Drinking, Smoking, Crowded place of residency, Male Predisposing Factors: Sedentary Lifestyle, Age, Diet, Heredity

Vasoconstriction

Atherosclerotic plaque Ulcerations, Thrombosis, Calcifications Decreased/absent circulating blood to neurons Ischemia of blood vessel in brain Blood flow not returned

Hypertensio n

Changes in mental status

Sensory Defects

Extraction of oxygen and glucose from the blood Release of glutamate and aspartate due to depletion of cellular energy stores Persistent membrane depolarization Influx of calcium inside the cells and leak of potassium outside cells Inflammatory cascade

Increased ICP Cerebral Edema

Coagulation necrosis of cell

Apoptosis

Hypoperfusio n Cascade of cell death among distal neurons 2006 2007 2008 Cardiovascular accident

Headache

Aphasia, Dysphagia, Dysarthria

X. Ecologic Model Hypothesis The factors that may have contributed to the clients condition are his lifestyle and vices before he got his disease. Chemicals from smoking and alcohol may have triggered a negative response to his body in addition to the hereditary strain that he has acquired from his father who died of the same disease. The environment may also had a contribution to the aggravation of his disease since a lot of cigarettes and alcoholic drinks are available anywhere and he had the capability of buying them Table Host
Agent

Environment

Age: 59 years old (beyond 40) Genetics: Family members having the same disease Human behavior: alcohol drinking and smoking

Endogenous Chemical: Chemical from cigarettes and alcohol

Socio-economic environment

Model

Interpretation: The disease that the client has is greatly influenced by the genetic disorder that he acquired from his father. The factors that predisposed the client to develop cardiovascular diseases are age, human behavior, socio-economic environment and the chemical substances found from cigarettes and alcoholic beverages. These factors have caused a chain of reactions that led him to obtain a cardiovascular accident. Analysis: Cerebrovascular accident (or stroke) is a term used to describe neurologic changes caused by an interruption in the blood supply to a part of the brain. The two major types of stroke are ischemic and hemorrhagic. Ischemic stroke is caused by a thrombotic or embolic blockage of blood flow to the brain. Bleeding into the brain tissue or the subarachnoid space causes a hemorrhagic stroke. Blood flow to the brain can be decreased in several ways. Ischemia occurs when the blood supply to a part of the brain is interrupted or totally occluded. Ultimate survival of ischemic brain tissue depends on the length of time it is deprived plus the degree of altered brain metabolism. Ischemia is commonly due to thrombosis or embolism. Thrombotic strokes are more common than embolic strokes. Strokes can also be large vessel and small vessel. Large vessel strokes are caused by blockage of a major cerebral artery such as the internal carotid, anterior cerebral, middle cerebral, posterior cerebral, vertebral, and basilar arteries. Small vessel strokes affect smaller vessels that branch off the larger vessels to penetrate deep into the brain. Reference: Medical-Surgical Nursing by Joyce Black, page 1843 Conclusion: It is therefore concluded that there are factors that causes Cerebrovascular Accident. Vices like smoking and alcohol consumption adds to the factors that block vessels in the body especially in the brain. Heredity is also a factor that added to the disposition of the patient to his disease. Proper management and comprehensive monitoring of the client is crucial to continue the quality of care even there are some neuronal deficits that are not already modifiable in terms of the severity of the case of the patient. Family and other person around the patient should render emotional support to the patient to elevate the self-esteem because social support is one of the powerful interventions that the patient should have to attain recovery or rather to sustain normal functions. Recommendation:

1. People should regularly have their blood pressure checked 2. Diet, including the reduction of sodium (salt) intake, exercise, and weight loss, if necessary, are all non-drug treatments for lowering blood pressure. a. Consumption of artichoke, which lowers the fat content of the blood, garlic, now believed to lower cholesterol and blood pressure as well as reduce blood's clotting ability, and ginkgo, which improves circulation and strengthens arteries and veins. b. The use of folic acid, lecithin, and vitamins B6, B12, C, and E is recommended as supportive measures in reducing blood pressure. 3. Frequent repositioning to prevent complications such as pneumonia and venous or pulmonary embolism and good skin care will prevent the development of pressure ulcers, or decubitus ulcers 4. Paralysis requires prevention of contractures (the tightening up of paralyzed limbs). a. Combination of stretching and splinting and, besides exercise b. Include the use of supportive braces for arms or hands, or using footboards or wearing sneakers when in bed to prevent foot drop. 5. Aspirin acts as a blood-thinning, or clot-reducing, medication when taken in small doses. One aspirin tablet per day provides this anti-coagulant prevention. 6. Medications to lower blood pressure: a.Beta blockers are used to reduce the force and speed of the heart-beat. b.Vasodilators are used to dilate the blood vessels. c.Diuretics reduce the total volume of circulating blood and thus the heart's work by removing fluid from the body. d.Lipid-lowering drugs increase the loss of cholesterol from the body or prevent the conversion of fatty acids to cholesterol. This lowers fat levels in the bloodstream. XI. Prioritized List of Nursing Problems

Nursing Problems Identified Bed Sore

Nursing Problems Identified Impaired Skin Integrity: dermal ulcer related to complete immobility

Cues

Justificati on This is a first prioritized nursing problem according to Maslows hierarchy of needs

I: The patients wife said, nilinis yung sugat niya na yan eh, debridemen t ata yung tawag dun. Lagi lang

kasi siya nakahiga samin, puro tulog lang ginagawa O: The client has a pressure ulcer on the right side of the back at the sacral area but it debridemen t has been done already. The client is routinely turned to different sides and a pillow is applied to his back to prevent contact of wound with the bed. Unresposiven ess Disturbed Sensory Perception: Tactile related to Altered Sensory Reception I: She related, Wala nga siya reaksiyon nung kuhanan siya ng dugo, wala, tulala lang. Di man lang nga niya

which is physiologic al needs.

We prioritized this problem 2nd in ranking because according to the Maslows hierarchy of needs it

nilayo yung kamay niya. Wala talaga siyang pakiramda m. O: The patient woke up after his wife communicat ed with him. He just opened his eyes and looked nowhere in the room. He then closed his eyes and went to sleep without responding to anything that was said to him Lack of hygiene Self-Care deficit r/t neuromusc ular impairment I: According to the wife of the client, Hindi na nga niya magalaw yung kanang kamay at binti niya, yung kaliwang

is a physiologic need.

This is a the 3rd prioritized nursing problem according to Maslows hierarchy of needs which is physiologic al needs.

binti at kamay na lang. The client is depedent and does not participate in any activity. The patients wife stated, Sa bahay kasi palagi siya nakahiga kaya siya nagkasugat siguro saka hindi na niya kasi masyado naigagalaw ung katawan niya, pag pinapaligua n nga namin siya nakaupo siya saka kami na talaga lahat gumagawa para sa kanya hindi kagaya dati pag dudumi siya sasamahan ko lang siya

tapos siya na yung maghuhuga s sa sarili niya O: The clients right lateral part of the body is immobilized due to paralysis. The client only has sponge bath done by his wife. His wife applies powder to the clients face,chest,b ack and perineal area. His teeth are not brushed since he was admitted to the hospital. His nails are not trimmed. The client have foul breath odor His skin is dry.

Immobility

Impaired physical mobility related to neuromusc ular impairment as evidenced by inability to purposefull y move involved body parts.

Have yellowish teeth. I: According to the wife of the client, Hindi na nga niya magalaw yung kanang kamay at binti niya, yung kaliwang binti at kamay na lang. The client is depedent and does not participate in any activity.

This problem is the 4th in priority with accordance to the Maslows hierarchy of needs. It is considered is at the physiologic level.

Paralysis

Risk for disuse related to immobility

I: the wife reported, Ayan nga eh, nilagyan nila ng unan sa likod niya saka pinapaikot siya sa kama pag kailangan na nung mga nurse. Hirap din kasi ako mag-isa na mag galaw

This problem is least prioritized because with accordance tothe Maslows hierarchy of needs. It is considered as physiologic need

sa kanya, mabigat kasi talaga siya. Kaya nga yung mga anak ko salitan kami dito sa pagbabanta y sa kanya O: The patient has an altered level of consciousne ss which is the cause of his immobility.

XII.

Nursing Care Plan

Nursing Diagnosis and Cues Impaired Skin Integrity: dermal ulcer related to prolonged bed rest I: The patients wife said, Di ko napansin yung sugat niya, di na rin naman kasi siya nakakapagsalita kung may masakit na sa kanya O: The client has a pressure ulcer on the right side of the back at the sacral area : the client is bed ridden

Rationale Impaired skin integrity is an altered epidermis and dermis. This may be due to immobility demanded by once condition or altered sensation which leads to a dermal ulcer. This condition may pose another risk for infection and alteration of deep tissue integrity. It requires strict monitoring and assistance to patients especially those who

Goal and Objectives GOAL: After 2 days of duty shift, the clients wound will be completely free from complications. OBJECTIVES: 1. Prevent the wound from infection

Interventions

Rationale

Evaluation Effectiveness: Has the clients wound maintained free from infection within 2 days?

2. Mobilize patient

>Encourage proper debridement of wound >Inspect clients wound on daily basis >Instruct clients SO regarding proper sterile dressing and home care of debridement of wound >Encourage passive range of motion exercises >Reposition client on regular

To promote healing of pressure ulcer

Yes No Why? Since the clients wound was maintained free from complications within the allotted period

To promote circulation and reduces risks associated with immobility To prevent

3. Prevent

have an altered sensation. (Prentice Hall Nursing Diagnosis Handbook with NIC Interventions and NOC Outcomes by Judith M. Wilkinson p. 475; Nursing Care Plans: Nursing Diagnosis and Interventions by Gulanick, Klopp and et. al. p.59)

another bed sore to occur

basis >Encourage turning of client in bed >Provide clean beddings >Inspect clients condition on daily basis

another decibitus ulcer to occur

Reference: Prentice Hall Nursing Diagnosis Handbook with NIC Interventions and NOC Outcomes by Judith M. Wilkinson p. 475-479

Nursing Diagnosis and Cues Self-Care deficit r/t neuromuscular impairment Cues: I: According to the wife of the client, Hindi na nga niya magalaw yung kanang kamay at binti niya, yung kaliwang binti at kamay na lang.

Rationale Impaired ability to perform feeding, bathing, or hygiene, dressing and grooming, or toileting activities for one self [on a temporary, permanent or progressing basis.] Reference: Nurses Pocket

Goal and Objectives Goal: At the end of the shift, the clients hygiene wil be maintained. Objectives: After nursing interventions the client will be: 1.Assessed for his intellectual functioning.

Interventions

Rationale

Evaluation Was client hygiene maintained at the end of the shift?

Yes -Assess abilities and level of deficit (0-4 scale) for performing ADLs. 1.Aids in anticipating/ planning for meeting individual needs.

No Why?

The client is depedent and does not participate in any activity.

The patients wife stated, Sa bahay kasi palagi siya nakahiga kaya siya nagkasugat siguro saka hindi na niya kasi masyado naigagalaw ung katawan niya, pag pinapaliguan nga namin siya nakaupo siya saka kami na talaga lahat gumagawa para sa kanya hindi kagaya dati pag dudumi siya sasamahan ko lang siya tapos siya na yung maghuhugas sa sarili niya

Guideby M. Doenges page 451 2.Provided with personal care and hygiene

-Assess barriers to participation in regimen -Assist or support SO in doing overall hygiene such as: --perineal care --oral care --bathing --changing of clothes and linens -Support SO in making health related decisions and assist in developing care practices and goals that promote health for the client. -Review the program periodically with SO 2.To reduce the risk of impaired skin integrity and dehydration.

Because the nurses skill was applied efficiently to maintain the cleanliness of the client.

3. Able to achieve wellness state

3. Enhances rehabilitation process and to continuously provide proper hygiene for the client.

O: The clients
right lateral part of the body is immobilized due to paralysis.

The client only has sponge bath done by his wife. His wife applies powder to the clients face,chest,back and perineal area. His teeth are not brushed since he was admitted to the hospital. His nails are not trimmed. The client have foul breath odor His skin is dry. Have yellowish teeth.

Nursing Diagnosis and Cues

Rationale

Goal and Objectives

Interventions

Rationale

Evaluation

Risk for disuse syndrome r/t immobilization.

I:the wife reported, Ayan nga eh, nilagyan nila ng unan sa likod niya saka pinapaikot siya sa kama pag kailangan na nung mga nurse. Hirap din kasi ako mag-isa na mag galaw sa kanya, mabigat kasi talaga siya. Kaya nga yung mga anak ko salitan kami dito sa pagbabantay sa kanya

The patient is at risk for deterioration of body systems as the result of unavoidable musculoskeletal inactivity. Complications from immobility can include pressure ulcer, constipation, stasis of pulmonary secretions, thrombosis, urinary tract infection or retention, decreased range of joint motion, disorientation, body image disturbance and powerlessness. (Prentice Hall Nursing Diagnosis Handbook with NIC Interventions

GOAL: After 2 weeks, the client will be able to be free of signs and symptoms of infectious processes.

Effectiveness: After 2 weeks, was the client able to be free of signs and symptoms of infectious processes?

OBJECTIVES: After nursing interventions, the nurse will be able to : Identify underlying conditions. (e.g.neurologica l conditions like stroke) Assess clients on going functional status including cognition, vision, and hearing;social support; abilities in performance of ADLs. That cause/exacer bate problems associated with inactivity and immobility. For comparative baseline; evaluate responses to treatment and to identify preventive interventions or necessary Yes

No

Why? Because the client was maintained free of infection.

1. Evaluate probability of developing complication s.

O: The patient has an altered level of consciousness which is the cause of his immobility

The clients right lateral part of the body is immobilized due to paralysis.

and NOC Outcomes by Judith M. Wilkinson p. 149)

services. Evaluate clients risk for injury. Risk is greater in client with cognitive difficulties, lack of safe or stimulating environment, sensoryperception problem.

The client only has sponge bath done by his wife. His wife applies powder to the clients face,chest,back and perineal area. His teeth are not brushed since he was admitted to the hospital. His nails are not trimmed. His skin is dry The client is not able to move his upper and lower extremities dependently

2. Identify individually appropriate preventive intervention s.

Monitor skin over bony prominences. Reposition frequently as individually indicated Provide skin care daily and prn, drying well and using gentle massage. Review nutritional status and monitor nutritional intake. Provide teaching regarding To relieve pressure. To stimulate circulation.

dietary needs, position changes and cleanliness. Monitor urinary output and characteristics. Observes signs of infection. Routinely evaluate circulation/nerv e function of affected body parts. Note changes in temperature, color, sensation, and movement. Provide adequate fluid.

To prevent dehydration and circulatory stasis. Injury may occur as a result of orthostatic hypotension . To prevent vascular congestion.

Assist with position changes as needed. Raise head gradually. Maintain proper body position; avoid use of constricting garments/restra

ints. To enhance safety and prevent/limit effects of disuse.

3. Promote wellness. Promote SOsupported activities. Review information about individual needs/areas of concerns.

Reference: Nurses Pocket Guide by Doenges page 270-275

XIII.

Discharge Plan

M- MEDICATION Follow medication regimen as prescribed by physician and never miss a dose: Vitamin B Complex 1 capsule BID Multivitamins 1 tablet once a day Imidapril 10 mg/cap once a day Citicholine 500 mc/cap evefy 6 hours Fenofibrate 200 mcg 1 tab OD Aspirin 80 mg 1 tab OD Allopurinol 200 mg 1 tab OD Clonidine (Catapres) 75 mcg PRN for BP 180/100 Metronidazole 500 mg 1 tab TID E-EXERCISE/ ACTIVITY Turning side to side every 2 hours Regularly mobilize lower and upper extremities Support the affected arm and leg when turning and positioning

T- TREATMENT Exercise therapy Place pillow between clients legs to provide support Massage therapy Elevation of extremities with edema to facilitate circulation at 45 degrees

H- HYGIENE Provide regular perineal care and oral care Always perform sponge bath with proper stroke handling -to facilitate circulation -done from cleanest to dirtiest part

O- OUTPATIENT Inform primary health care provider for any unusual decrease in level of consciousness and vital signs

D- DIET Bland diet: (low sodium) Vegetables (kangkong, talbos ng kamote, dahon ng ampalaya, malunggay etc.) Fruits (banana, ponkan, apple, papaya, pineapple etc.) Steamed fish without salt Less fluid intake Assess the following in feeding: -head control -assist in correct position

S- SPIRITUAL Advise significant others to invite visitors for the consistency of praying for the clients condition.