CHAPTER 1: ASSESSMENT A.

NURSING HEALTH HISTORY

PERSONAL DATA Our patient initial is B.L. He is 73 years old. He was born on June 5, 1935. He currently residing at 9 th Ave., Caloocan City. He is Filipino, pure Roman Catholic and married with 5 children. Educational attainment was high school graduate. Before, he was a painter but now his sons and daughters support him. Our source of reliability of information is his eldest child and his 3 rd child. And the date of interviewed was May 15, 2009. CHIEF COMPLAINT Nahihilo ako. As stated HISTORY OF PRESENT ILLNESS Few hours prior to admission, the patient experienced dizziness and the patient was rushed to the hospital because his son saw him that he fell down in the ground. The patient was conscious but not responsive. He was admitted May 8, 2009 at 3:30 P.M. with vital sign of Temp: 36.8C, PR: 90 bpm, RR: 21 cpm, BP: 130/90 mmHg. The patient was diagnosed with post C.V.A.

HISTORY OF PAST ILLNESS According to the daughter of our patient, patient B. L. Experienced C.V.A. 3 years ago. Two months ago B.L. experienced ulcer. The patient doesnt have any allergies in medications, foods and environment. He didnt go in any surgery FAMILY HEALH HISTORY They have a history of Hypertension and 1 died with heart attack in their family. SOCIAL HISTORY According to the son, his father is a responsible father., he gives all the necessary needs of his children. He said that if his father is mad he was still quiet and keep it to himself. B. L. Is very close to their neighbors, he spends time playing billiards with them. REVIEW SYSTEM PSYCHOLOGICAL Our patient is a hard working person at the age of 19 he already work as a helper this consider him as a responsible father. He is small frame. It is a big chance in his body and mind. He already have memory gap and hi skin became dry and less elastic, his hair is white. He already experienced C.V.A. 3 years ago but he recovered from that. ROLE RELATIONSHIP PATTERN Our patient is lives with his eldest child. He is 73 years old turning 74 next month. He stopped working when their children started to have new own families. His family was extended and very close with their neighbors. SEXUALITY AND REPRODUCTIVE Our patient is not sexually active anymore because of his age and status. Before, when he was a teenager he always use contraceptive method like condom is 100% safe to use. He is already circumcised when he was first year high school at the age of 11 years old. COGNITIVE PERCEPTUAL PATTERN Our patient B. L. is not using any devices like auditory and visual devices but when was diagnosed with C. V. A. he forgot everyone in his family. He is a high school graduate. VALUE BELIEF PATTERN He is not a religious person. He is satisfied with his life. He has superstitious belief like Bawal lumabas ang baby pag gabi because the baby will get sick. ELIMINATION When the patient not diagnosed in C.V.A. he eliminates 2-3 times a day and the characteristics of his stool is hard, brown in color, smells bad and the bowel movement is normoactive, he urinates regularly, the characteristics of his urine is clear and the yellow in color but when he hospitalize with the diagnosed in C.V.A. he defecate irregular and the characteristics of his tool is slight yellow in color, sticky, smells bad and the bowel movement is hypoactive, he urinates regularly, the characteristics of his urine is yellow in color and clear. REST AND ACTIVITY Because he is too old, he did not exercise everyday. His daily activities includes playing billiards with his friends. He has enough of sleep about 8 hours a day he feel complete when he has sufficient rest a day. SLEEP REST PATTERN When the patient not diagnosed in C.V.A. he sleeps 8 hours a day. He sleep 10 P.M. in the evening and woke up 6:00 A.M. he has a good quantity of sleep, but when he hospitalize with the diagnosed in C.V.A. he sleeps irregularly because having stroke feels pain, not comfortable, irritability and restlessness. SAFE AND ENVIRONMENT He doesnt have any allergies in the environment. There is one lesion oh his right elbow. He has a fever and the temperature was 38.8C. I.

OXYGENATION

The patients is always takes good care of his grand children and spends time time playing billiards. He smokes and drinks alcohol until the first attack of his C. V. A.

NUTRITION The patient was advised to have low salt, low fat and low cholesterol diet

BREAKFAST

FOOD INTAKE NGT (low salt, low fat, low cholesterol)

FLUID INTAKE 1 glass of water

LUNCH

NGT (low salt, low fat, low cholesterol

1 glass of water

DINNER

NGT (low salt, low fat, low cholesterol

1 glass of water

a. Physical Assessment Vital signs The clients pulse rate is 90 beats per minute, his respiratory rate is 21 breaths per minute, temperature is 36.8c.

General appearance The client is in medium frame with stooped posture, the client is bedridden since he was admitted to the hospital last may 8, 2009. Well groomed and has no body odor. He doesnt have any deformity.

Mental status The client is conscious and cooperative. The client cant talk because he was stroke.

Skin The clients skin is of normal racial tone which is brown. It is dry and smooth. The skin turgor is wrinkled and loss of elasticity. The body hair is evenly distributed. He doesnt have any edema. But he has a skin lesion on his right elbow.

Nail The clients nail shape is convex clubbing, the nail is rough and the nail bed is pink. The capillary refill is within 3 seconds and thise is an absence of beaus line.

Head and Face The clients skull is proportionate to the body size, Thise were no tenderness in the scalp. Thise were no presence of nodules, and infestation. His hair is evenly distributed and the strands are thin and brittle. The color of his hair is a mixture of white and black. His head is round and symmetrical its consistency is hard. He cant control his head and the shape of his face is round and asymmetrical and its consistency is soft.

Eyes The condition of his eyes is straight normal; the eye brows are evenly distributed. Eyelids have effectively closure. The blink response is bilateral, eye balls are symmetrical, bulbar conjunctiva is clear, the palpebral conjunctiva is pink and the sclera is white. The palpebral slant is aligning with the tip of the pinna. The corneal sensitivity reflex is present cornea is transparent, the color of his eyes are brown, the shape are equal, it is uniform in color. Pupils are equal in size. Pupils are equally round and reactive to light and accommodation. He can execute the occular movements. He can recognize objects within 12-14 inches away. The lacrimal apparatus are moist.

Ear The color of the ear is of normal racial tone which is brown, it is symmetrical. The alignment of the pinna is symmetrical. The pinnas are elastic and recoil when folded. The mastoid process is tender. The auditory canal contains some cerumen, the color is brown and there is an absent of discharges.

Nose The color of the clients nose is of racial tone which is brown. His septum is in the midline. The mucosa is pink, nostrils are both patent, nasal flaring is absent. Landmarks are visible. Sinuses are non-tender. There is an NGT in his right nostrils.

Mouth and Oropharynx The lips is symmetrical and pink, the consistency is smooth, buccal mucosa is pink, the gum is pink, the tongue is in the midline, the color is pink and it is smooth. The tongue movements are not that smooth. Its texture is rough. The color of the hard and soft palate is pink. And it is intact. The tonsils are inflamed grade of + 2. Ther is presence of mucous. Uvula is in the midline, gag reflex is absent. The teeth are incomplete. Neck The neck has involuntary movement and with resistance, the muscle strength 3/5. The trachea is in the midline, thyroid is in the midline and it is smooth. Maxillary lymph nodes are palpable.

Breast

The breasts are symmetrical with flat contour. Shape is flat, the skin surface is smooth. Lympnodes are not palpable. The areola is color brown, shape is round and the nipple is everted, there are no discharges and there are no Lympnodes and no tenderness.

Chest and Lungs The color of the chest is of normal racial tone which is brown, the shape is AP to lateral ratio 1:2. There are absence of intercoastal retraction, costal angle is 45 chest wall are symmetrical, and the chest expansion is symmetrical. Rib slope is less than 90. Respiratory rhythm is regular. The respiratory depth is shallow. Respiratory pattern is normal. When palpated he doesnt feet any tenderness. The vocal fremitus is normal, tactile fremitus is symmetrical. The lung expansion is normal. When percussed the sound is resonance. When auscultated brondual is absent. No adrentition sound. Respiratory rate is 21 breaths per minute.

Heart The rhythm is regular. PMI is located in the apical pulse. Heart rate is 90 beats per minute. Abdomen Skin is of normal racial tone which is brown, the contour is flat. Peristalsis is non-visible. The color of his stool is brown, it is solid and formed. The bowel sound is normo active and no bruits. When percussed the sound is tympany. When palpated he doesnt have any tenderness and when light palpation is done muscle guarding is absent. The liver is not palpable. Upper extremities The client cannot resist force when asked to resist. Muscle strength is 3/5. He have a skin lesion in his right elbow, The peripheral pulses are equal. Lympnodes are not palpable. The IV site is in his left arm.

Lower extremities The client cannot resist force when asked to resist. Muscle strength is 2/5. He doesnt have any deformity. The peripheral pulses are equal. Lympnodes are non-palpable. Genital(according to the client) The client is circumcised and his genitals are fully developed C. Diagnostic Procedure 1. Name of Diagnostic Procedure - Hematology

Description:

The branch of biology (physiology), pathology, clinical laboratory, internal medicine, and pediatrics that is concerned with the study of blood, the blood forming organs, and blood diseases.

Indication: - this is used to evaluate anemia, leukemia, reaction to inflammation and infections, peripheral blood cellular characters, state of hydration and dehydration, polycythemia, hemolytic disease of the newborn, to manage chemotheraphy decisions. Nursing Responsibilities: Pre-test Explain procedure Gather all equipments Fasting is not necessary During Test Record the result Post Test Monitor patient response Document

Results: Name of Procedure Date Ordered Normal Values Hct: mo. 40-0,56 Hgb: M 135-180 g/L RBC: 5.0-6.5x10 g/L Hematology May 8, 2009 WBC: 4.5-11.00x10g/L Values Obtained 0.45 152 4.86 15.2 Interpretation Normal Normal Normal Above normal: values obtained is higher than the normal values Normal Above normal: values obtained is higher than the normal values Normal

Platelet count: adequate Neutrophils: 0.50-0.70

Adequate 0.82

Lymphocytes 0.20-0.40

0.18

2. Name of Diagnostic Procedure - Radiology Definition: -is the branch of specialty of medicine that deals with the study and application of imaging technology like x-ray and radiation to diagnosing and treating disease. Nursing Diagnosis: Pre-test Explain procedure Check Vital Signs before the procedure During Test Remove all jewelries Record the result Post Test Result: No acute parenchymal infiltrates seen Atherosclerotic Aorta Monitor patient response Check Vital Signs after the procedure Document

Date of Examination: May 8, 2009

3. Name of Diagnostic Procedure - CT Scan Definition: - is a medical imaging method employing tomography. Digital geometry processing is used to generate a three-dimensional image of the inside of an object from a large series of two dimensional x-ray images taken around a single axis of rotation.

Indication: CT Scanning of the head is typically used to detect: 1. 2. 3. 4. Bleeding, brain injury and skin fractures Brain Tumors A blood clot or Bleeding Enlarged brain cavities ,etc..

Nursing Responsibilities:

Pre-test Explain procedure Check Vital Signs before the procedure During Test Remove all jewelries Record the result Post Test Monitor patient response Check Vital Signs after the procedure Document

Results:

Technique: Plan axial CT Images of the head sad 20m slices was done.

Findings:

There is widening of the sulci and narrowing of the gyri in both cerebral hemisphere. The Cerebral vessels are calcified There are low alterat ions noted in the left temporo-parietal lobes.

Impression:

Age related to cerebral atrophy with ex-vasodilatation at the ventricles Atheromatous cerebral vessels Acute to subacute infarcts in the distribution area of the left middle cerebral artery

Date of examination: May 8, 2009

4. Name of Diagnostic Procedure - Ultrasound

Definition: - Ultrasound, also known as sonography, or ultrasonography, is a diagnostic procedure that transmits high-frequencysound waves, inaudible to the human ear, through body tissues. The echoes are recorded and transformed into video or photogrsphic images of the internal structures of the body.

Nursing Responsibilities:

Pre-test During Test Explain procedure Check Vital Signs every 2 hours and check for patients skin

Provide Privacy Determine if the test is accurately performed according to the procedure Record the result Post Test Monitor patient response Document

Results:

- An irregular calcification is noted within the central zone of the prostate. The dimension measures 39x35x37 mm. The capsule is irregular and echoic. No masses noted.

Impression:

- Prostate hypertrophy with evidence of repeated episodes of prostatitis.

Date of Examination: May 14, 2009

D. anatomy and physiology

BRAIN Cerebrum- The biggest part of the brain is the cerebrum. The cerebrum makes up 85% of the brain's weight, and it's easy to see why. The cerebrum is the thinking part of the brain and it controls your voluntary muscles Cerebellum- The cerebellum is at the back of the brain, below the cerebrum. It's a lot smaller than the cerebrum at only 1/8 of its size. But it's a very important part of the brain. It controls balance, movement, and coordination (how your muscles work together). Brain Stem- The brain stem sits beneath the cerebrum and in front of the cerebellum. It connects the rest of the brain to the spinal cord, which runs down your neck and back. The brain stem is in charge of all the functions your body needs to stay alive, like breathing air, digesting food, and circulating blood. 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 is the lower portion of the brainstem. It deals with autonomic functions, such as breathing and blood pressure. The cardiac center is the part of the medulla oblongata responsible for controlling the heart rate.

Hypothalamus- The hypothalamus is like your brain's inner thermostat (that little box on the wall that controls the heat in your house). The hypothalamus knows what temperature your body should be (about 98.6 Fahrenheit or 37 Celsius). PATHOPHYSIOLOGY OF HEMMORHAGIC STROKE Tissue injury Causing compression of tissue Expanding hematoma or hematomas Distort and injure tissue The pressure may lead to a loss of blood supply to affected tissue with resulting infarction The blood released by brain hemorrhage appears to have direct toxic effects on brain tissue and vasculature CHAPTER II: PLANNING

Nursing Diagnoses Impaired verbal communication related to neuromuscular impairment as evidence by absence of responding

Rank 1

Justification It is the 1st prioritized diagnoses because the client cant express his feelings and emotions, and it needs to have an immediate intervention

Impaired walking related to neuromuscular impairment as evidence by paralyzed extremities

it is my 2nd prioritized diagnoses because the client cant walk because of the neuromuscular impairment that needs immediate intervention

Impaired physical mobility as evidence by functional level of 0

It is my 3rd prioritized diagnoses because the patient cant mo w/ or w/out assistance

Risk for skin integrity related to physical immobility

It is the 4th because it may cause of bedsore

Readiness for enhanced power 5

It is the last prioritized diagnoses because the patient wants to gain his power

TREATMENT

INTRAVENOUS FLUID PNSS 1000M/12 hours (27.28 gtts/min.) IVF is an essential when patient are unable to take enough food and fluids orally. It is effective and efficient method of supplying liquids directly into the IVF compartment and replacing electrolyte losses. NURSING RESPONSIBILITIES

1. 2. 3.

Explain the purpose of the IVF to the patients family Checks the doctor order before looking the IVF Frequently check the IVF site for infiltration, dislodge and inflammation

DIET

The patient was advised to have low salt. Low fat diet and he was feed through NGT.

ACTIVITY

The patient was ordered to have complete bedrest because the patient is weak and he needs to conserve energy changing of position is required and advisable for proper blood circulation.

NURSING RESPONSIBILITIES

1. 2. 3. 4.

Monitors patients vital signs frequently specially blood pressure because patient is unstable in her condition. Monitor patients I and O Encourage bed rest Check the IVF volume, follow flow rate and adjust it to prescribe

NURSING MANAGEMENT Obtain vital sign and pulse oximetry measurements every 2 -4 hours or as ordered for 24 hours on all patients with diagnosis of stroke. Asses level of consciousness, random movements, response to stimuli, eye contact and speech. Document. Patient should have at least one IV access site in the non-paralytic side. Monitor blood pressure every 30 minutes. Check for urinary retention. Initiate physical therapy.

 Activity needs to be advanced as tolerated. Avoid immobility. Apply high knee ted hose for patients with impaired mobility. Initiate the pressure ulcer prevention, general skin care, immobility management and fall prevention management. CLIENTS DAILY PROGRESS CHART Diagnostic Procedure Admission Diet Activity Medication Treatment Surgery

Low Salt Low Fat Diet

NGT 2000 Kcal / feeding. IV PNSS 1 L 27 gtts to run for 16 hours

Day 1

Low Salt Low Fat Diet

NGT 2000 Kcal / feeding. IV PNSS 1 L 27 gtts to run for 16 hours

Day 2

Low Salt Low Fat Diet

NGT 2000 Kcal / feeding. IV PNSS 1 L 27 gtts to run for 16 hours

Discharge

Low Salt Low Fat Diet

NGT 2000 Kcal / feeding. IV PNSS 1 L 27 gtts to run for 16 hours

Chapter IV: Evaluation

Narrative Evaluation During the two days of hospital duty in the President Diosdado Macapagal Memorial Medical Center, patient shows sign of improvement compare to his condition during admission. Tonsils were not that inflamed, from a grade of 2 to the grade of 1. Vital sign became normal, blood pressure decreased. M-edication Patient has to continue his medication. Amlodipine 5mg/ tab once a day, Zantac 150 mg twice a day, 8am and 6pm. E-xercise The patient was advised to have complete bed rest until strength is regained. Have turn side to side every 2 hours to prevent bed soars. Have ROM exercise on to enhance client's body function.

T-reatment

Insist physical therapy for improving strength and walking. Occupational therapy for regaining dexterity of the arms and hands. Should undergo speech therapy to learn talking and swallowing. Oxygen inhalation if necessary and if possible 3-4 liters per minute.

H-ealth teaching

Teach the client how to have a healthy lifestyle. Teach patient the foods to eat and the foods to avoid. Teach the family members how to prepare low sodium and low fat diet. Encourage environmental modification to enhance safety and prevent injury.

O-ut Patient The client was advised to have a follow-up check-up, as indicated by the physician. D-iet Patient was instructed to maintain the low salt and low fat diet. The low salt diet is designed to induce a loss of sodium and water from the body or avoid sodium retention. A 2000 mg low sodium diet is sufficient to control blood pressure. A low fat diet help lose weight to decrease risk of having CVA again

Table of Contents Introduction................................................................................................................................................................................................................................1 Objectives...........................................................................................................................................................................................................................................................2 Chapter I: Nursing health history ..................................................................................................................................................................................................................3 Review of system................................................................................................................................................................................................................................................4 Physical assessment ..........................................................................................................................................................................................................................................6 Diagnostic procedure ........................................................................................................................................................................................................................................9 Anatomy and physiology............................................................................................................. 13 Chapter II: Prioritize Nursing diagnoses..................................................................................15 Nursing Care Plan 1..................................................................................................................... 16 Nursing Care Plan 2..................................................................................................................... 17 Nursing Care Plan........................................................................................................................ 18 Chapter III: Medication 1........................................................................................................... 19 Medication 2 ................................................................................................................................ 20 Medication 3................................................................................................................................ .21 Treatment, Diet, and Activity..................................................................................................... 22 Nursing Management............................................................................................................. 22-23 Clients Daily Progress Chart..................................................................................................... 23 Chapter IV: Narrative Evaluation............................................................................................. 24 METHODS................................................................................................................................... 24

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