Académique Documents
Professionnel Documents
Culture Documents
College of Nursing
Capitol Site, Batangas City
Presented By:
Alvarez, Nhicko V.
Atienza, Julius M.
Bagos, Ann Sherilyn
BSN 3-5
Presented To:
Ms. Sharon P. Remolana RN
(clinical Instructor)
Family History
Mrs. X, a 52 year old woman who owns a small
grocery store, is still living with her husband Mr. X, 65 year
old man who smokes and drinks alcoholic beverages
occasionally. Mr. & Mrs. X were blessed with 8 children.
Five boy ages 31, 30, 27, 25, 23 and three girls ages 29, 16
and 13. The common health problems their family encounters
are also common colds and fever. Their family and other
relatives are in good mental condition. They have no known
family history of heart disease, cancer, hypertension,
tuberculosis and diabetes mellitus.
Personal history
Mrs. X do smokes and drinks alcoholic beverages like
her husband ocassionally. She smokes 5 sticks per day. She
is fond of eating salty and fatty foods such as fried “sap -
sap”, “sinigang na baboy” and rarely fish and vegetables.
There is no specific pattern of rest and sleep since she is the
one who opens their store and fetch early in the morning for
the fruits that she is going to sell. She sleeps late at night and
wakes up early in the morning to prepare breakfast and
uniforms for her two daughters and opens her store.
Social History
Mrs. X is an elementary graduate. She was not able to
finish her secondary education due to financial problem; she
was only a first year high – school student when she stopped
studying. She got married at the age of 18. She has a good
attachment to her family. They always have time to bond and
share thoughts during weekends. Every Sunday, Mrs. X,
together with her husband and two daughters, attends mass
to praise and thank God for all the blessings that they
received. Mrs. X is a business woman but sometimes accepts
laundries while Mr. X is a baker.
According to Mrs. X, their monthly income is Php 5,000
which is not enough to meet their daily needs. Their house is
made mostly of wood. They live in a community where health
programs and services are implemented and are very
accessible. Mrs. X brings her children and grandchildren in
their Community Health Center for consultation and when
there is a health problem.
Their family is a typical Filipino family who had different
cultural beliefs in regarding their way of living. They believe in
the negative power like bad karmas and those unseen things in
this world that could hurt or cure them.
Psychological History
Her work as an owner of a mini grocery store and laundry
woman causes her to become stressful especially when she is
still working late at night because of the clothes that she is going
to wash and wakes up early in the morning to prepare uniforms
and foods for her two daughters. Financial constraint was also a
major stressor for her. Seeing her grandchildren happy and healthy
makes her happy.
History of Present Illness
Year 1999, Mrs. X was diagnosed with hypertension.
Even though she was diagnosed of hypertension, she did not
have any regular blood pressure monitoring in the community
because of too much busy. Four years after, year 2003, she
had experienced severe headache which led her to seek
consultation with increasing blood pressure that ranges from
190/120 mmHg and her normal blood pressure is just only
130/90 mmHg. She was diagnosed of CVD and was advised
for confinement in the hospital, Batangas Provincial Hospital.
She was confined for five days, and during her stay, she was
administered with anti – hypertensive drugs like Norvasc and
CalciBloc. She has recovered and the attending physician
gave Amlodipine, as her maintenance drug. Due to financial
incapability, she had no monthly check – up and cannot avail
her maintenance drug.
Two days, prior to admission at Martin Marasigan
Hospital, Mrs. X experienced nape pain associated with head
ache; but she just rest and ignored the symptoms. Early
morning, on January 13, 2009, Mrs. X experienced body
weakness after washing the clothes. Her son noticed slurring
of speech, so her husband brought her immediately at Martin
Marasigan Hospital for consultation.
There, she was managed as a case of CVD, HPN. She was
given Clonidine, Citecholine and Nicardipine. January 17,
2009, she was then transferred to Batangas Regional Hospital
for referral. Just before the admission at BRH, she had
sudden onset of left sided body weakness and loss of
consciousness and they immediately rushed the patient to
hospital at 5:40 pm. The resident on duty notified the
attending physician, Dr. Brucal, and made the admitting
diagnosis which is Cerbrovascular Disease ( CVD ).
PHYSICAL
ASSESSMENT
January 18, 2008
GENERAL APPEARANCE
Mrs. X looked weak in appearance and afebrile with
ongoing PNSS incorporated with Vit.B IV fluid in his right
hand regulated at 30 gtts per minute, awake, lying in bed,
experiencing difficulty of breathing and conscious when we
met her. She uses accessory muscle when breathing.
>Absence of >Normal.
masses or nodules
>Symmetrical >Normal.
facial movements.
>Normal.
>Palpation >Absence of
nodule or masses
Eyes
>Symmetrically >Normal.
aligned.
>Abnormal. This is
b. Speech >Inspection >Difficulty of caused by impaired
speaking Brocca’s area or the
speech center of the
brain.
Mouth
>Positioned at >Normal.
midline.
Anterior
Thorax
- Chest and >Inspection >Regular rhythm >Normal.
Lungs.
>Within normal rate RR= 19 >Normal.
breaths per minute.
>Smooth >Normal.
Neurologic
System
She has short black with few white – gray hairs and
hair color gradually changes with age. The amount of melanin
in the hair can decrease causing hair to become faded or
white. Gray hair usually a mixture of unfaded, faded and white
hairs. We noticed that her eyebrow in the left part is
asymmetrically aligned and the movement is not equal. These
conditions are caused by the neurologic impairment in CN III
(Occulomotor). Her eyelids in the left part is also
asymmetrically aligned and this caused also by the neurologic
impairment in CN III (Occulomotor).
Upon assessing for her posterior and anterior thorax, her shoulder
and back are asymmetry at the left side. This is caused by the impairment
of the right hemisphere. Crackles were heard upon auscultation because
there is sudden opening of small airways that contain fluid. Any condition
where air hunger exists has the potential to create audible and
noisy breathing. The body is attempting to meet its oxygen
demands.
Abnormal.
Elevated glucose
Glucose 7.18 mmol/L 3.88 – 5.83 mmol/L level may indicate
that Mrs. X has a
possible diabetes
mellitus.
Abnormal.
Decreased BUN
BUN 3.15 mmol/L 6.26 – 8.33 mmol/L level may indicate
a possible
malnutrition and
over hydration.
Character Slightly turbid Clear Abnormal. May indicate urinary tract infection.
Microscopic Exam
CHEST X-RAY
Findings:
Impression:
Most of the cranial nerves come from the brainstem. The brainstem is the
pathway for all fiber tracts passing up and down from peripheral nerves
and spinal cord to the highest parts of the brain.
Cerebellum - The portion of the brain (located at the back) which helps
coordinate movement (balance and muscle coordination). Damage may
result in ataxia which is a problem of muscle coordination. This can
interfere with a person's ability to walk, talk, eat, and to perform other self
care tasks.
Frontal Lobe - Front part of the brain; involved in planning, organizing,
problem solving, selective attention, personality and a variety of "higher
cognitive functions" including behavior and emotions.
The anterior (front) portion of the frontal lobe is called the prefrontal cortex.
It is very important for the "higher cognitive functions" and the
determination of the personality.
The posterior (back) of the frontal lobe consists of the premotor and motor
areas. Nerve cells that produce movement are located in the motor areas.
The premotor areas serve to modify movements.
The frontal lobe is divided from the parietal lobe by the central culcus.
Occipital Lobe - Region in the back of the brain which processes visual
information. Not only is the occipital lobe mainly responsible for visual reception, it
also contains association areas that help in the visual recognition of shapes and
colors. Damage to this lobe can cause visual deficits.
Parietal Lobe - One of the two parietal lobes of the brain located behind the frontal
lobe at the top of the brain.
Parietal Lobe, Right - Damage to this area can cause visuo-spatial deficits (e.g.,
the patient may have difficulty finding their way around new, or even familiar,
places).
Parietal Lobe, Left - Damage to this area may disrupt a patient's ability to
understand spoken and/or written language.
The parietal lobes contain the primary sensory cortex which controls sensation
(touch, pressure). Behind the primary sensory cortex is a large association area
that controls fine sensation (judgment of texture, weight, size, shape).
Temporal Lobe - There are two temporal lobes, one on each side of the brain
located at about the level of the ears. These lobes allow a person to tell one smell
from another and one sound from another. They also help in sorting new
information and are believed to be responsible for short-term memory.
Right Lobe - Mainly involved in visual memory (i.e., memory for pictures and
faces).
Left Lobe - Mainly involved in verbal memory (i.e., memory for words and names).
Brain Structures and their Functions
Cerebrum
Cerebellum
Limbic System
Brain Stem
The nervous system is your body's decision and communication center. The central
nervous system (CNS) is made of the brain and the spinal cord and the peripheral nervous
system (PNS) is made of nerves. Together they control every part of your daily life, from
breathing and blinking to helping you memorize facts for a test. Nerves reach from your brain
to your face, ears, eyes, nose, and spinal cord... and from the spinal cord to the rest of your
body. Sensory nerves gather information from the environment, send that info to the spinal
cord, which then speed the message to the brain. The brain then makes sense of that
message and fires off a response. Motor neurons deliver the instructions from the brain to the
rest of your body. The spinal cord, made of a bundle of nerves running up and down the
spine, is similar to a superhighway, speeding messages to and from the brain at every
second.
The brain is made of three main parts: the forebrain, midbrain, and
hindbrain. The forebrain consists of the cerebrum, thalamus, and hypothalamus
(part of the limbic system). The midbrain consists of the tectum and tegmentum.
The hindbrain is made of the cerebellum, pons and medulla. Often the midbrain,
pons, and medulla are referred to together as the brainstem.
The Cerebrum: The cerebrum or cortex is the largest part of the human brain,
associated with higher brain function such as thought and action. The cerebral
cortex is divided into four sections, called "lobes": the frontal lobe, parietal lobe,
occipital lobe, and temporal lobe. Here is a visual representation of the cortex:
Note that the cerebral cortex is highly wrinkled. Essentially this makes the brain
more efficient, because it can increase the surface area of the brain and the
amount of neurons within it. We will discuss the relevance of the degree of cortical
folding (or gyrencephalization) later.
A deep furrow divides the cerebrum into two halves, known as
the left and right hemispheres. The two hemispheres look
mostly symmetrical yet it has been shown that each side
functions slightly different than the other. Sometimes the right
hemisphere is associated with creativity and the left
hemispheres is associated with logic abilities. The corpus
callosum is a bundle of axons which connects these two
hemispheres.
The Cerebellum: The cerebellum, or "little brain", is similar to the
cerebrum in that it has two hemispheres and has a highly folded surface or
cortex. This structure is associated with regulation and coordination of
movement, posture, and balance.
Thalamus - a large mass of gray matter deeply situated in the forebrain at the
topmost portion of the diencephalon. The structure has sensory and motor
functions. Almost all sensory information enters this structure where neurons send
that information to the overlying cortex. Axons from every sensory system (except
olfaction) synapse here as the last relay site before the information reaches the
cerebral cortex.
Midbrain/ Mesencephalon- the rostral part of the brain stem, which includes the tectum and
tegmentum. It is involved in functions such as vision, hearing, eyemovement, and body
movement. The anterior part has the cerebral peduncle, which is a huge bundle of axons
traveling from the cerebral cortex through the brain stem and these fibers (along with other
structures) are important for voluntary motor function.
Pons- part of the metencephalon in the hindbrain. It is involved in motor control and sensory
analysis... for example, information from the ear first enters the brain in the pons. It has parts
that are important for the level of consciousness and for sleep. Some structures within the
pons are linked to the cerebellum, thus are involved in movement and posture.
Medulla Oblongata- this structure is the caudal-most part of the brain stem, between the
pons and spinal cord. It is responsible for maintaining vital body functions, such as breathing
and heartrate
pathophysiology
NON- MODIFIABLE FACTOR MODIFIABLE FACTOR
FEMALE OCCUPATION
>In females, the weak branching points of arteries give rise to >Business woman & laundry woman
protrusions with a very thin covering of endothelium that can
tear o bleed easily rise of BP
Stress
LIFESTYLE
>Drinks alcohol occasionally & smoking 5 sticks of cigarettes a day
DIET
>high in fats and high in sodium
Ischemic Stroke
Left side paralysis[hemiplegia] Loss of coordination Loss of balance Inability to walk Numbness/weakness Change of alertness
(Weakening of the (Lethergy)
receptors in the body)
>Monitored vital signs >To obtain baseline data. (Pediatric Nursing Care Plans, 3rd
especially the RR. edition,Karla L. Luxner,RNC,ND,pg. 67)
>Auscutated the lung >Bronchial lung sounds are commonly heard over areas of lung
sounds, noting areas of density or consolidation. Crackles are heard when fluid is present.
decreased ventilation and (Nursing Care Plan, 6th edition, Gulanick/Myers pg. 480)
presence of adventitious
sounds.
>Monitored chest x – ray >These determine progression of disease process. (Nursing Care
reports. Plan, 6th edition, Gulanick/Myers pg. 480)
INTERVENTION RATIONALE
>Advised the realtives >Positioning facilitates chest expansion and respiratory efficiency
elevate the head of bed at by reducing pressure of abdominal organs on diaphragm. (Pediatric
least 30 degrees. Nursing Care Plans, 3rd edition,Karla L. Luxner,RNC,ND,pg. 68)
>Assisted on nebulizer > Relaxes bronchial and uterine smooth muscle by acting on beta –
treatment. Nebulization adrenergic receptors. (MIMS page 345)
done as per doctor’s order
every 12 hours.
>Instructed the client to >Discharges from the nebulizer are often foul tasting and
have oral care after smelling. (Nursing Care Plan, 6th edition, Gulanick/Myers
each nebulization. pg. 480)
>Instructed the >Discharges from the nebulizer are The client maintained
client to have oral often foul tasting and smelling. airway patency as
evidenced by
care after each (Nursing Care Plan, 6th edition, expectorating clear
nebulization. Gulanick/Myers pg. 480) secretions readily.
>Monitored and recorded >This information is used to determine and prevent life –
neurological status using Glasgow threatening complications such as severe hypertension
Coma Scale. and increased ICP. (Nursing Care Plan, 6th edition,
Gulanick/Myers pg. 561)
>Monitored intake and output and >Because of cerebral edema, fluid balance must be
specific gravity. regulated. Fluids may be restricted if the patient has
significant increase in ICP. (Nursing Care Plan, 6th
edition, Gulanick/Myers pg. 562)
>Assisted the client in repositioning >Helps the client in performing ADL’s. (Nursing Care
herself. Plan, 6th edition, Gulanick/Myers pg. 562)
>Provided safety measures such >Enhances safety. (Nursing Care Plan, 6th edition,
as putting pillow on bedside of the Gulanick/Myers pg. 562)
patient to prevent fall.
>Taught perform active ROM >Active ROM increases muscle mass, tone and strength
exercises on unaffected limbs and improves cardiac and respiratory functioning.
within levels of patient’s tolerance. (Nursing Care Plan, 6th edition, Gulanick/Myers pg. 563)
INTERVENTION RATIONALE
>Performed passive ROM in affected limbs at >A voluntary muscle will lose tone and
least three to four times daily. Exercises are strength and becomes shortened from
done slowly to allow the muscles time to relax, reduced range of motion or lack of exercise.
and support the extremity above and below (Nursing Care Plan, 6th edition,
the joint to prevent strain on joints and Gulanick/Myers pg. 563)
tissues. Stopped point when pain and
resistance is met.
>Scheduled activities with adequate rest >Reduces fatigue and maximizes energy
periods during the day. production. (Nursing Care Plan, 6th edition,
Gulanick/Myers pg. 563)
>While the client is in bed, the following steps >Prolonged immobility and impaired
were performed to maintain alignment: neurosensory function can cause permanent
contractures. (Nursing Care Plan, 6th edition,
Gulanick/Myers pg. 564)
a. Used pillows to serve as footboard. >This measure helps prevent foot drop.
(Nursing Care Plan, 6th edition,
Gulanick/Myers pg. 564)
d. Used a pillow when on Fowler's position >This measure prevents flexion contracture of the
placed on the back of the head. neck. (Nursing Care Plan, 6th edition,
Gulanick/Myers pg. 564)
e. When client is in lateral position, placed >This measure prevents internal rotation and
pillows to support the leg from groin to adduction of the femurs and hip and also internal
foot and a pillow to flex the shoulder adduction of shoulder. (Nursing Care Plan, 6th
and elbow slightly. edition, Gulanick/Myers pg. 564)
>Provided progressive mobilization by >Prolonged bed rest can cause a sudden drop in
maintaining head of bed at least 30 blood pressure (orthostatic hypotension) as blood
degree angle and assisted the client returns to peripheral circulation. (Nursing Care
slowly from lying to sitting position. Plan, 6th edition, Gulanick/Myers pg. 565)
INTERVENTION RATIONALE EVALUATION
>Kept the patient’s >This position promotes venous The client was able to
head and neck in drainage from the brain and maintain and increase
strength and function of
neutral position. decreases ICP. (Nursing Care affected and
Plan, 6th edition, Gulanick/Myers compensatory body part
as evidenced by:
pg. 565)
> Increased ROM such as
turning from side to side
>Avoided >Frequent stimulation of the patient as observed.
unnecessary care increases brain activity and ICP.
> Able to move her hand
activities. Clustering care activities in a short as response
period of time also increases ICP.
> Able to flex extremities
(Nursing Care Plan, 6th edition, with assistance from the
Gulanick/Myers pg. 565) relatives.
ASSESSMENT NURSING SCIENTIFIC EXPLANATION
DIAGNOSIS
“Salamat” as verbalized by
the client.
Frequency:
Q8
Form:
Solution
CONTRAINDICATION NURSING MONITORING
RESPONSIBILITIES PARAMETERS
>Contraindicated in >Assess patient for >May increase creatinine
patients hypersensitive to abdominal pain. Note and ALT levels.
drug and those with acute presence of blood in
porphyria. emesis, stool or >May cause false-
gastric aspirate. positive results in urine
>Use cautiously in protein test using
patients with hepatic >Drug may be added Multistix.
dysfunction. Adjust to total parenteral
dosage in patients with solutions. NORMAL VALUES:
renal function. Creatinine= 53.1-115.0
umol/L
Frequency:
q12
Form:
Liquid
CONTRAINDICATION NURSING RESPONSIBILITIES MONITORING
PARAMETERS
>Contraindicated in >Obtain baseline assessment of >May decrease in
patients hypersensitive patient’s respiratory status, and potassium level.
to drug or its assess patient often during K=3.5 – 5 mol/L
components. therapy.
>Evaluate the client’s respiratory
>Use cautiously in status and V/S.
patient with CV >Be alert for adverse reactions and
disorders. drug interactions.
>Teach the mother the correct use
of inhalation devices.
>Advise the mother not to use
more doses that ordered.
>Oral care after nebulization.
NAME OF CLASSIFICATION INDICATION ADVERSE
DRUG REACTION
Generic Name: Diuretics >Oliguria CNS: dizziness,
Mannitol
>Increase osmotic headache
Brand Name: pressure of >To reduce
Osmitrol
glomerular filtrate intracranial CV: hypertension
Dose: inhibiting tubular pressure
75 ml
reabsorption of h2o EENT: blurred
Route: & electrolytes; drug vision
IV
elevates plasma
Frequency: osmolality, GI: thirst
Q8 increasing h2o flow
Form:
Tablet
CONTRAINDICATION NURSING MONITORING
RESPONSIBILITIES PARAMETERS
>Contraindicated in patients >Use only drug only after diet >May ↑ ALT,
hypersensitive to drug and those and other non drug therapies AST and CK
with active liver disease / prove ineffective. Patients levels.
conditions that cause should follow a standard low –
unexplained persistent elevation cholesterol diet during
of transaminase levels. therapy. ALT= 5-83 u/L
AST= 15-30
>Contraindicated in pregnant >40mg daily significantly u/L
and breast feeding women in reduces risk of death from
women of child bearing age. coronary heart disease, non
fatal MI, stroke and
>Use cautiously in patient who revascularization
has history of liver disease. procedure.
NAME OF CLASSIFICATION INDICATION ADVERSE
DRUG REACTION
Generic Name: Non – opioid analgesics >Mild pain Skin: rash
Aspirin
>To prevent GI: GI
Form:
Tablet
CONTRAINDICATION NURSING MONITORING
RESPONSIBILITIES PARAMETERS
>Contraindicated in >For inflammatory >May ↓ platelet and WBC
patients hypersensitive to conditions, rheumatic count.
drug and those with fever & thrombosis give
NSAID induced sensitivity aspirin on a schedule >May ↑ liver function test
reactions, G6PD or rather than as needed. values.
bleeding disorders.
>For patients with >May falsely ↑ protein-
>Use cautiously in swallowing difficulties, bound iodine level.
patients with GI bleeding, crush non enteric-coated
impaired renal function, aspirin and dissolve in soft Platelet= 150,000 –
hypothrombinemia, vit. K food/liquid. 450,000 cubic mm
deficiency, WBC= 4,500 – 11,000
thrombocytopenia cubic mm
Prognosis
Mrs. X was admitted last January 17, 2009 at 5:40 pm at
Batangas Regional Hospital with a chief complaint of left sided
body weakness.
Several laboratory examinations were done to her which
includes hematology, blood chemistry, urinalysis and chest x –
ray.
After 4 days of therapeutic management, the prognosis
for recovery is fair although Mrs. X’s blood pressure subsided to
130/90 mmHg. There was also a decrease evidence of
respiratory distress hence discharge planning was possible. He
responded to it positively that medicates the improvement with
Mrs. X’s status. She was advised to seek to seek consultation
after a week. She is still subjected to series of examinations for
continuous monitoring of her condition.
She was discharged on a wheelchair last January 21,
2009 at 4:45pm.
DISCHARGE PLANNING
Subjective:
“Pwede na raw kaming umuwi sabi ng Doktor”.
Objective:
-Stable vital signs:
BP - 130/90 mmHg
Temperature - 36.8oC
Respiratory rate - 18 breaths per minute
Pulse rate - 88 beats per minute
-Can move her left upper and lower extremities in minimal range
Assessment:
May go home as per Doctor’s order.
Planning:
After 1 hour of nursing interventions, the client will be able to
enumerate ways on how to provide adequate care.
Implementation:
Conducted health teaching to the mother as follows:
MEDICATONS:
> Instructed the client to take the home medications as
prescribed by the doctor upon discharge:
TREATMENT:
> Informed the patient regarding the importance of her
compliance to medication as part of his treatment regimen.
> Advised the relatives that the head of the bed must be
elevated at 300.
> Encouraged client to increased activity if tolerated.
> Advised the relatives to initiate therapy prevent further
complications.
> Discussed with the client the relaxation techniques to combat
stress.
HYGIENE:
> Encouraged client to promote proper oral hygiene to
prevent any complication.
> Instructed the client to perform self care activities such
as bathing and dressing if tolerated.
OPD:
> Informed the client and relatives that further monitoring
will be conducted and so the need for regular check – up
is highly recommended. To come back at the hospital
after 1 week.
DIET:
> Advised the client to eat a variety of foods, those with
moderate amount of salt and sodium.
> Advised the client to avoid high cholesterol foods.
> Advised the client to have adequate caloric intake.
SPIRITUALITY:
Evaluation: