LEVEL 4 .

SY 2011-2012

2ND

SEMESTER

Page |1

Level 4

CASE PRESENTATION
2nd Semester SY 2011-12 Cerebrovascular accident (CVA) is the medical term for what is commonly termed as stroke. It refers to the injury to the brain that occurs when flow of blood to brain tissue is interrupted by a clogged or ruptured artery, causing brain tissue to die because of lack of nutrients and oxygen. The severity associated with cerebrovascular accident can best be demonstrated by many facts. It has been noted that CVA is the leading cause of adult disability in the world. Worldwide, one-quarter of all strokes are fatal. Two-thirds of strokes occur in people over the age of 65. Strokes affect men more often than women, although women are more likely to die from a stroke. The incidence of strokes among people ages 30 to 60 is less than 1%. This figure triples by the age of 80. According to the World Health Organization, 15 million people suffer stroke worldwide each year. Of these, 5 million die and another 5 million are permanently disabled. High blood pressure contributes to over 12.7 million strokes worldwide. Europe averages approximately 650,000 stroke deaths each year. In developed countries, the incidence of stroke is declining - largely due to efforts to lower blood pressure and reduce smoking. However, the overall rate of stroke remains high due to the aging of the population. Sources: World Health Report - 20011, from the World Health Organization; International Cardiovascular Disease Statistics (2011 Update), a publication from the American Heart Association.

I.

Statement of Objectives A. General Objectives

This case analysis aims to increase the understanding and knowledge of student nurses on how to care for patients with CEREBROVASCULAR DISEASE effectively and efficiently. B. Specific Objectives Specifically, this case analysis aims to: 1. Define CEREBROVASCULAR DISEASE and its effects to the body as a whole; 2. Illustrate the pathophysiology of CEREBROVASCULAR DISEASE and in relation to the signs and symptoms specifically observed in the client; 3. Describe and identify the common signs and symptoms of CEREBROVASCULAR DISEASE; 4. Discuss the medical and surgical interventions for the management of CEREBROVASCULAR DISEASE; 5. Formulate appropriate nursing care plans suited for the client based on the assessment findings; 6. Identify care measures to be given to the patient and family to promote continuity of care and independence after discharge. II. Clients Profile Name Age Birth date Sex Ethnic Background Civil Status Address Religion Occupation Admitting Diagnosis: Final/Principal Diagnosis Admitting Physician Date and Time Admitted : : : : : : : : : : : : Patient Sy B. Dee 65 years old March 26, 1946 Male Igorot Single Dangao, Kapangan Roman Catholic None Cerebrovascular Disease, Essential Hypertension Stage 2 CVD, Hemorrhagic Stroke, HPN Stage 2, type 2 Diabetes Mellitus Dr. Baniqued November 17, 2011 at 08:30 PM

III. Chief Complaint Decreased sensorium, dizziness and right sided body weakness

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

Page |2

IV. History of Present Illness Patient Sy B. Dee, 65 year old male from Dangao, Kapangan was admitted at Benguet General Hospital last November 17, 2011 at 08:30 PM with chief complaints of decreased sensorium, dizziness and right sided body weakness. A week prior to admission, he experienced episodes of severe headache and dizziness few hours after his meal. During this incident, he took in Paracetamol to relieve the headache and decided to have a rest, but no medical consultation was made. Two days prior to admission, the said condition worsened accompanied by nape pain. The patient was a known hypertensive and was also of diagnosed of having type 2 Diabetes Mellitus, as claimed by his younger sibling. One day prior to admission, his younger sibling noticed the flagging condition of Mr. Sy B. Dee when he found him lying in bathroom floor, unable to speak and move the right side of his body. The patient was then rushed to Kapangan District Hospital and was prescribed to start on clonidine drip +mannitol 100 cc IV and furosemide. The patient was referred later on Benguet General Hospital and was subsequently admitted for further evaluation and management. At the ER, he was seen stuporous, with vital signs of: BP: 280/ 120 mmHg CR: 125 bpm RR: 22 bpm T: 38.0 C V. Past History of Illness

The patient has no known allergies to food and medications. The client experiences minor illnesses such as cough, colds, and fever. These conditions were remedied with over-the-counter drugs such as Symdex and Biogesic. The client also uses herbal medicines and water therapy with rest. His younger sibling further claimed that his brother was admitted at Baguio General Hospital and Medical Center in his high school years because of an accident and undergone an operation of amputation of the left leg. It was around 2008 when patient Sy B. Dee was diagnosed with DM Type II. On December of 2009, the patient experienced his first attack of stroke. During this time, Mr. Sy B. Dee was again brought to Baguio General Hospital and Medical Center because of slurring of speech while he was chatting with his friends. He was then prescribed by the physician in the said institution some maintenance drugs for his DM which is Metformin (taken every evening) and Insulin (25 units during morning and another 15 units during evening). Another maintenance drug for his hypertension is Losartan which he takes 10mg every day. In March of 2010, the patient was again admitted at Kapangan District Hospital due to increased blood pressure and dizziness. The patient was a known hypertensive since he was at his younger years, as claimed by his younger sibling. On the 17th of November, 2011, the patient was found lying in bathroom floor, with slurred speech and was unable to move his right side of the body. He was then rushed to Kapangan District Hospital. He was then referred on that day to Benguet General Hospital and was subsequently admitted for further evaluation and management in the said institution. VI. Family Health History The patients sibling claimed to have familial history of hypertension on their mothers side. According to his brother, their mother died from stroke 11 years ago. Other than that, the patients sibling claimed no history of Hypertension and Coronary Artery Disease on her fathers family. Health problem such as Asthma, kidney diseases, cancer, or mental illness was also verbalized to be absent. VII. Developmental History The client is the oldest son of a five-child family, which is composed of three females and two males. He is 65 years of age and is considered a mid-adult with the task of developing Generativity and Stagnation according to Erik Eriksons Psychosocial Developmental theory. In this stage of development, the patient is supposed to build his own life by focusing on his career and family. However, due to the amputated left leg of the patient, he was unable to finish his secondary level of education. He stayed at their mothers house and became a helper; he did not marry and concentrated on helping in the household

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

Page |3

chores at the level of his capability. On these reasons, he did not have a chance to experience the joy of being a teenager and failed to marry and have his own family. This unsuccessful phase in his life contributed to his failure and feeling of unproductivity and uninvolved in the community. Thus, he was currently going through the so-called stagnation phase, as identified by Erik Erikson. According to Erikson, stagnation is an extension of intimacy which turns inward in the form of self-

interest and self-absorption. It's the disposition that represents feelings of selfishness, selfindulgence, greed, lack of interest in young people and future generations, and the wider world.
The condition of Mr. Sy B. Dees amputated left leg resulted from not having an outlet or opportunity for contributing to the good or growth of children and others, and potentially to the wider world. VIII. Social and Environmental History According to Mr. Sy B. Dees siblings, the patient was a smoker during his adolescent period and he drinks occasionally. No verbalized other vices were identified. He preferred to stay at their house and was not fond of socializing to other people. The patient stays at his younger brothers house made up of semi-permanent and permanent materials such as wood and cement, there are four bedrooms and a kitchen and a sala. They use spring water for their daily consumption and for drinking. They use stove for cooking but sometimes they also use wood. Their house is at the mountain surrounded with different kinds of trees, they have a garden and animals like dogs, pigs and chicken. IX. Lifestyle and Health Practices The family of the patient consumes meat and vegetables as their main dish since they have a garden of vegetables and have animals for a livelihood. The patient also consumes foods with high- fat and sodium content. According to his brother, he enjoys eating barbecue, lechon, pickled food and other preserved goods. However, hes diet is now controlled on low salt, low fat diet after he was diagnosed of DM, type II and Hypertension. He smokes 2-3 cigarettes per day, but already cut down the habit when he experienced his first attack of stroke in 2008. He was not fond of engaging to physical activities and other forms of exercises because of his disability. The patient does not seek consultation from a physician when dealing with minor ailments. He relies on self care first before consulting medical attention. The patient has his maintenance drugs for his DM which is Metformin (taken every evening) and Insulin (25 units during morning and another 15 units during evening). Another maintenance drug for his hypertension is Losartan which he takes 10mg every day. X. Health Assessment A. General Survey

The client was received asleep lying on bed in a semi-fowlers position with an ongoing IVF of 90cc PNSS + nicardipine drip regulated at 15 gtts/minute infusing well over the left hand; with an O2 inhalation via nasal cannula at 2-3 lpm; with an intact NGT; with an intact indwelling foley catheter connected to a urine bag, with a urine output of 150 cc, urine characterized as slightly turbid. Client is bed ridden, appears weak, and needs full assistance when assuming activities of daily living like toileting, grooming, hygiene and changing positions. Client wears a fairly neat gown. Client is not conversant. No various interruptions in skin integrity are found but his present condition put him to risk for pressure ulcers. With initial vital signs as follows: BP 140/ 100 mmHg, PR 55 bpm, CR 110 bpm, RR 19 bpm, and Temp 37 C, and with a Glasgow Coma Scale score of 4. Glasgow Coma Scale Score 1 Eyes Does not open eyes Makes no sounds 2 Opens eyes in response to painful stimuli Incomprehensible sounds Extension to painful stimuli (decerebrate response) 3 Opens eyes in response to voice Utters inappropriate words Abnormal flexion to painful stimuli (decorticate response) 4 Opens eyes spontaneously Confused, disoriented Flexion / Withdrawal to painful stimuli 5 N/A Oriented, converses normally Localizes painful stimuli 6 N/A

Verbal

N/A

Motor

Makes no movements

Obeys commands

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

Page |4

B. 1.

Head to Toe Assessment Head Normocephalic, hair is black, coarse to touch, evenly distributed. Scaling is noted on the scalp. No lesions noted but with tenderness upon palpation in the tempoparietal area.

2. 3.

Eyes Ears

Eye lids are symmetrical. Eyebags noted. Pale palpebral conjunctivas. Unable to distinguish colors. Pupil size is equal. Equal in size bilaterally. No lesions, lumps or nodules. No ear piercings. The ear lobes are bean shaped, parallel and symmetrical. Auricles are firm. No discharges or lesions are noted at the ear canal. However, patient is unable to hear words clearly. Does not respond when asking questions.

4.

Nose and sinuses

Nasal mucosa is pale, moist and free of exudates. No nasal flaring is noted. However patient is connected to an O2 inhalation via nasal cannula. Nasal structure is smooth and symmetric. Nasolabial fold is symmetrical. Nasal septum is intact. External nose is not tender and no presence of lesions.

5.

Mouth

Lips are pale and dry without lesions. Gums are moist with firm texture. Teeth appeared white-yellowish in color, with dental caries noted. He has an incomplete set of teeth (2 tooth extractions are noted). Dental status is noted to be poor. The tongue is on central position. There is no breakdown in the integrity of membranes. Patient is unable to speak.

6.

Neck

Neck movement is supple. Neck is centered and symmetrical. Lymph nodes are not palpable. Trachea is placed in the midline of the neck. The neck is straight with no jugular vein distention.

7.

Chest

Appears symmetrical with ribs sloping downward. Scapula is symmetric and nonprotruding. No tenderness noted upon palpation. No adventitious sounds heard upon auscultation. Chest expansion is symmetrical with no retractions

8.

Cardiac

Heart sounds are distinct, slightly bradycardic. Apical pulse is palpable with regular rate and rhythm. .The patient has a dynamic precordium, normal rate and regular rhythm but slightly bradycardic (110 bpm). No murmurs were appreciated upon auscultation. No visible pulsations in the precordium.

9.

Breast

No gynecomastia is noted. Patients breast is equal, skin is uniform in color and intact. There is no tenderness, masses or nodules present. The nipples are round, averted and equal in size.

10. Abdomen

Bowel sounds heard are audible but slightly hypoactive upon auscultations in all quadrants. Bowel sounds: 8 upon auscultation. Patients abdomen is uniform in color. No ascites. Umbilicus is sunken.

11. Genito-urinary 12. Musculoskeletal

Patient has an indwelling foley catheter connected to a urine bag with an output of 150 cc. Urine was characterized as slightly turbid in color. Muscle strength on both upper and lower extremities were graded as 1 (Cannot moved against resistance). Needs full assistance when repositioning and doing activities of daily living. Unable to move the lower extremities due to paralysis. Muscles appear to be wasted. Peripheral pulses are regular but slightly weak (55 bpm).

13. Integumentary

Skin appears pale and dry. (+) pallor on palms. Capillary refill of 3 seconds. Pale nail beds are observed and nails are smooth, firm and untrimmed. With scattered moles noted over the skin.

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

Page |5

C. Thirteen Areas of Assessment 1. Social Status Mr. Sy B. Dee is a 65 year old male, born on March 26, 1946. He resides at Dangao, Kapangan and lives together with his younger brother. The patient was in good terms with the siblings family. The patients younger brother has a wife and they were both local vendors at Baguio City. The said brother had 2 sons and one daughter who are all college graduates. The eldest son was an Overseas Filipino Worker at Dubai and the other two siblings live in La Trinidad and Kapangan with their own families but sometimes visit their parents in times of needs. Mr. Sy B. Dees medical expenses and other financial needs are supported by his siblings especially his younger brother. During his younger years, he usually mingles with neighbors and goes to church for his spiritual needs. However due to his first attack of stroke in 2008, he became socially inactive. He also smokes 2-3 cigarettes per day in in his younger years, but already cut down the habit when he experienced the said stroke. In addition, he was not fond of engaging to physical activities and other forms of exercises because of his amputated leg. Norms: Social status includes family relationships that state the patients support system in time of needs and stress. It meets the fundamental human need for social ties, making life less stressful and social support buffers the negative effects of stress, thus indicating indirectly contributing to good health outcomes (Friedman and Smith, Fundamentals of Nursing 7th edition). Analysis: Based on the above statement, Mr. Sy B. Dee has a good relationship with his younger brother, as well as the family of the said sibling. The financial and emotional support being given to him buffers the ineptness of his present condition. However, his current social status was very much affected by his present condition. The inability to talk and express feelings, as well as the paralysis on both upper and lower extremities contributes to being socially indolent. 2. Mental Status The patient is not oriented to person, place and time during the assessment. He was not verbally cooperative and was unable to recall recent and remote memories due to neuronal damage, unable to write and participate in ADLs due to motor deficits. He is unresponsive. Norms: The patient must be oriented to person, place and time, can identify past and recent memories and should be able to verbalize concrete messages. The patients ability to read and write should match his educational level. The patient should be able to respond to questions and identify all objects presented to him. The patient should evaluate and act appropriately in situations (Estez Health Assessment and Examination 3rd edition). Analysis: Being not oriented, unresponsive, and the inabilities to recall memories, write and participate to ADLs like patients case indicate that mental capabilities are not functioning normally. 3. Emotional Status The patient does not exhibit any emotional concerns and apprehensions due to the inability to express concerns. Nevertheless, the patients sibling continues to pray for his brothers recovery. According to him, everything has a reason and the situation per see is in Gods plan. Norms: In this stage of development, the patient is supposed to build his own life by focusing on his career and family. He is considered a mid-adult with the task of developing Generativity according to Erik Eriksons Psychosocial Developmental theory. Analysis: The fact that the patient has no wife, career and social peers indicate that he was experiencing stagnation. According to Erikson, stagnation is an extension of intimacy which turns inward in the form of selfinterest and self-absorption. It's the disposition that represents feelings of selfishness, self-indulgence, greed, lack of interest in young people and future generations, and the wider world. This unsuccessful phase in his life contributed to his failure and feeling of unproductivity and uninvolved in the community. 4. Sensory Perception Sense of Sight: The patient was unable to open his eyes independently during the assessment of Glasgow coma score, thus visual acuity using the Snellens Chart was not done. Exraocular eye movement using a pen light was vague. Though the patients eyes are symmetrical and the sclera is white in color, the palpebral conjunctivas were pale during the assessment and inspection. According the patients health history, he experienced blurring of vision prior to hospital admission. Sense of Taste: The patient was unable to differentiate various taste of food such as salty, bitter, sweet and sour due to the inability to take in food. Nasogastric tubing was connected to the left nostril allowing the passage of fluids and medications.

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

Page |6

Sense of Hearing: For the auditory acuity, the voice whisper test was used. Phrases were whispered and instructed the patient to repeat the said words. The patient was unable to respond and comprehend to the words whispered. Sense of Smell: The patients nose was at the midline, connected to the nostrils was a nasogastric tubing. He was unable to respond to any aroma being provided such as the smell of a perfume and coffee. Tactile Sensitivity: The patient does not withdraw to painful stimuli. Norms: Each of the five senses became less efficient in older adulthood. Changes result in loss of visual acuity, less power of adaptation to darkness and dim light, decreased in accommodation to near and far objects. The loss of hearing ability related to aging affects people over age 65. Gradual loss of hearing is more common among man than women, perhaps because men are more frequently in noisy environments. Older people have a poorer sense of taste and smell and are less stimulated by food than the young. Loss of skin receptors takes place gradually, producing an increased threshold for sensations of pain, touch and temperature (Barbara Kozier, Fundamentals of Nursing 7 th edition). Analysis: Mr. Sy B. Dees visual acuity and extraocular muscle movements are considered impassive due to the state of his cerebrovascular disease. The patients sense of tase, smell, hearing and touch do not perceive stimuli accordingly. 5. Motor Stability and Gait The patient needs full assistance and support when assuming self care needs and feedings. He was always seen in a semi- fowlers position throughout the assessment. He can do passive exercise such as bending elbows and flexing the knees with the help of the nurse. Movements through full range of motion can not be done without the assistance of the nurse or the significant others. Norms: In standing position, the torso and head are upright. The head is midline and perpendicular to the horizontal line of the shoulders and the pelvis. The shoulders and hips are level, symmetry of the scapulae and iliac crests. The arms are freely from the shoulders. The feet are aligned and the toes point forward. Walking initiated in one smooth rhythmic fashion. The foot is lifted 2.5 to 5 cm to the floor ad propelled 30 to 45 cm forward in a straight path. The patient remains erect and balanced during all stages of gait. The patient should be able to transfer easily to various positions. There should be absence of discomfort during range of motion exercise (Mary Ellen Zator Estez, Health Assessment and Physical Examination). Analysis: Due to the patients diagnosis of hemorrhagic cerebrovascular disease, loss of cerebrovascular feedback mechanisms occur leading to neuronal loss and cessation of physiologic functioning. This state affected the motor control and gait of the patient. 6. Body Temperature The table shows the recorded body temperature of the patient throughout the 3-days of duty. Date Assessed November 21, 2011 Time 10 am 2 pm Time 10 am 2 pm Time 10 am 2 pm Temperature 37.1 C 37. 4 C Temperature 38.1 C 37.8 C Temperature 37.7 C 36.9 C Analysis Normal Normal Analysis Abnormal Normal Analysis Normal Normal

Date Assessed November 22, 2011

Date Assessed November 23, 2011

Norms: The normal core body temperature of a healthy, resting adult human being is stated to be at 98.6 degrees fahrenheit or 37.0 degrees celsius. Though the body temperature measured on an individual can vary, a healthy human body can maintain a fairly consistent body temperature that is around the mark of 37.0 degrees celsius. 7. Respiratory Status The table shows the recorded respiration of the patient throughout the 3-days of duty. Date Assessed November 21, 2011 Time 10 am 2 pm Respiration 17 19 Analysis Normal Normal

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

Page |7

Date Assessed November 22, 2011

Time 10 am 2 pm Time 10 am 2 pm

Respiration 20 18 Respiration 19 16

Analysis Normal Normal Analysis Normal Normal

Date Assessed November 23, 2011

Norms: Respiratory quality or character refers to those aspects of breathing that are different from normal. Normal breathing sounds are a Vesicular- soft, low pitched, heard over periphery of lungs. b Broncho-vesicular- soft, medium-pitched, heard over major bronchi. c Bronchial- loud, high pitched, heard over trachea G & N notes-Gregory N. Yalma, M.D.. A normal respiratory rate ranges from 1220 cpm (Kozier, Fundamentals of Nursing, 7th Edition).

8. Circulatory Status The table shows the recorded cardiac rate, as well as the blood pressure of the patient throughout the 3-days of duty. Date Assessed November 21, 2011 Time 10 am Cardiac Rate 83 bpm Blood Pressure 160/ 110 mmHg Analysis Cardiac rate is within the normal range. High BP Indicates 2 Hypertension Cardiac rate is within the normal range. High BP Indicates 2 Hypertension Analysis Cardiac rate is within the normal range. High BP Indicates 2 Hypertension Cardiac rate is within the normal range. High BP Indicates 2 Hypertension Analysis Cardiac rate is within the normal range. High BP Indicates 2 Hypertension Cardiac rate is within the normal range. High BP Indicates 2 Hypertension

2 pm

79 bpm

160/ 110 mmHg

Date Assessed November 22, 2011

Time 10 am

Cardiac Rate 76 bpm

Blood Pressure 170/110 mmHg

2 pm

79 bpm

160/ 110 mmHg

Date Assessed November 23, 2011

Time 10 am

Cardiac Rate 81 bpm

Blood Pressure 170/ 110 mmHg

2 pm

80 bpm

170/ 120 mmHg

Norms: Normal cardiac rate is 60- 100 beats per minute while the normal blood pressure is 120/ 80 mmHg. The working capacity of the heart diminishes with aging. The heart rate of older people is slow to return to normal after stress. Reduced arterial elasticity results in diminished blood supply to the parts of the body especially the extremities (Kozier et.al, 2004). 9. Nutritional Status Prior to admission, Mr. Sy B. Dee consumes meat and vegetables as his main dish since they have a garden of vegetables and have animals for a livelihood. The patient also consumes foods with high- fat and sodium content. According to his brother, he enjoys eating barbecue, lechon, pickled food and other preserved goods. However, hes diet was controlled on low salt, low fat diet after he was diagnosed of DM, type II and Hypertension. However, during the assessment, the patient was then connected to a nasogastric tubing to allow passage of fluids, necessary nutrients and prescribed medications. Norms: According to the Health Asian Diet Pyramid, there should be a daily intake of rice, grains, bread, fruit and vegetables; optional daily for fish, shellfish, and dairy products; weekly for sweets, eggs and poultry, and monthly for meat.

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

Page |8

There should be an increase intake of a wide variety of fruits and vegetables. Include in the diet foods higher in vitamins C and E, and omega-3 fatty acid rich foods (Brunner and Suddarths Textbook of Medical- Surgical Nursing). Analysis: Salt and sodium restriction prevents water retention in the body while fat restriction prevents complications in fat digestion and absorption. However, the patient only maintain his nutritional needs through the connected NGT during assessment due to the inability to swallow food. 10. Elimination Status Mr. Sy B. Dee defecated only 3 times in the entire 3 days of duty, with a characteristic of watery stool. He voids through an indwelling foley catheter connected to a urine bag, slightly turbid in color and had a strong odor with an output of 50mL per hour. Norms: Normal bowel movement of a person must be 1 to 2 times a day and voiding in 3 to 4 times a day with an output of 1200 to 1500 ml a day. A normal stool is brown in color and well formed, urine is clear to yellowish in color (Kozier, Fundamentals of Nursing 2007). Analysis: The patient has a poor elimination status. But has a regular urination pattern. 11. Reproductive Status Patient Sy B. Dees brother verbalized that his sibling had been circumcised. The said family member refused to have his brothers reproductive system assessed for dignity and privacy concerns. 12. Sleep- rest Pattern Before the admission, the patients brother stated that Mr. Sy B. Dee sleeps at least 8 hours a day. He usually sleeps at 9:00 pm and wakes at 6:00 am for breakfast. He also takes a nap in the afternoon. However, his sleeping pattern had changed after his hospitalization. He was always in a semi- fowlers position, with log rolling order every 2 hours, and sleeping most of the time. Norms: Sleep refers to altered consciousness with general slowing of physiologic process while rest refers to relaxation and calmness, both mental and physical. The adults average amount of sleep per day is 7 to 8 hours (Rick Daniels, Nursing Fundamentals). Analysis: The patient is in fractional coma. 13. State of Skin and Appendages As we assessed the client, there is an IV site at his left hand. There is an absence of infiltration or phlebitis. Patient was pinched at the abdomen and observed that the skin returns slowly to its original state. His conjunctiva is slightly pale and sclera is white in color. His skin was warm and non tender. Skin feels dry, wrinkled with presence of scaling at the lower extremities. Hair was thin, fine and gray in color probably due to aging, with even distribution on the eyebrows and eye lashes. His nails are long and nail beds are pale in color. Norms: Obvious changes occur in the integumentary system (skin, hair, nails) with age. The skin becomes drier and more fragile, the hair loses color, the finger nails and toe nails become thickened and brittle. These integumentary system changes accompany progressive loses of subcutaneous fat and muscle tissue, muscle atrophy, and loss of elastic fibers (Barbara Kozier, Fundamentals of Nursing 7th edition). The palpebral conjunctiva should appear pink and moist. Normally, the skin is a uniform whitish pink or brown color, depending on the patients race. Normally, the nail has a pink cast in light-skinned individuals and is brown in dark-skinned individuals (Mary Ellen Zator Estes, Health Assessment and Physical Examination 3rd edition). Analysis: The patients skin has decreased skin turgor, maybe due lack of fluid in the tissues and aging process. Localized or systemic tenderness is absent.

D. Cranial Nerves Assessment Cranial Nerve I Olfactory Function Smell reception and interpretation Method Ask client to close eyes and identify different mild aromas such alcohol, Normal Findings Client should be able to distinguish different smells Clients Responses The client was unable to distinguish or identify aromas due to the state of disease.

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

Page |9

powder and vinegar. II Optic Visual acuity and fields Ask client to read newsprint and determine objects about 20 ft. away Assess ocular movements and pupil reaction Client should be able to read newsprint and determine far objects Client should be able to exhibit normal EOM and normal reaction of pupils to light and accommodation Client should be able to move eyeballs obliquely Client blinks whenever sclera is lightly touched; able to feel the wisp of cotton over the area touched; able to discriminate blunt and sharp stimuli The patient was unable to open his eyes.

III

Oculomotor

Extraocular eye movements, lid elevation, papillary constrictions lens shape Downward and inward eye movement Sensation of face, scalp, cornea, and oral and nasal mucous membranes. Chewing movements of the jaw

Exraocular eye movement using a pen light was vague.

IV

Trochlear

Ask client to move eyeballs obliquely Elicit blink reflex by lightly touching lateral sclera; to test sensation, wipe a wisp of cotton over clients forehead for light sensation and use alternating blunt and sharp ends of safety pin to test deep sensation

Eye movement using a pen light was vague.

Trigeminal

The patient was not able to respond to the stimuli presented.

Assess skin sensation as of ophthalmic branch above

Client is able to sense and distinguish different stimuli

Ask client to clench teeth

Client should be able to clench teeth VI Abducens Lateral eye movement Taste on anterior 2/3 of the tongue Facial movement, eye closure, labial speech Ask client to move eyeball laterally Ask client to do different facial expressions such as smiling, frowning and raising of eyebrows; ask client to identify various tastes placed on the tip and sides of the mouth: sugar, salt and coffee Client should be able to move eyeballs laterally Client should be able to do different facial expressions such as smiling, frowning and raising of eyebrows; able to identify different tastes such as sweet, salty and bitter taste Movement of the eyeballs was vague. The patient was not able to display different facial expressions, unable to identify different taste. The patient was connected to a nasogastric tubing to allow fluids and nutrients passed to the GI tract.

VII

Facial

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 10

VIII

Acoustic

Hearing and balance

Assess clients ability to hear loud and soft spoken words; do the watch tick test Apply taste on posterior tongue for identification (sugar, salt and coffee); ask client to move tongue from side to side and up and down; ask client to swallow and elicit gag reflex through sticking a clean tongue depressor into clients mouth Ask client to swallow; assess clients speech for hoarseness

Client should be able to hear loud and soft spoken words; able to hear ticking of watch on both ears Client should be able to identify different tastes such as sweet, salty and bitter taste; able to move tongue from side to side and up and down; able to swallow without difficulty, with (+) gag reflex

The patient was not responsive to the sounds presented.

IX

Glossopharyngeal

Taste on posterior 1/3 of tongue, pharyngeal gag reflex, sensation from the eardrum and ear canal. Swallowing and phonation muscles of the pharynx

The patient was not able to identify different tastes such as sweet, salty and bitter taste; unable to move tongue from side to side and up and down; unable to swallow, with negative gag reflex

Vagus

Sensation from pharynx, viscera, carotid body and carotid sinus

Client should be able to swallow without difficulty; has absence of hoarseness in speech Client should be able to shrug shoulders and turn head from side to side against resistance from nurses hands Client should be able to protrude tongue at midline and move it side to side

The patient manifests dysphagia.

XI

Spinal accessory

Trapezius and sternocledomastoid muscle movement

Ask client to shrug shoulders and turn head from side to side against resistance from nurses hands Ask client to protrude tongue at midline, then move it side to side

The patient has paralysis on upper and lower extremities. Log rolling and frequent repositioning is needed every 2 hours. The patient was not able to protrude tongue at midline and move it side to side.

XII

Hypoglossal

Tongue movement for speech, sound articulation and swallowing

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 11

XI. Diagnostics Diagnostic Procedure URINALYSIS Description of the Procedure Laboratory examination of a urine sample for clinical information. Modern routine urinalysis can be divided in to two basic procedures; macroscopic and microscopic analysis. Significance/pu rpose of the procedure Urinalysis is an important test used in diagnosing disease of the genitourinary tract. Date of Procedure November 18, 2011 Color Normal Pale yellowamber Clear-slightly hazy Findings and Implications

Result Straw

Indication

Transparency

Slightly turbid

Urine may be turbid because of the presence of urinary tract infection, presence of WBC, RBC and bacteria in the urinary tract.

WBC RBC Bacteria

0-3hpf 0-4hpf None

0-2 hpf Moderate

Normal Normal Since urine in the bladder of normal animals is sterile, bacteria are not normally seen in urine. Bacteria from the surrounding skin can enter the urinary tract at the urethra and move up to the bladder. Normal May indicate an abnormal metabolic process; When crystals form as urine is being made in the kidney, they may group together to form kidney "stones" or calculi. These stones can become lodged in the kidney itself or in the ureters, tubes that pass the urine from kidney to the bladder, causing extreme pain.

Mucous threads Amorphous urates PO4

Few Few

Few moderate

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 12

Specific gravity pH

1.001-1.035 4.5-8.0

1.010 7.5

Normal Normal; The kidneys maintain normal acid-base balance primarily through the reabsorption of sodium and the tubular secretion of hydrogen and ammonium ions.

Protein Sugar

Negative Negative

negative

Normal Normal

Diagnostic Procedure

SERUM ELECTROLYTES
Sodium Potassium

Description of the Procedure The sodium test is used to measure levels of sodium in relation to the amount of water in the body. This test measures the amount of potassium in the blood. Potassium (K+) helps nerves and muscles communicate. It also helps move nutrients into cells and waste products out of cells.

Significance/ purpose of the procedure Signs of a sodium imbalance or disorders associated with abnormal sodium levels.

Date of Procedure November 22, 2011

Normal Values 135-148mmol/L 158.0 mmol/L

Findings and Implications If the amount of fluid in your body is low, you may have fluid loss or dehydration due to excessive sweating, diarrhea, use of diuretics. Normal

Because potassium is important to heart function, your doctor may order this test if you have signs of high blood pressure or heart problems. Small changes in potassium levels can have a big effect on the activity of nerves and muscles, especially the heart. Low levels of potassium can lead to an irregular heartbeat or other electrical malfunction of the heart. High levels cause

November 22, 2011

3.50-5mmol/L

3.60 mmol/L

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 13

decreased heart muscle activity. Either situation can lead to life-threatening heart problems. Chloride To test for signs of a disturbance in body's fluid level or acid-base balance. A sample of venous blood may be collected for this test. November 22, 2011 98-107 mmol/L 118.5 mmol/L High; Chloride can become too high because of conditions including, dehydration, conditions causing excessive urination, severe vomiting or diarrhea High; diseases and conditions that can result in an elevated blood glucose level include acute stress (response to trauma, heart attack, and stroke for instance) Normal

Glucose

A blood glucose test measures the amount of a sugar called glucose in a sample of your blood.

A blood sample is needed.

November 22, 2011

3.60 6.00 mmol/l

9.29 mmol/l

Cholesterol

Serum cholesterol is a term

that includes the total level of cholesterol that is found in the bloodstream. Measuring the level of total cholesterol includes identifying all types or classes of cholesterol that are found in the system. This helpful measurement makes it possible to determine if the balance between the HDL or good cholesterol and LDL or bad cholesterol is within acceptable limits. The uric acid blood test is used to detect high levels of this compound in the blood in order to help diagnose gout. The test is also used to monitor uric

A blood sample is needed.

November 22, 2011

3.00-7.25 mmol/l

4.47 mmol/l

Uric Acid

A blood sample is needed.

November 22, 2011

210 430 mol/l

387.80 mmol/l

Normal

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 14

Triglycerides

HDL

LDL

acid levels in people undergoing chemotherapy or radiation treatment. Rapid cell turnover from such treatment can result in an increase in uric acid. A triglyceride level may be ordered to see how well the body processes fats. It is usually ordered as part of a lipid profile to help evaluate risk factors for coronary heart disease, or CHD. Triglyceride levels are an independent risk factor for coronary heart disease. This means that a person's risk for CHD is increased whenever triglyceride levels are high. HDL stands for high-density lipoprotein. It's also sometimes called "good" cholesterol. Lipoproteins are made of fat and protein. They carry cholesterol, triglycerides, and other fats, called lipids, in the blood from other parts of the body to the liver. High LDL cholesterol increases the risk of damage to the arteries that leads to heart disease.

A blood sample is needed.

November 22, 2011

0.45-1.31

0.82 mmol/

Normal

A blood sample is needed.

November 22, 2011

0.51-1.56

1.24 mmol/l

Normal

A blood sample is needed.

November 22, 2011

1.04-4.04

3.07 mmol/l

Normal

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 15

Diagnostic Procedure COMPLETE BLOOD COUNT

Description of the Procedure The complete blood count (CBC) is a common blood test that evaluates the three major types of cells in the blood: red blood cells, white blood cells, and platelets.

Significance/purpose of the procedure CBC is for the enumeration of the cellular elements of the blood, evaluation of RBC indices and determination of cell morphology by means of attained smears.

Date of Procedure November 21, 2011

Findings and Implications Normal Values Hgb 120-160g/L Result 142g/L Indication Normal

Erythrocyte volume fraction

0.40-0.54%

0.43%

Leukocyte

4.5-11.0g/L

9.4x10g/L

Normal

Differential Count Neutrophils Lymphocytes Monocytes 40.0 74.0% 19.0-48.0% 3.4-9.0% 74% 26% 3.1% Normal Normal Normal; Monocytes help other white blood cells remove dead or damaged tissues, destroy cancer cells, and regulate immunity against foreign substances Normal

Eosinophils

0.0-10%

0.10

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 16

XII. Comprehensive Pathophysiology Precipitating factors

Predisposing factors

Diet high in fats, glucose content, cholesterol and sodium

Sedentary Lifestyle

Smoking

Diagnosis of DM, type II

Diagnosis of HPN Stage II

Previous Stroke

Age (65 years old)

Poor Exercise Pattern Increase attraction of water in the blood

Vasoconstriction

Increase blood sugar

Deposits of fatty materials in the arterial walls of arteries

Poor O2 circulation in the blood

Decreased oxygen carrying capacity of blood

Increase vascular resistance

Increase pressure in cerebral blood vessels

Increase blood viscousity

Impaired cerebral autoregulation

Degenerative changes in the function of the bodily functions and blood vessels

Increase Blood volume

Accumulation of fatty streaks in the arterial wall

Loss of elasticity

Impaired cerebral auto regulation

Increase workload of the heart

Increase vascular resistance Altered arterial integrity

Cardiomegaly
Weakening of vessel lumen Heart weakened over time Decreased cardiac output

Increase in blood cholesterol level and blood pressure

Uncontrolled High Blood Pressure

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 17

Continuous peripheral resistance Minute blood vessels dilate

Stimulation of nociceptive neural receptors Nape pain

Increase pressure weakens the blood vessels

Rupture of cerebral blood vessels

Spontaneous rupture of blood vessels in the brain causes intracerebral bleeding

CEREBROVASCULAR DISEASE, Hemorrhagic Stroke

Ischemia in the brain tissues

Decrease cerebral perfusion

Brain Hypoxia

Loss of cerebral feedback mechanisms

Neuronal Damage Occurs

Cessation of Physiologic Functions

Motor loss Motor weakness Limited movement Paralysis

Communication loss Dysarthria Dysphasia Aphasia

Perceptual and sensory loss Impairment of the sensation of the nerve endings

Cognitive Effect Reduced Level of consciousness and mentation activity Depressed gag reflex

Effect on the Gastrointestinal System Relaxation sphincter muscles Decrease in bowel sounds Decrease peristaltic activity Decrease motility of the GI tract

Effect on the Respiratory System Deficit oxygenation at the capillary- alveoli membrane Ventilation-perfusion imbalance Abnormal ABG/ arterial pH

Effect on the Cardiovascular System Decreased cardiac muscle function Decreased cardiac output

Self care Deficit

Impaired verbal communication Impaired physical mobility

Risk for impaired skin integrity

Risk for Aspiration Impaired gas exchange Ineffective tissue perfusion

Decreased cardiac output

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 18

XIII. Treatment/Management A. Drugs Name Classification Dosage Antibacterial 1.5 gms IV q 8 hrs Mechanism of Action Sulbactam inhibits many bacterial penicillinase enzymes, thus broadening the spectrum of ampicillin. Nursing Implication Assess patient for infection (vital signs, wound appearance, sputum, urine, stool, and WBCs) at beginning and throughout therapy. Obtain a history before initiating therapy to determine previous use of and reactions to penicillins or cephalosporins. Caution patient to notify physician if fever and diarrhea occur, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without consulting health care professional. May occur up to several weeks after discontinuation of medication. Do NOT use Mannitol if: you are allergic to any ingredient in Mannitol you have a history of heart failure you have decreased or absent production of urine due to severe kidney disease, certain severe lung problems (eg, pulmonary congestion or pulmonary edema), bleeding in the brain, or severe dehydration Do not expose solutions to low temperatures; crystallizations occur. If crystal are seen, warm the bottle in a hot water bath, then cool to body temperature before administering. Significance Bactericidal action. Active against: Streptococci, Penumococci, Enterococci, Haemophilus influenzae Instruct patient to notify physician if symptoms do not improve.

Generic: SulbactamAmpicillin Brand: Unasyn

Generic: Mannitol Brand: Osmitrol

Osmotic diuretic 100 cc IV q 4 hrs

Elevates the osmolarity of the glomerular filtrate, thereby hindering the reabsorption of water and leading to a loss of water, sodium, chloride. Creates an osmotic effect, leading to the decreased swelling on the post-transurethral prostatic resection.

Prevents or treats excess body water in certain kidney conditions, reducing swelling of the brain, or reducing pressure in the eye. It may also be used for other conditions as determined by your doctor. Mannitol is an osmotic diuretic. It works by increasing the amount of fluid excreted by the kidneys and helps the body to decrease pressure in the brain and eyes.

Generic: Irbesartan Brand: Avapro

Antihypertensive 100 mg 1 tab OD @ lunch

Selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth

Before you take irbesartan, tell your doctor if you have kidney or liver disease,

Irbesartan is in a group of drugs called angiotensin II receptor antagonists. Irbesartan keeps blood

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 19

muscles and adrenal gland; this action blocks the vasoconstriction effect of the reninangiotensin system as well as the release of aldosterone, leading to decreased BP.

congestive heart failure, or if you are dehydrated. Drinking alcohol can further lower your blood pressure and may increase certain side effects of irbesartan. Your blood pressure will need to be checked often. Visit your doctor regularly. If you are being treated for high blood pressure, keep using this medication even if you feel well. High blood pressure often has no symptoms.

vessels from narrowing, which lowers blood pressure and improves blood flow. Irbesartan is used to treat high blood pressure (hypertension). It is sometimes given together with other blood pressure medications. Irbesartan is also used to treat kidney problems caused by type 2 (not insulindependent) diabetes.

Generic: Metropolol Brand: Lopressor

Antihypertensive Beta1- selective adrenergic blocker 1 tab q 12 hrs (12 nn and 12 MN)

Competitively blocks beta- adrenergic receptors in the heart and juxtaglomerular apparatus, decreasing the influence of the sympathetic nervous system and excitability of the heart, decreasing cardiac output, lowering BP.

WARNING: Do not discontinue drug abruptly after long-term therapy (hypersensitivity to catecholamines may have developed, causing exacerbation of angina, MI, and ventricular arrhythmias). Taper drug gradually over 2 wk with monitoring. Ensure that patient swallows the ER tablets whole; do not cut, crush, or chew them. Give oral drug with food to facilitate absorption. Provide continual cardiac monitoring for patients receiving IV metoprolol.

Hypertension, alone or with other drugs, especially diuretics Prevention of reinfarction in MI patients who are hemodynamically stable or within 310 days of the acute MI Treatment of angina pectoris Treatment of stable, symptomatic CHF of ischemic, hypertensive, or cardiomyopathic origin

Generic: Furosemide Brand: Lasix

Loop Diuretic 40 mg q 8 hrs

Inhibits reabsorption of sodium and chloride from the proximal and distal tubules and ascending limb of the loop of Henle, leading to a sodium- rich diuretic.

Administer with food or milk to prevent GI upset. Reduce dosage if given with other antihypertensives; readjust dosage gradually as BP responds. Give early in the day so that increased urination will not disturb sleep. Avoid IV use if oral use is at all possible. Do not mix parenteral solution with highly acidic solutions with pH below 3.5 Do not expose to light, may discolor tablets or solution; do not use discolored drug or solutions.

Used to treat edema associated with heart failure, cirrhosis, and renal disease.

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 20

Discard diluted solution after 24 hr. Refrigerate oral solution. Measure and record weight to monitor fluid changes. Arrange to monitor serum electrolytes, hydration, liver function. Arrange for potassiumrich diet or supplemental potassium as needed. Generic: Paracetamol Brand: Acetamenophen Nonopioid analgesic, Antipyretic 500 mg q 4hrs May produce analgesic effect by blocking pain impulses by inhibiting prostaglandin or pain receptor sensitizers. May relieve fever by acting in hypothalamic heatregulating center. Bisacodyl works by stimulating enteric nerves to cause colonic mass movements. It is also a contact laxative; it increases fluid and NaCl secretion. Action of bisacodyl on small intestine is negligible; stimulant laxatives mainly promote evacuation of the colon. Assess clients pain or temperature before and during therapy. Be alert for adverse reactions and drug interactions such as rashes and urticaria. To normalize increased body temperature.

Generic: Besacodyl Brand: Dulcolax

Stimulant Laxative To be given q 4 hrs if no bowel movement

When bisacodyl is administered orally, it is usually taken at bedtime. Oral administration is known to produce no action for more than eight hours and then to work suddenly and without much warning. If taken in the afternoon or early evening, the action of this drug will start during sleep with undesirable results. If taken at the maximum dosage, there will likely be a sudden, extremely powerful, uncontrollable bowel movement and so precautions should be taken.

Works directly on the large colon to produce a bowel movement. It is typically prescribed for relief of constipation and for the management of neurogenic bowel dysfunction as well as part of bowel preparation before medical examinations, such as for a colonoscopy.

Generic: Glimepiride Brand: Amaryl

Antidiabetic 2 mg 1 tab OD pre breakfast

Stimulates insulin release from functioning beta cells in the pancreas; may improve binding between insulin and insulin receptors or increase the number of insulin receptors, thought to be more potent in effect than first generation sulfonylurea.

Monitor urine or serum glucose levels frequently to determine the effectiveness if the drug. Use IV glucose if severe hypoglycemia occurs. Take this drug once a day with breakfast or the first main meal of the day.

An oral diabetes medicine that helps control blood sugar levels. This medication helps your body respond better to insulin produced by your pancreas.

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 21

Generic:Citicholine Brand: CDP Choline

Psychostimulant /nootropic 100 mg 1 tab BID

CDP-choline (cytidine5'-diphosphocholine) is a unique form of choline that readily passes through the blood-brain barrier directly into brain tissue. CDP-choline is a rate-limiting intermediate in the biosynthesis of phosphatidylcholine, an important component of the neural cell membrane.

Citicoline seems to be safe when taken short-term (up to 90 days). The safety of long-term use is not known. Most people who take citicoline don't experience problematic side effects. But some people can have side effects such as trouble sleeping (insomnia), headache, diarrhea, low or high blood pressure, nausea, blurred vision, chest pains, and others. Before taking amlodipine, tell your doctor if you have congestive heart failure or liver disease. Drinking alcohol can further lower your blood pressure and may increase certain side effects of amlodipine. If you are being treated for high blood pressure, keep using amlodipine even if you feel well. High blood pressure often has no symptoms. You may need to use blood pressure medication for the rest of your life.

Used for Alzheimer's disease and other types of dementia, head trauma, cerebrovascular disease such as stroke, age-related memory loss, Parkinson's disease, and glaucoma. Preliminary research has found that citicoline supplements help improve focus and mental energy and may possibly be useful in the treatment of attention deficit disorder Amlodipine is used to treat high blood pressure (hypertension) or chest pain (angina) and other conditions caused by coronary artery disease. This medication is for use in adults and children who are at least 6 years old.

Generic: Amlodipine Brand: Norvasc

Antianginal Antihypertensive Calcium channel blocker

Amlodipine is a dihydropyridine calcium channel blocker that inhibits the transmembrane influx of calcium ions into vascular smooth muscle and cardiac muscle. Experimental data suggest that amlodipine binds to both dihydropyridine and nondihydropyridine binding sites. The contractile processes of cardiac muscle and vascular smooth muscle are dependent upon the movement of extracellular calcium ions into these cells through specific ion channels. Selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle and adrenal gland. This action blocks the vasoconstriction effect of the renin angiotensin system.

Generic: Losartan Brand: Cozaar

Antihypertensive 150 mg 1 tab BID

Before taking amlodipine You should not take this medication if you are allergic to amlodipine. If you have any of these other conditions, you may need a dose adjustment or special tests: a heart valve problem called aortic stenosis; congestive heart failure; or liver disease. Your chest pain may become worse when you first start taking amlodipine or when your dose is increased.

In combination with cisplastin as the first line treatment of inoperable, locally advanced or metastatic non small- cell lung cancer, breast cancer and ovarian cancer.

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 22

Generic: Diazepam Brand: Valium

Antiepileptic Anxiolytic 5 mg IV PRN for frank seizures

Diazepam is a benzodiazepine that binds to a specific subunit on the GABAA receptor at a site that is distinct from the binding site of the endogenous GABA molecule. The GABAA receptor is an inhibitory channel which, when activated, decreases neuronal activity.

Diazepam should be used for only a short time. Do not take this medication for longer than 12 weeks (3 months) without your doctor's advice. Do not stop using diazepam suddenly without first talking to your doctor. You may have increased seizures or unpleasant withdrawal symptoms when you stop taking diazepam. To be sure diazepam is not causing harmful effects; your blood may need to be tested often. Your liver function may also need to be tested.

Diazepam is used to treat anxiety disorders, alcohol withdrawal symptoms, or muscle spasms. It is sometimes used with other medications to treat seizures.

Generic: Phenytoin Brand: Dilantin- 125

Antiarrhytmic Antiepileptic Hydantoin 100 mg 10 caps NGT, then 1 cap TID

Has antiepileptic activity without causing general CNS depression; stabilizes neuronal membranes and prevent hyperexcitability caused by excessive stimulation; limits the spread of seizure activity.

Take this drug as exactly as prescribed, with food to reduce GI upset. Maintain good oral hygiene to prevent gum disease. Monitor your urine and blood glucose level regularly. Do not discontinue this drug abruptly or change dosage, except on the advice of your health care provider. Give laxative syrup orally with fruit juice, water, or milk to increase palatability. Do not administer other laxatives while using lactulose. For laxative use, do not use continuously for longer than 1 week unless directed by your health care provider. Make sure you have readily access to bathroom; bowel movements will be increased to two to three per day. You may experience these effects: Abnomal fullness, flatulence, belching. Report diarrhea, severe belching, and abdominal fullness.

Phenytoin (fnit'oin, IPA) acts to suppress the abnormal brain activity seen in seizure by reducing electrical conductance among brain cells by stabilizing the inactive state of voltage-gated sodium channels. Aside from seizures, it is an option in the treatment of trigeminal neuralgia

Generic: Lactulose Brand: Cozaar 30 cc OD HS until with regular bowel movement

The drug passes unchanged into the colon where bacteria break it down to organic acids that increase the osmotic pressure in the colon and slightly acidify the colonic contents, resulting in the increase in stool water content, stool softening, laxative action.

Lactulose is a synthetic, nondigestible sugar used in the treatment of chronic constipation[1] and hepatic encephalopathy, a complication of liver disease. It is a disaccharide (doublesugar) formed from one molecule each of the simple sugars (monosaccharides) fructose and galactose.

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 23

Generic: Nicardipine Brand: Cardene

Antianginal Antihypertensive Calcium channel blocker Nicardipine drip. Infuse in IVF + 10 cc PNSS

Calcium entry blocker (slow channel blocker or calcium ion antagonist) which inhibits the transmembrane influx of calcium ions into cardiac muscle and smooth muscle without changing serum calcium concentrations. The contractile processes of cardiac muscle and vascular smooth muscle are dependent upon the movement of extracellular calcium ions into these cells through specific ion channels. The effects of Nicardipine are more selective to vascular smooth muscle than cardiac muscle. In animal models, Nicardipine produces relaxation of coronary vascular smooth muscle at drug levels which cause little or no negative inotropic effect.

Monitor the patient carefully: BP, cardiac rhythm and output while drug is being titrated to therapeutic dose. Because Nicardipine decreases peripheral resistance, careful monitoring of blood pressure during the initial administration and titration of Nicardipine is suggested. Nicardipine, like other calcium channel blockers, may occasionally produce symptomatic hypotension. Caution is advised to avoid systemic hypotension when administering the drug to patients who have sustained an acute cerebral infarction or hemorrhage.

Nicardipine hydrochloride (Cardene) is a medication used to treat high blood pressure and angina.

B.

IV Fluids Classification Isotonic volume expander and electrolyte replacer Component/s 9 g/L Sodium chloride = 308 mOsmol/L = 154 mEq/L Sodium and Chloride Use & Effects An isotonic solution causes no increase in the flow of lymph from the capillary blood vessels but a hypertonic solution may cause a large increase so that the wound is flooded with lymph. It is a useful solution in preventing and clearing up infection. An isotonic solution is desirable when liquid is being injected into blood stream. Usually prescribed following trauma, surgery or other with other diseases because it keeps plasma and electrolytes in the body balanced and prevent dehydration. Significance Restores ECF volume and a plasma volume expander.

Name Normal Saline Solution (PNSS)

Balance Multiple Maintenance Solution (BMMS)

Fluid and Electrolyte

The ratio of electrolytes and water in BMMS is carefully balanced so that it can be used efficiently by the body. In every 100 mL of BMMS, there are 600 mg of sodium chloride, 20 mg of calcium chloride, 30 mg of potassium chloride and 310 mg of sodium lactate. The pH is adjusted to be 6.6, and a liter of this solution has 9 calories.

Used generally to keep the electrolytes in the body balanced and prevent dehydration.

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 24

A. 1.

Prioritization of Problems

List of Problems 1. Impaired Gas Exchange related to ventilation- perfusion imbalance due to increase vascular resistance secondary to Stage II HPN as manifested by changes in ABGs/pulse oximetry, and decreased cardiac output 2. Ineffective tissue perfusion related to Reduced coronary blood flow secondary to CVD secondary to decreased cardiac output, Abnormal arterial blood gases (ABGs) and Low oxygen saturation (86%) 3. Decreased Cardiac Output related to Alterations in heart rate, rhythm, electrical conduction as manifested by bradycardia, decreased LOC 4. Risk for aspiration related to Depressed cough/ gag reflexes, presence of NGT and delayed gastric emptying as manifested by decreased LOC and Situations hindering elevation of upper body (paralysis) 5. Self care deficit related to Decreased strength and endurance, motor impairment and Neuromuscular impairment, secondary to cerebrovascular accident (CVA)

6. Impaired physical mobility related to loss of motor reflexes due to cognitive deficits secondary to CVA, intracerebral bleeding as manifested by upper and lower body paralysis 7. Risk for impaired skin integrity related prolonged bed rest, decreased level of activity/immobility and Poor circulation 8. Impaired verbal communication related to neuronal deficits that adversely affects the transmission, reception or interpretation of language or other forms of communication secondary to CVA, intracerebral bleeding

2.

Basis of Prioritization

List of Problems
1. Impaired Gas Exchange related to ventilation- perfusion imbalance due to increase vascular resistance secondary to Stage II HPN as manifested by changes in ABGs/pulse oximetry, and decreased cardiac output 2. Ineffective tissue perfusion related to Reduced coronary blood flow secondary to CVD secondary to decreased cardiac output, Abnormal arterial blood gases (ABGs) and Low oxygen saturation (86%) 3. Decreased Cardiac Output related to Alterations in heart rate, rhythm, electrical conduction as manifested by bradycardia, decreased LOC

Justification
Oxygen is the most in-demand need of the body. Any problem related to the oxygen supply/circulation needed to addressed first since lack of oxygen could immediately cause death to the patient.

Perfusion would come in second since we need to be able to allow the bodys needs to be distributed to the different parts of the body for them to be used and for the organs to function well.

Blood carries everything the body needs. A low cardiac output would also mean decreased supply to the body with its needs so considering the problem as the third would mean that it should not be delayed so much as prolonged low supply of blood could cause terrible damage to the body. As mentioned, the airway is a very vital part which should always be kept free from problem since the inability of the airway to function could cause immediate death. Aspiration is one of the risks that should be taken seriously since it

4. Risk for aspiration related to Depressed cough/ gag reflexes, presence of NGT and delayed gastric emptying as manifested by decreased LOC and Situations hindering

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 25

elevation of upper body (paralysis)

concerns the integrity of the airway and preventing anything from going into it should be done. Self care should be done. A persons inability to perform personal hygiene will definitely increase the risk for acquiring an illness. This goes down to 5th since preventive measures regarding the problem are easy to do and is pretty much a part of our daily life. Mobility concerns the physical structure of the body. Effects of immobility takes too long to take effect and the preventive measures done to decrease the chance of such effects to manifest are very simple and easy to do thats why it ranks 6th. At risk for skin being adversely altered is the next concern since when the patient is able to move and do his ADLs, the probability of having the skin integrity compromised will be condense. Verbal communication ranks last since the needs of the patient can immediately be identified and given even without the patient being able to say what they are. The ability to speak becomes just a bonus for the nurse to identify the needs of the patient. The patient doesnt need to say what his basic needs are.

5. Self care deficit related to Decreased strength and endurance, motor impairment and Neuromuscular impairment, secondary to cerebrovascular accident (CVA)

6. Impaired physical mobility related to loss of motor reflexes due to cognitive deficits secondary to CVA, intracerebral bleeding as manifested by upper and lower body paralysis 7. Risk for impaired skin integrity related prolonged bed rest, decreased level of activity/immobility and Poor circulation

8. Impaired verbal communication related to neuronal deficits that adversely affects the transmission, reception or interpretation of language or other forms of communication secondary to CVA, intracerebral bleeding

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 26

B.

Nursing Care Plans

1. Impaired Gas Exchange

Assessment Explanation of the Problem Objectives of Care Nursing Interventions Scientific Rationale Evaluation

S>Nahihirapan siyang huminga kaya naka-oxygen siya, as verbalized by the patients SO O > Changes in ABGs/pulse oximetry >decreased cardiac output >Cyanosis: pale lips,pale conjunctive and pale oral mucous membranes noted >changes in mentation >appears weak >with an O2 inhalation via nasal cannula

Gas exchange refers to the exchange of gases (oxygen and carbon dioxide) at the alveolar-capillary membrane and the process by which these gases are exchanged is called diffusion. The alveolar capillary membrane is ideal for diffusion because of its thinness and large surface area. The relationship between ventilation (air flow) and perfusion (blood flow) determines the efficiency of gas exchange so that adequate gas exchange depends on an adequate ventilation-perfusion (V/Q) ratio. In a healthy lung, a given amount of blood passes an alveolus and is matched with an equal amount of gas. The normal ratio is 1:1 (ventilation matches perfusion). Impaired gas exchange results when there is alteration in the balance between the ventilation and perfusion (V/Q) ratio. Low V/Q ratios and high V/Q ratios both result in lower oxygen delivery to the body. Reference: Doenges, Marilyn E.,

STO: After 30 minutes of nursing interventions, the clients SO will be able to understand patients condition and the reason of the need to maintain the oxygenation of the patient and other proper management.

Dx: 1. Auscultate lungs for air movement taking note areas of reduced ventilation and for presence of adventitious breath sounds.

STO: > Adequate gas exchange depends on an adequate ventilation-perfusion (v/Q) ratio since reduced ventilation affects gas exchange. Presence of adventitious breath sounds indicates problems or conditions that affect ventilation, which in turn influence gas exchange, for example, crackles suggest presence of secretions that affect the flow of air in and out of the airways of the lungs. >Aids with comfort procedures to decrease fever and chills. Elevated temperature greatly adds to metabolic demands and oxygen consumption and modifies cellular oxygenation. >Both fast, shallow breathing patterns and hypoventilation influence gas exchange. Variations of the quality, rate, pattern, and depth of respiration may indicate compensation of the compromised or impaired gas exchange. >Placing the most congested lung areas in the dependent position (where perfusion is greatest) fascilitates ventilation and perfusion imbalances. GOAL MET. After series of nursing interventions, the clients SO was able to verbalize understanding on the etiology and management of the patients condition.

Nursing Diagnosis Impaired Gas Exchange related to ventilationperfusion imbalance due to increase vascular resistance secondary to Stage II HPN as manifested by changes in ABGs/pulse oximetry, and decreased cardiac output

LTO: After 24 hours of nursing interventions, the clients SO will be able to: 1. Participate in procedures to optimize oxygenation and in management regimen within level of capability/condition through proper positioning. 2. Patient will maintain maximum gas exchange as manifested by normal arterial blood gases (ABGs) and alert responsive mentation or no further decrease in mental status.

LTO: GOAL MET After series of nursing care and intervention, the clients SO was able to Participate in procedures to optimize oxygenation and in management regimen within level of patients capability/condition through proper positioning. The patient also showed improvement in result of O2 saturation: 90%

2. Check body temperature, as necessary.

3. Check respirations: observe quality, rate, pattern, depth, and breathing effort.

4. Check results of position changes on oxygenation.

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 27

Moorhouse, Mary Frances, Murr, Alice C. Nurses Pocket Guide: Diagnosis, Prioritized Interventions and Rationales. 11th edition.

5. Examine ABG results and pulse oximetry readings.

6. Monitor color of skin, mucous membranes, and nailbeds, observing existence of peripheral cyanosis or central cyanosis.

Tx 1. Give supplemental oxygen using nasal cannula, partial rebreathing mask, or highhumidity face mask as ordered.

2. Adjust patients position every two hours (as tolerated and if not contraindicated), if the patient experiences retention of secretions. 3. Raise head of bed as patient needed or tolerated.

Edx 1. Instruct SO some explanation about the type of oxygen therapy being utilized and why its continuance is significant.

>Check hemoglobin (Hb) levels. ABG values are reflection of how good or poor gas exchange is. Elevating PaCO2 and diminishing PaO2 are manifestations of respiratory failure. >Both peripheral and central cyanosis are physical manifestations of poor oxygenation, which may be indicative of ineffficient gas exchange. Impaired gas exchange results in lower oxygen delivery to the body tissues. >Impaired gas exchange greatly affects oxygenation of the body and oxygen saturation is ought to be sustained at 95% or greater. Oxygen therapy with a flow rate of between 2 and 10 L/min via nasal cannula. >Position changes promote mobilization of secretions improving ventilation and consequently improving gas exchange. >Enhances optimal chest expansion, making it easier to breathe and improving physiological or psychological comfort. Adequate ventilation is a prerequisite of an efficient gas exchange. >Issues in relation with home oxygen use, storage, or precautions require to be addressed.

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 28

2. Ineffective Tissue Perfusion

Assessment Explanation of the Problem Objectives of Care Nursing Interventions Scientific Rationale Evaluation

S>Mababa daw yung oxygen sa tissues niya kaya naka oxygen siya, as verbalized by the clients SO O > Weakness Low oxygen saturation: 86% >Inadequate urine output >decreasing levels of consciousness >cyanosis (central) >Abnormal arterial blood gases (ABGs) >decreased cardiac output (110 bpm)

Nursing Diagnosis Ineffective tissue perfusion related to Reduced coronary bloodflow secondary to CVD as manifested by decreased cardiac output, Abnormal arterial blood gases (ABGs) and Low oxygen saturation (86%)

The process involving the passage of blood through the blood vessels to body tissues in order to supply nutrition and oxygen is called perfusion. Anything that impairs, blocks, or alters this process renders its ineffectiveness. Alteration of blood flow is the primary cause of ineffective tissue perfusion. Two factors that influence most the adequate blood flow are volume of circulating blood and patency of the blood vessels, so that when the circulating blood volume is reduced or when blood vessels are partially or totally occluded, ineffective tissue perfusion occurs. While the adequacy of circulating blood volume is dependent on three interrelated components of the cardiovascular system (the heart, vascular tone, and blood volume), the problem on patency may be dependent on the extent of occlusion or narrowing. The other major factor that leads to poor tissue perfusion is the direct destruction or rupture of the blood vessels. Just like the brain, the heart is also perfused in the expense of other less vital organ to preserve cardiac metabolism because the heart together with the lungs, is

STO: After 30 minutes of nursing interventions, the clients SO will be able to understand patients condition and the reason of inadequate tissue perfusion

Dx: 1. Assess heart rate and blood pressure; monitor their changes.

STO: > When cardiac perfusion is poor, the hearts contractility decreases resulting to the stimulation of the sympathetic nervous system; tachycardia and increase in blood pressure are responses to sympathetic stimulation. > When cardiac perfusion is poor, oxygen demands increases. In response to the increasing oxygen needs, the respiratory rate increases as the body attempts to increase its intake of oxygen. > Low oxygen saturation reflects hypoxia > Restlessness is an initial sign of poor brain perfusion. Decreasing levels of consciousness (e.g., restlessness, confusion, lethargy, and stupor) is an indication of decreasing cerebral tissue perfusion. Poor myocardial perfusion results to cardiac pump malfunction decreasing the cardiac output, which results to the decrease perfusion of vital organs including the brain. >Decreased or absence of peripheral pulses are indicative of decreased tissue perfusion from (systemic) vasoconstriction of the blood vessels (often as a result of decreased cardiac output). GOAL MET. After series of nursing interventions, the clients SO was able to verbalize understanding on the etiology of the patients condition

2. Monitor respiratory rate; monitor its changes. LTO: After 24 hours of nursing interventions, the client will be able to: 1. Maintain maximum tissue perfusion to other vital organs and peripheries, as manifested by a. warm and dry skin, b. present and strong peripheral pulses, c. normal vital signs within patients normal range, d.absence of edema, e. adequate urine output, f. normal ABGs results, \ g. alert level of consciousness

LTO: GOAL NOT MET After series of nursing care and intervention, the client was not able to show improvement in cardiac output.

3. Monitor pulse oximetry readings/results. 4. Monitor changes in mental status or level of consciousness.

5. Monitor peripheral pulses. Observe the quality of every pulse.

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 29

very important for the perfusion of all the tissues in the body. The heart receives venous (deoxygenated) blood and delivers it to the lungs to be oxygenated and goes back to the heart to be pumped to the different body organs and tissues to supply oxygen. When the heart becomes inadequately perfused in anyway, its functions are greatly affected leading to localized and systemic problems and complications. Reference: Doenges, Marilyn E., Moorhouse, Mary Frances, Murr, Alice C. Nurses Pocket Guide: Diagnosis, Prioritized Interventions and Rationales. 11th edition.

Absence of peripheral pulses must be reported and managed promptly. Tx 1. Give supplemental oxygen using nasal cannula, partial rebreathing mask, or highhumidity face mask as ordered. > Supplemental oxygen increases myocardial supply of oxygen. Oxygen saturation is ought to be sustained at 95% or greater. The use of such devices to give supplemental oxygen makes the most of available oxygen. >Optimal cardiac output helps guarantee sufficient perfusion of vital organs. Assistance may be necessary to help peripheral circulation. >It is important to make sure that ventilation is adequate for sufficient oxygenation; problems on ventilation may worsen the condition of poor perfusion. > Increased physical or psychological strain can increase myocardial and oxygen demands. >Stress activates the sympathetic nervous system with the release of endogenous catecholamines, which increase myocardial oxygen consumption. Also, with increased epinephrine, the pain threshold is decreased, and pain increases myocardial oxygen consumption.

2. Sustain optimal cardiac output (e.g., provide IV or oral fluids as ordered, as necessary, as tolerated). 3. Promote measures that facilitate adequate ventilation (e.g., fowlers position, proper and effective breathing), as appropriate and as needed. Edx 1. Encourage physical and mental rest. 2. Instruct the family to keep the patient on bed rest with a quiet, restful environment. Bed rest decreases myocardial oxygen demands.

References: Swearingen, Pamela L. All-in-One Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans.

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 30

3. Decreased Cardiac Output

Assessment Explanation of the Problem Objectives of Care Nursing Interventions Scientific Rationale Evaluation

S>Sabi ng doctor niya, mabagal daw ang pagtibok ng puso niya, as verbalized by the patients SO O > Bradycardia (110 bpm) > Cold, clammy, pale or ashen (cyanotic) skin; diaphoresis > Decreased LOC > Prolonged capillary refill (23 seconds)

Nursing Diagnosis Decreased Cardiac Output related to Alterations in heart rate, rhythm, electrical conduction as manifested by bradycardia, decreased LOC

Cardiac output refers to the volume of blood pumped by each ventricle for a given period. A number of factors affect the hearts pumping action and contractility. Common etiologies of decreased cardiac output include the following: angina, myocardial infarction, severe hypertension, valvular heart disease, congenital heart disease, cardiomyopathy, pulmonary disease, arrhythmias, chronic heart failure, cardiac surgery, acute and chronic renal failure, Graves disease, drug effects, fluid overload, decreased fluid volume, and electrolyte imbalance. These conditions can result in decreased contraction (systole), decreased filling (diastole), or both. Due to decreased blood volume ejected from the ventricles, epinephrine and norepinephrine are stimulated to increase heart rate and contractility and support the myocardium. This causes vasoconstriction, increases blood pressure and afterload. As the hearts work load increases, contractility of the myocardial muscle fibers decreases. This results in a decrease in cardiac output which affects various organs

STO: After 30 minutes of nursing interventions, the clients SO will be able to understand patients condition and the reason of inadequate cardiac output of the patient.

Dx: 1. Assess color and temperature of skin and time of capillary refill.

STO: > Cold, clammy skin is due to compensatory increase in sympathetic nervous system stimulation, reduced cardiac output, and desaturation. > In the early stages, restlessness is seen; in later stages, severe anxiety and confusion are being manifested. > To compensate for reduced ventricular contractility, tachycardia is usually present even at rest. Tachycardia results from the sympathetic response as a result of the release of catecholamines. Irregularities or dysrrhythmias develop with electrolyte shifts or imbalances. > In the early stages, sinus tachycardia and augmented arterial blood pressure are being manifested; blood pressure drops as the state deteriorates. > This may indicate insufficient cerebral perfusion secondary to reduced cardiac output. > Giving of fluid increases extracellular fluid volume and consequently elevates cardiac output. GOAL MET. After series of nursing interventions, the clients SO was able to verbalize understanding on the etiology of the patients condition

2. Assess mentation status

LTO: After 24 hours of nursing interventions, the client will be able to: 1) Patient will demonstrate an improved or adequate cardiac output as evidenced by enhancement in activity tolerance or absence of palpitations, fatigue, dyspnea or shortness of breath with activity, or by relief of specific symptoms experienced by the patient associated with decreased cardiac output (refer to subjective and objective data). 2) Patient will demonstrate unwavering cardiac rhythm and rate within own normal range. 3) Patient will maintain BP within standard limits; have regular cardiac rhythms;

3. Auscultate apical pulse; monitor heart rate, rhythm (if telemetry is available record dysrrhythmia).

LTO: GOAL NOT MET After series of nursing care and intervention, the client was not able to show improvement in cardiac output.

4. Monitor heart rate and blood pressure.

5. Observe changes in sensorium (anxiety, confusion, depression, disorientation, and lethargy). Tx 1. Sustain optimal fluid balance. 2. Maintain physical and

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 31

due to impairment of perfusion or blood supply. Geriatric patients are at high risk of developing this problem since their ventricles have reduced compliance due to aging process. Though advances in diagnostic procedures that allow prompt and more precise diagnoses, so that early management could be initiated before significant debilitation occurs are available, heart disease still remains a chronic condition. The overall goals of management are to relieve patient symptoms, to improve functional status and quality of life, and to extend survival.

maintain warm, dry skin; clear lung sounds, and strong bilateral, equal peripheral pulses.

emotional rest, as in the following: a. Limit activity.

b. Offer quiet, relaxed milieu. C. Systematize nursing and medical care. 3. Administer supplemental oxygen as needed.

> This decreases oxygen demand reducing myocardial decompensation and workload. > Emotional stress adds to cardiac demands. > This permits rest periods. > This increases oxygen available for the heart to compensate from decreased oxygenation due to perfusion problems. It reduces ischemia and lactic acid levels as well as it improves cardiac contractility. > This reduces the extracellular fluid volume that will also decrease the cardiac workload and help improve cardiac contractility. > Gives the patient pertinent information for self-specific etiologic factors that may contribute to reduced cardiac output. May help the patient modify lifestyle or behavior contributory to reduced cardiac output. > Information gives the client more knowledge that promotes adherence and compliance to medications. References:

Edx 1. Explain to the SO diet restrictions especially regarding fluid and sodium. 2. Instruct the SO on the details on symptoms and management for reduced cardiac output related to respective etiological factors.

Reference: Doenges, Marilyn E., Moorhouse, Mary Frances, Murr, Alice C. Nurses Pocket Guide: Diagnosis, Prioritized Interventions and Rationales. 11th edition.

4. Give explanation about the drug regimen, purpose, dose, and possible side effects.

Swearingen, Pamela L. All-in-One Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans.

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 32

4. Risk for Aspiration

Assessment Explanation of the Problem Objectives of Care Nursing Interventions Scientific Rationale Evaluation

O > Presence of NGT noted > decreased LOC > body paralysis noted >depressed gag reflex noted > unable to swallow foods

Nursing Diagnosis Risk for aspiration related to Depressed cough/ gag reflexes, presence of NGT and delayed gastric emptying as manifested by decreased LOC and Situations hindering elevation of upper body (paralysis)

Aspiration of stomach contents into the lungs is a serious complication that can cause pneumonia and hypoxia by destabilizing the alveoli and increasing airway resistance, and result in the following clinical picture: tachycardia, dyspnea, central cyanosis, hypertension, hypotension, and finally death. It can occur when the protective airway reflexes are decreased or absent due to either one or more of the following: seizure activity, decreased level of consciousness, nausea and vomiting in patient with decreased LOC, swallowing disorders, cardiac arrest, silent aspiration head injury, spinal cord injury, neuromuscular weakness, hemiplegia and dysphagia from stroke, postanesthesia effects from surgery or diagnostic tests, use of tube feedings for nutrition, endotracheal intubation, radical neck surgery, laryngectomy, parenteral/enteral feeding or mechanical ventilation. In addition to this, oropharyngeal secretions, or solids or fluids could also enter tracheobronchial passages due to decreased coughing, gag, and glottic reflexes. Prevention is the primary goal

STO: After 30 minutes of nursing interventions, the clients SO will be able to understand patients condition and the reason for need to observe some risks of both silent aspiration and aspiration.

Dx: 1. Assess cough and gag reflexes. 2. Assess level of consciousness. 3. Assess pulmonary status for clinical evidence of aspiration. Auscultate breath sounds noting for crackles and rhonchi. 4. Monitor the use of oxygen masks in patients at risk for vomiting.

STO: > A diminished cough or gag reflex increases the risk of aspiration. >The primary risk factor of aspiration is decreased level of consciousness. > Aspiration of small amounts can happen with sudden onset of respiratory distress or without coughing particularly in patients with diminished levels of consciousness. > Refrain from using oxygen masks for comatose individuals. Use of mask encourages patient to actively breathe through as it covers both nose and mouth, increasing chances of aspirating vomitus and other gastric or pulmonary secretions especially for patients with diminished level of consciousness. > This eliminates residuals and reduces pocketing of food that can be aspirated. >The combination of lying position and decreased level of consciousness at night when the patient goes to sleep further increases the risk for aspiration. >Misplacement of nasoenteral feeding tubes may cause aspiration of enteral formula. Patients at high risk include those who are obtunded, GOAL MET. After series of nursing interventions, the clients SO was able to verbalize understanding on the etiology of the patients condition and the reason for need to observe some risks of both silent aspiration and aspiration.

LTO: After 24 hours of nursing interventions, the client will be able to: 1. Maintain a patent airway with clear breath sounds. 2. Patients risk of aspiration will be decreased with the correction of factors that can lead to aspiration

LTO: GOAL MET After series of nursing care and intervention, the patient was able to 1. Maintain a patent airway with clear breath sounds. 2. Patients risk of aspiration will be decreased with the correction of factors that can lead to aspiration

Tx 1. Assist in oral care after meals. 2. Do not give bolus feedings at night.

3. Validate placement of nasoenteral feeding tubes. Tube position can be checked by x-ray, affirmation of pH of 05 of the gastric fluid

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 33

when caring for patients at risk for aspiration. Evidence confirms that one of the main preventive measures for aspiration is placing at-risk patients in a semirecumbent position. Other measures are compensating for absent reflexes, assessing feeding tube placement, identifying delayed stomach emptying, and managing effects of prolonged intubation. Reference: Doenges, Marilyn E., Moorhouse, Mary Frances, Murr, Alice C. Nurses Pocket Guide: Diagnosis, Prioritized Interventions and Rationales. 11th edition.

withdrawn through tube, or gurgling sound heard upon auscultation when air is injected. 4. Maintain head of bed raised at 3045 degrees when feeding and at least 1 hour after feeding. Edx 1. Discuss to patient and significant others the need for proper positioning. 2. Instruct on and encourage caregiver to watch out for signs and symptoms of aspiration. 3. Demonstrate suctioning techniques and train client to suction self or train family members in suctioning to prevent accumulation of secretions in the oral cavity.

intubated, those who have had a cerebrovascular accident or stroke, surgery of the head or neck and upper GI system. > Reduces risk of regurgitation or gastric reflux and aspiration.

> This reduces the risk of aspiration > This helps in appropriately evaluating high-risk conditions and determining when to call for help and further evaluation >Avoids pooling of oral secretions, reducing risk of aspiration. It also prevents complications, and enhances both safety and selfsufficiency.

Reference: Doenges, Marilyn E., Moorhouse, Mary Frances, Murr, Alice C. Nurses Pocket Guide: Diagnosis, Prioritized Interventions and Rationales. 11th edition. www.caneclicks.com

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 34

5. Self-care Deficit
Assessment Explanation of the Problem Objectives of Care Nursing Interventions Scientific Rationale Evaluation

S>Hindi na nga nakakaligo dahil nga bed ridden na siya, as verbalized by the clients SO O > Difficulty finishing toileting tasks > unkempt appearance > body odor noted >Impaired capability to put on or take off clothing >Inability to bathe self independently, get bath supplies and wash body or body parts >Poor oral and personal hygiene >scaling on the scalp noted

Nursing Diagnosis Self care deficit related to Decreased strength and endurance, motor impairment and Neuromuscular impairment, secondary to cerebrovascular accident (CVA)

Dorothea Orems theory, first published in 1971, includes three related concepts: self care, self-care deficit, and nursing systems. Self-care theory is based on four concepts: self-care, self-care agency, self-care requisites, and therapeutic self. Self-care refers to those activities an individual performs independently throughout life to promote and maintain personal well-being. Self-care agency is the individuals ability to perform self-care activities. It consists of two agents: a self-care agent (and individual who performs selfcare independently) and dependent care agent (a person other than the individual who provides the care.) Self care requisites, also called self-care needs, are measures or actions taken to provide self-care. Therapeutic self-care demand refers to all self-care activities required to meet existing self-care requisites, or in other words, actions to maintain health care and well being. Self-care deficit results when self-care agency is not adequate to meet the known self-care demand. Orems self-care deficit theory explains not only when nursing is needed but

STO: After 30 minutes of nursing interventions, the clients SO will be able to understand the importance of proper hygiene and decide to participate in the hygiene care of the patient.

Dx: 1. Determine exact cause of each deficit. For instance, weakness, visual problems, and cognitive impairment. 2. Evaluate capability and level of deficit (04 scale) to perform ADLs such as feeding, dressing, grooming, and bathing, toileting, transferring, and ambulating on regular basis.

STO: > Varied etiological factors may require more specific interventions to enable selfcare. >The patient may only need support with some self-care measures. Also help in anticipating and development for managing patient needs. GOAL MET. After series of nursing interventions, the clients SO was able to verbalize understanding on the etiology of the patients condition as well as knowing the importance of proper hygiene and decide to participate in the hygiene care of the patient.

LTO: After 8 hours of nursing interventions, the clients SO will be able to safely execute self-care activities to utmost capability of the patient.

Tx 1. Uphold a supportive, firm attitude and provide enough time for patient to accomplish tasks.

2. Foresee hygienic requirements and calmly support as necessary with care of nails, skin, and hair, mouth care, shaving. 3. Help out patient with care of fingernails and toenails as needed. Edx 1. Educate family and significant others to promote autonomy and to intercede if the patient is not capable to

> This aids patient to put in order and perform self-care skills. Patients could do with empathy and to be assured that caregivers will be constant in their providing of adequate and appropriate assistance as necessary. >Significant others illustration can provide a matter-of-fact tone for handling needs that many be awkward to patient or repulsive to significant other. > Patients may need podiatric care to avoid harm to feet when trimming nails. >This displays caring and concern but does not hinder with patients efforts to attain autonomy.

LTO: GOAL MET After series of nursing care and intervention, the clients SO will be able to safely execute self-care activities to utmost capability of the patient.

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 35

also how people can be assisted through five methods of helping: acting or doing for, guiding, teaching, supporting, and pr0viding an environment that promotes health. Medical conditions that could lead to self care deficit are as follows: cerebrovascular accident, stroke, multiple sclerosis, renal dialysis, rheumatoid arthritis, and a lot more. In addition, the deficit may be the result of transient limitations, such as those one might experience while recuperating from surgery; or the result of progressive deterioration that erodes the individuals ability or willingness to perform the activities required for caring for himself or herself. Reference: Doenges, Marilyn E., Moorhouse, Mary Frances, Murr, Alice C. Nurses Pocket Guide: Diagnosis, Prioritized Interventions and Rationales. 11th edition.

carry out task.

References: Doenges, Marilyn E., Moorhouse, Mary Frances, Murr, Alice C. Nurses Pocket Guide: Diagnosis, Prioritized Interventions and Rationales. 11th edition. www.caneclicks.com

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 36

6. Impaired Physical Mobility

Assessment Explanation of the Problem Objectives of Care Nursing Interventions Scientific Rationale Evaluation

S> Paralisado na nga siya eh, as verbalized by the brother of the patient. O >needs full assistance in doing activities of daily living >with upper and lower body paralysis >weak in appearance >with urine catheter connected to a urine bag

STO: Alteration in mobility may be a temporary or a more permanent problem. Any injury to the musculoskeletal system (e.g., sprains of ligaments, fractures to bones, dislocated joints, muscle strains, amputated extremities or digits, burns) can lead to a decrease in the clients mobility. Other causes of impaired mobility are injuries to the vertebral bodies, spinal cord, and the brain. Examples of conditions that may lead to these injuries include cerebrovascular accident (CVA), craniocerebral trauma, disc surgery, herniated nucleus pulposus. For those with impaired mobility, movement must be fostered to the full extent of capability to facilitate a satisfying life. No matter what their level of mobility, they must be encouraged to breathe fully, engage their abdominal muscles, and move as much as possible to prevent the physical and psychoemotional hazards of immobility. Nursing goals are to maintain functional ability, prevent additional impairment of physical activity, ensure a safe After an hour of nursing care and intervention, the clients significant others will verbalize understanding of the situation and individual treatment regimen needed to improve clients status.

Dx: 1. Note presence of factors contributing to inability to do move

STO: > ongoing disease process affects both the clients actual and perceived ability to participate in activities >provides comparative baseline and provides information about needed education/ interventions regarding quality of life > to determine current status and needs associated with participation in needed/ desired activities >stress and/or depression may be increasing the effects of an illness, or depression might be the result of being forced into inactivity > to prevent overexertion and prevent further injuries GOAL MET. After an hour of nursing interventions, the clients SO was able to verbalize understanding of situation and individual treatment regimen as manifested by willingly participating to the treatment regimen

2. Evaluate clients actual and perceived limitations of usual status

Nursing Diagnosis Impaired physical mobility related to loss of motor reflexes due to cognitive deficits secondary to CVA, intracerebral bleeding as manifested by upper and lower body paralysis

LTO: After 8 hours of nursing care and intervention, the clients significant others will: 1. Demonstrate properly techniques/ behaviors that enable resumption of activities such as: a. moderate passive ROM exercise b. frequent log rolling to prevent pressure ulcer

3. Ascertain ability to do ADL and move about and degree of assistance necessary/use of equipment 4. Assess emotional/ psychological factors affecting the current situation

LTO: GOAL PARTIALLY MET. After 8 hours of nursing interventions, 1. The clients SO was able to participated in some activities such as feeding, oral care and self-grooming but with assistance but the patients condition still not improved. Full assistance is still needed.

Tx: 1. Adjust activities. Reduce intensity level or discontinue activities that cause undesired physiological changes 2. Provide positive atmosphere while acknowledging difficulty of the situation for the client such as quiet and calm environment 3. Provide comfort measures such as frequent repositioning to prevent pressure ulcers

> helps to minimize frustration and to re-channel energy

> to prevent further breakage in the integrity of skin > to improve blood circulation

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 37

environment, increase tolerance for physical activity, enhance physical fitness, restore or improve capability to ambulate, and improve social, emotional, and intellectual well-being, and prevent complications associated with impaired mobility. Reference: Doenges, Marilyn E., Moorhouse, Mary Frances, Murr, Alice C. Nurses Pocket Guide: Diagnosis, Prioritized Interventions and Rationales. 11th edition. page 70-74

5. Assist in moderate ROM exercises, with the help of the nurse 6. Assist client in appropriate safety measures by putting up the side rails of the bed 7. Support affected body part/ joints using pillows/ rolls 8. Assist in turning client from side to side, as indicated Edx 1. Encouraged SOs to participate in the care and management 4. Encouraged continuation of exercises (passive ROM exercise) with the full assistance of the nurse.

and prevent ulcer due to immobility > to prevent falls/ injuries

> to maintain position of function and improve blood circulation > to maintain blood circulation, to prevent pressure ulcer, and to avoid further immobility > to enhance sense of wellbeing > to maintain/ enhance gains in strength/ muscle control

References: Swearingen, Pamela L. All-in-One Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. Doenges, Marilyn E., Moorhouse, Mary Frances, Murr, Alice C. Nurses Pocket Guide: Diagnosis, Prioritized Interventions and Rationales. 11th edition.

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 38

7. Risk for Impaired Skin Integrity

Assessment Explanation of the Problem Objectives of Care Nursing Interventions Scientific Rationale Evaluation

O > dry skin >poor circulation as manifested by pale mucous membranes and conjunctivas >presence of scaling on the lower extremities due to aging

Nursing Diagnosis Risk for impaired skin integrity related prolonged bed rest, decreased level of activity/immobility and Poor circulation

The skin is the largest organ in the body and serves a variety of important functions in maintaining health and protecting the individual from injury. Important nursing functions are maintaining skin integrity and promoting wound healing. Impaired skin integrity is not a frequent problem for most healthy people but is a threat to elders; to clients with restricted mobility, chronic illness, or trauma; and to those undergoing invasive health care procedures. Like the case of Mr. Sy B. Dee, he is in the highest risk for altered skin integrity because he is confined to bed for prolonged periods of time;; have altered sensation that triggers the normal protective weight shifting; and have serious medical conditions. The major goals for clients at Risk for Impaired Skin Integrity are to maintain skin integrity and to avoid potential associated risks. To protect the skin and manage wounds effectively, the nurse must understand the factors affecting skin integrity, the physiology of wound healing, and specific measures that promote optimal skin

STO: After 30 minutes of nursing interventions, the clients SO will be able to understand patients condition and the reason for the need of repositioning, log rolling at regular intervals.

Dx: 1. Evaluate general status of skin. Observe color, turgor, sensation skeletal prominences, presence of edema, areas of altered circulation or pigmentation, or emaciation. Explain or measure lesions and note changes. 2. Evaluate patients capability to move. 3. Evaluate patients consciousness of the sensation of pressure.

STO: > Healthy skin differs from person to person, but must have good turgor, feel warm and dry to the touch, be free of injury, and have fast capillary refill (<6 seconds). This institutes comparative baseline, giving chance for timely treatment. >Immobility is the utmost risk factor in skin breakdown. >Usually, individuals shift their weight off pressure areas every few minutes; this takes place more or less automatically, even throughout sleep. Patients with diminished sensation are unconscious of unpleasant stimuli and do not shift load. This results in protracted pressure on skin capillaries, and in the end, skin ischemia. > Locations where skin is stretched tightly over bony prominences are at greater risk for breakdown because the potential of ischemia to skin is high as an effect of compression of skin capillaries between a hard surface and the bone. > An albumin level less than 2.5 g/dl is a severe sign, LTO: GOAL PARTIALLY MET After series of nursing care and intervention, Patients skin was kept intact, as manifested by absence of redness over bony prominences, however mucous membranes and conjunctivas are still pale in color and would contribute to longer periods of physiology of wound healing, and will affect specific measures that promote optimal skin conditions. GOAL MET. After series of nursing interventions, the clients SO was able to verbalize understanding on the importance of the need of repositioning, log rolling at regular intervals.

LTO: After 16 hours of nursing interventions, the client will be able to: Patients skin will be kept intact, as manifested by absence of redness over bony prominences and capillary refill less than 6 seconds over areas of redness.

4. Particularly assess skin over bony prominences.

5. R eview patients nutritional status, including weight,

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 39

conditions. In addition, prevention of skin breakdown includes a wide range of surfaces, specialty beds and mattresses, and other devices. Reference: Doenges, Marilyn E., Moorhouse, Mary Frances, Murr, Alice C. Nurses Pocket Guide: Diagnosis, Prioritized Interventions and Rationales. 11th edition.

weight loss, and serum albumin levels.

6. Verify age.

signifying grave protein reduction. Research has revealed that patients whose serum albumin is less than 2.5 g/dl are at greater risk for skin breakdown, all other factors being alike. > Geriatric patients skin is usually less resilient and has less moisture, making for greater risk of skin injury. > Enhances blood flow, reducing tissue hypoxia. Note: Direct massage of compromised area may lead to tissue injury. Avoid massaging bony prominences. > If powder is desirable, utilize medical-grade cornstarch; keep away from talc. Keep cleanliness without irritating the skin. > Reduces pressure on tissues, avoiding skin breakdown. > Moisture exacerbates pruritus and augments risk of skin breakdown. > Improves venous return. Decreases edema formation. > Improves circulation and avoids unnecessary pressure on skin or tissues. Additionally, a schedule that does not

Tx 1. Boost tissue perfusion by offering gentle massage around reddened or blanched areas.

2. Clean, dry, and moisturize skin, particularly over bony prominences, twice daily or as necessary. 3. uard bony prominences with sheepskin, heel or elbow protectors, pillows, as necessary. 4. Maintain linens dry and free of winkles, crumbs. 5. Reposition; Raise lower extremities occasionally, if tolerated. 6. Persuade execution and posting of a turning schedule, limiting time in one position to 2 hours or less and modifying

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 40

the schedule to patients routine and caregivers needs. Edx 1. Persuade patient and/or caregiver/significant other to keep functional body alignment and to shift body weight frequently. 2. Persuade with repositioning on a regular schedule, even as in bed or chair, and performing active or passive ROM exercises as suitable. 3. Educate patient and caregiver the reason(s) of pressure ulcer development: a) Pressure on skin, particularly over bony prominences b) Incontinence c) Poor nutrition d) Shearing or friction against skin

hinder with the patients and caregivers activities is most expected to be followed. > Helps to distribute pressure in the entire body instead of concentrating force and pressure on certain body parts. > Repositioning decreases pressure on edematous tissues to promote circulation. Exercises improve circulation and enhance or keep joint mobility. > Empowers them and encourages their participation in avoiding such contributing factors by helping them understand the role such factors play in pressure ulcer development..

References: Doenges, Marilyn E., Moorhouse, Mary Frances, Murr, Alice C. Nurses Pocket Guide: Diagnosis, Prioritized Interventions and Rationales. 11th edition. www.caneclicks.com

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 41

8. Impaired Verbal Communication

Assessment Explanation of the Problem Objectives of Care Nursing Interventions Scientific Rationale Evaluation

S>Hindi na siya nakakapagsalita, as verbalized by the patients SO. O > difficulty vocalizing words >Inability to speak dominant language >(+) dysarthria > absence of eye contact > decrease LOC

There are various barriers to and conditions that can impair (verbal) communication. These include brain injuries, language (cultural) differences, sensory deficits (visual and/or auditory), cognitive impairments, degenerative neurologic disorders, structural problems, fatigue, and dyspnea. Brain injuries, especially affecting the speech center(s) of the brain will result to verbal communication impairment. For instance, in stroke, the loss of verbal communication may be caused by the ischemia of the dominant cerebral hemisphere, leading to loss of the function of the muscles that produce speech. Brain injury-related impairment to verbal communication can either result to expressive or receptive aphasia or both, depending on the location of injury. The former is a result of injury to the Brocas area while the latter is due to the damage to the Wernickes area, or when both areas are injured, both aphasias can occur.

STO: After 30 minutes of nursing interventions, the clients SO will be able to understand patients condition and the reason of inability to communicate

Dx: 1. Determine the cause(s) of or contributory factor(s) of verbal communication impairment. 2. Assess for presence of expressive aphasia and receptive aphasia.

Nursing Diagnosis Impaired verbal communication related to neuronal deficits that adversely affects the transmission, reception or interpretation of language or other forms of communication secondary to CVA, intracerebral bleeding

LTO: After 24 hours of nursing interventions, the client will be able to: Utilize a form of communication to get requirements met and to relate successfully with persons and his or her surroundings.

3. Assess energy level.

Tx 1. Anticipate patient needs and be attentive to nonverbal cues. 2. Manipulate the environment as necessary: a. Provide a calm and relaxing environment.

> The management plan and therapy are devised according to the cause(s) or contributory factor(s); interventions may vary depending on the cause and contributory factors. >Expressive aphasia (inability to convey information verbally) affects patients ability to verbally communicate while receptive aphasia impairs ability to understand received messages (e.g., word meaning may be scrambled during the processing of information by the patients brain). >Fatigue can make communication difficult or impossible; adequate energy is necessary to perform activities and communicate effectively. Activities are designed based on patients energy level. >Non-verbal cues are used by patients to communicate their needs and sometimes, they do not really tell their needs for certain reasons >A calm and relaxing environment helps reduce anxiety.

STO: GOAL MET. After series of nursing interventions, the clients SO was able to verbalize understanding on the etiology and the inability to communicate of the patient

LTO: GOAL PARTIALLY MET After series of nursing care and intervention, the client was not able to talk in a dominant language but was able to use murmuring sounds for affirmative responses while doing nursing care.

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 42

Reference: Doenges, Marilyn E., Moorhouse, Mary Frances, Murr, Alice C. Nurses Pocket Guide: Diagnosis, Prioritized Interventions and Rationales. 11th edition.

b. Promote and keep a quiet environment.

c.Keep the room or environment well-lighted.

> A quiet environment with limited distractions will make the most of the communication efforts of both the client and the nurse and increase the possibility of effective communication >Sufficient light will help in conveying nonverbal messages, which is especially important if visual or auditory acuity is impaired. >Patient may feel so useless, helpless with rude treatment. Also, it is damaging to a patients self-image if others appear to be embarrassed or amused by the clients attempts to communicate. >Family involvement is significant in patients recovery.

Edx 1. Instruct family how to communicate with the aphasic patient: be calm, patient, and gentle.

2. Instruct family how to communicate with patient, as appropriate to the condition.

References: Doenges, Marilyn E., Moorhouse, Mary Frances, Murr, Alice C. Nurses Pocket Guide: Diagnosis, Prioritized Interventions and Rationales. 11th edition. www.caneclicks.com

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 43

XIV. Discharge Plan CRITERIA a. Diet HEALTH TEACHINGS When the patient improve the state of his condition and regain consciousness, he and his significant others must be knowledgeable on the diet of an individual with stroke to help hasten his recovery period. A healthy diet for people with a stroke should include: Control calories:

o Eat just enough calories to achieve and maintain a healthy weight. Eat quality fats: o Use virgin olive oil and other unsaturated, low-cholesterol fats. Eat the right amount of fats, carbohydrates and protein: o Limit your fat intake to 20 or 30 percent, but don't substitute simple
carbohydrates for fat.

o Less than 7% of the day's total calories from saturated fat. o Up to 10% of the day's total calories from polyunsaturated fat. o Up to 20% of the day's total calories from monounsaturated fat Avoid fad diets: o Eat a well-rounded diet instead. o Eat small, frequent meals. o Avoid large and heavy meals. Limit cholesterol in diet: o To less than 200 milligrams a day. Limit iron intake: o Too much iron can increase atherosclerosis. Eat enough dietary fiber: o Whole grains are best. Eat plenty of fresh fruit and vegetables Reduce salt in your diet o Optimal: no more than 2 grams per day. Check with your doctor about supplementing your diet with B vitamins: o Vitamin B1 (thiamine) o Vitamin B2 (riboflavin) o Vitamin B3 (niacin) o Vitamin B5 (pantothenic acid) o Vitamin B6 (pyridoxine) o Vitamin B12 (cobalamin)
Instruct family to promote a diet high in fiber and liquid intake of 2000 to 3000 ml per day unless contraindicated. High fiber diet helps prevent constipation, a common immobility complication. Liquids maximize hydration status and avoid hardening of stool; also decreases risk of skin irritation or breakdown. Reminding the family is essential to coincide with the hospital therapeutic regimen.

b. Activities

If the patient still unable to do ADLs upon discharge, instruct or coach the caregiver / significant others on the following: a) Emphasize principles of passive exercise, reinforcing that joints are to be exercised to the point of pain, not beyond.

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 44

b)

Instruct to perform deep breathing and coughing exercises. Lift head of bed as appropriate. Deep breathing and coughing exercises help mobilize secretions, enhance lung expansion, and decrease risk of respiratory complications, for instance, atelectasis, and pneumonia. Persuade family or significant others to support and assist with ROM exercises. Give emphasis to the significance of actions such as position change, ROM, coughing, and exercises. Permits family or significant other to be active in patient care and facilitates more consistent therapy. Persuade the patient (if able to comprehend to instructions) and significant others to help the patient move and exercise or support weaker or immobile side/extremity. Patient may react as if affected side/extremity is no longer part of body and requires support and active training to reincorporate it as a part of own body. Instruct the family to keep patients head/neck in midline of neutral position, maintain with small towel rolls and pillows; avoid placing head on large pillows; check position or fit of cervical collar or tracheostomy ties when utilized. Rotating head to one side compresses the jugular veins and holds back cerebral venous drainage, thus increasing ICP. Tight fitting collar or ties can also hold back jugular venous mobilization.

c)

d)

e)

c. Medications

Instruct patient/ significant others to help the patient continue drug regimen: a) Generic: Irbesartan Brand: Avapro 100 mg 1 tab OD @ lunch b) Generic: Metropolol Brand: Lopressor 1 tab q 12 hrs (12 nn and 12 MN) c) Generic: Furosemide Brand: Lasix 40 mg q 8 hrs d) Generic: Besacodyl Brand: Dulcolax To be given q 4 hrs if no bowel movement e) Generic: Glimepiride Brand: Amaryl 2 mg 1 tab OD pre breakfast f) Generic: Losartan Brand: Cozaar 150 mg 1 tab 3x a day g) Generic: Lactulose Brand: Cozaar 30 cc OD HS until with regular bowel Avoid drinking alcohol while taking the drug. It can further lower the blood pressure and may increase certain side effects of irbesartan. Blood pressure will need to be checked often. Do not discontinue drug abruptly after long-term therapy (hypersensitivity to catecholamines may have developed, causing exacerbation of angina, MI, and ventricular arrhythmias). Taper drug gradually over 2 wk with monitoring. Administer with food or milk to prevent GI upset. Take early in the day so that increased urination will not disturb sleep. This is usually taken at bedtime.

Take this drug once a day with breakfast or the first main meal of the day.

Your chest pain may become worse when you first start taking amlodipine or when your dose is increased.

Give laxative syrup orally with fruit juice, water, or milk to increase palatability. Do not administer other laxatives while using lactulose. For laxative use, do not use continuously for longer than 1

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 45

movement

week unless directed by your health care provider. Make sure you have readily access to bathroom; bowel movements will be increased to two to three per day.

d. Others

Educate patient or caregiver/significant others on the following: a) Explain diet restrictions especially regarding fluid and sodium. This reduces the extracellular fluid volume that will also decrease the cardiac workload and help improve cardiac contractility. Educate patient or caregiver/significant other on the appropriate use and maintenance of pressure-relieving devices to be utilized at home. Promotes independence and prepares for adequate management of risk for impaired skin integrity at home particularly in relieving pressure. Warn against keeping pillow under lower-extremity stump or allowing BKA (below the knee amputation) limb to hang dependently over side of bed or chair. Utilization of pillows can cause lasting flexion contracture of hip; a dependent position of stump impedes venous return and may augment edema formation. Instruct family how to communicate with the aphasic patient: be calm, patient, and gentle. Patient may feel so useless, helpless with rude treatment. Also, it is damaging to a patients self-image if others appear to be embarrassed or amused by the clients attempts to communicate.

b)

c)

d)

e)

Instruct on and encourage caregiver to watch out for signs and symptoms of aspiration. This helps in appropriately evaluating high-risk conditions and determining when to call for help and further evaluation. Instruct on food preparation (size, consistency, and amount) of foods that are easier to swallow. Encourage significant others to offer patients food preferences in this preparation. Facilitates adequate nutritional intake without compromising safety during mealtimes.

f)

g) Persuade expression of feelings, strengths, weaknesses, and concerns. Expression of feelings and concerns alleviates anxiety and provides reassurance, which may enhance patients participation and compliance on the treatment plan. Verbalization of strengths and weaknesses help in figuring out the appropriate actions and limitations.

REFERRAL: Remind client that follow-up check-up would be after 7 days if no complications occurred but consult immediately to health care provider if severe headache, dizziness, blurring of vision, severe weakness or muscle wasting, very high blood pressure, delirium and hallucinations, or other complications occurred.

XV. Conclusions and Recommendations Individuals who experience a stroke may require a variety of rehabilitation services including physical therapy, occupational therapy, speech therapy, and orthotic management. Therapy should begin as soon as the individual is medically stable, usually within 72 hours. Acute inpatient rehabilitation should continue daily until the individual is discharged from the hospital. Individuals discharged to a rehabilitation hospital or skilled nursing unit should have several hours of therapy daily. Individuals discharged to home should have the appropriate home care services several times a week for about 6 to 9 weeks. Additional outpatient therapy may be indicated.

Speech therapy may be required to strengthen the muscles of the face for improved speech and swallowing. Individuals learn to move the facial muscles in a balanced manner both by manual assistance and visual cueing using a mirror. Individuals perform tongue exercises that allow improved speech and easier eating. Individuals

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 46

learn to speak with greater clarity through activities such as sustained vocal expressions (e.g., saying "ah"). To assist in the swallowing reflex, individuals begin eating semi-moist, pureed food that is easier to swallow and then progress to food that is rich in taste, smell, and texture. Individuals also learn to achieve sucking control and saliva production first by sucking on small ice chips and progressing to sucking thick liquids through a straw. Follow these guidelines and the advice of your doctor to lower your chances of stroke.

Risk Factors You Can Change

1. You can change some risk factors for stroke, by taking the following steps: a) b) c) d) e) f) g) h) i) Do not smoke. If you do smoke, quit. Control your cholesterol through diet, exercise, and medicines, if needed. Control high blood pressure through diet, exercise, and medicines, if needed. Control diabetes through diet, exercise, and medicines, if needed. Exercise at least 30 minutes a day. Maintain a healthy weight by eating healthy foods, eating less, and joining a weight loss program, if needed. Limit how much alcohol you drink. This means 1 drink a day for women and 2 a day for men. Avoid cocaine and other illegal drugs. Talk to your doctor about the risk of birth control pills. Birth control pills can increase the chance of blood clots, which can lead to stroke. Clots are more likely in women who also smoke and who are older than 35.

2. Good nutrition is important to your heart health and will help control some of your stroke risk factors. a) b) c) d) e) Choose a diet rich in fruits, vegetables, and whole grains. Choose lean proteins, such as chicken, fish, beans and legumes. Choose low-fat dairy products, such as 1% milk and other low-fat items. Avoid sodium (salt) and fats found in fried foods, processed foods, and baked goods. Eat fewer animal products and foods that contain cheese, cream, or eggs.

3. Read labels, and stay away from "saturated fat" and anything that contains "partially-hydrogenated" or "hydrogenated" fats. These products are usually loaded with unhealthy fats. Your doctor may suggest taking aspirin or another drug called clopidogrel (Plavix) to help prevent blood clots from forming. DO NOT take aspirin without talking to your doctor first. If you are taking these drugs or other blood thinners, you should take steps to prevent yourself from falling or tripping.

LEVEL 4 . SY 2011-2012

2ND

SEMESTER

P a g e | 47

XVI.

List of References

Akley, Betty J. and Ladwig, Gail B. Nursing Diagnosis Handboook: Guide to Planning Care. 6th edition. p. 159-164. Bare, Brenda G., Cheever, Kerry H., Hinkle, Janice L. and Smeltzer, Suzzane C. Brunner and Suddarths Textbook of Medical-Surgical Nursing. 11th edition. Volume 2. p. 1589-1591. Black, Joyce M. and Hawks, Jane Hokanson. Medical-Surgical Nursing: Clinical Management for Positive Outcomes. 7th edition. volume 2. p. 772-773, 882, 917-918. Doenges, Marilyn E., Moorhouse, Mary Frances, Murr, Alice C. Nurses Pocket Guide: Diagnosis, Prioritized Interventions and Rationales. 11th edition. p. 70-76, 88-94, 409-413, 433- 437, 498-503, 630-634. Green, Carol J., Marck, Jane F., Monahan, Frances D., Neighbors, Marianne, and Sands, Judith K. Phipps MedicalSurgical Nursing: Health and Illness Perspective. 8th edition. p. 977-980. Gutierrez, Kathleen and Queener, Sherry F. Pharmacology for Nursing Practice. p. 1052-1059. Huether and McCane. Understanding Pathophysiology. 4th edition. Malseed, Roger T. Springhouse Nurses Drug Guide. 6th edition. Nettina, Sandra M. and Mills, Elizabeth Jacqueline. Lippincott Manual of Nursing Practice. 8th edition. p.760-770. Paulanka, Betty J., Kee, Joyce L., Puraell, Larry D. Handbook of Fluids, Electrolytes and Acid-Base Imbalances. 2nd edition. p. 95, 153-154. Seeley, Rod R., Stephens, Trent D. and Tate, Philip. Essentials of Anatomy and Physiology. 6th edition. p. A2-A5. Shannon, Margaret T., Shields Kelly M, and Wilson, Billie Ann. Prentice Hall Nurses Drug Guide 2009. p. 283-285, 336-378, 1259-1261. Smith, Nancy E. and Timby, Barbara K. Introductory: Medical-Surgical Nursing. 10th edition. p. 920-931. Swearingen, Pamela L. All-in-One Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. p. 48, 86, 176-177, 273-278, 274, 503- 504, 777- 778. Venable, Samantha. Springhouse Nurses Drug Guide. 8th edition. p. 99-100. Weber, Janet and Kelley, Jane H. Health Assessment in Nursing. 3rd edition. p. 202-203, 226-231, 260-263, 281-288, 588. Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S, et al. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011 Feb;42(2):517-84. Epub 2010 Dec 2. [PubMed] Sacco, R. L. "Newer Risk Factors for Stroke." Neurology 57 5 (2001): 31-34. MD Consult. 27 Jul. 2004. Elsevier, Inc. 22 Oct. 2004 <http://home.mdconsult.com/das/journal/view/394347912/N/12029915?sid=286878571&source=MI>. Becker, J. U., C. R. Wira, and Jeffrey L. Arnold. "Stroke, Ischemic." eMedicine. Eds. Richard S. Krause, et al. 18 Nov. 2003. Medscape. 22 Oct. 2004 <http://emedicine.com/emerg/topic558.htm>. Jauch, Edward C., Brett Kissela, and Brian Stettler. "Acute Stroke Management." eMedicine. Eds. Thomas A. Kent, et al. 28 Aug. 2004. Medscape. 22 Oct. 2004 <http://emedicine.com/neuro/topic9.htm>. Elkind, Mitchell, Devin Brown, and Bradford Burke Worrall. "Genetic and Inflammatory Mechanisms in Stroke." eMedicine. Eds. Richard M. Zweifler, et al. 28 Aug. 2003. Medscape. 22 Oct. 2004 <http://emedicine.com/neuro/topic710.htm>. Singh, Niten, et al. "Atherosclerotic Disease of the Carotid Artery." eMedicine. Eds. Vincent Lopez Rowe, et al. 7 2006. Medscape. 16 Dec. 2008 <http://emedicine.com/med/topic2964.htm>. Beers, Mark H., et al., eds. "Ischemic Stroke." The Merck Manual of Diagnosis and Therapy. 18th ed. Whitehouse Station, NJ: Merck Laboratories, 2006. http://www.caneclicks.com