Bsn3-2c UC-BCF CVA Case Study

BSN3- SECTION2-GROUP C
NCM 103
1ST SEM
SY 2013-2014
ACKNOWLEDGEMENT The proponents of this case study would like to extend their warmest gratitude to all the people who made the success of this undertaking a reality. First and foremost, to the Almighty Father, for His unceasing love and blessings; for giving us enough power and fortitude to face all the hardships in the making of this work. To Him be all glory and praise! To our Clinical Instructors, Mrs. Josephine Minger RN MAN, Ms. April Anne Balanon RN MSN, Mr. Ken Fias-Ilon RN MAN, Mrs. Mediatrix Lee RN MAN and Dr. Josephine Rivera MD for their invaluable time, knowledge, effort and suggestions rendered to us and in securing information that made a valuable involvement to our case study. To all doctors and staff nurses of Stroke Unit of Baguio General Hospital and Medical Center, for the openhanded assistance and services they showed and for giving us the opportunity to complete this endeavor. The researchers also greatly acknowledge Mr. X significant others, for cooperation and willingness she showed. To the researchers loving parents for expressively and economically supporting the career the researchers have been taking and for their never ending support and understanding; for always being there to guide us and care for us after the long days of duties. To our classmates, friends, mentors and colleagues, for giving us the inspiration to finish this seemingly impossible task. To the group, we would like to recognize each other for our own radical efforts in order to complete this case study; for sticking together through thick and thin and for simply being there. With this, we are proud to say that we are indeed the mighty Group C. Lastly, to each and everyone who helped realize this job into completion, may it be direct or indirect, no matter how minimal, the gratitude and pleasure for the achievement of this task is ours to share. Thank You Very Much!!!! And God Bless You All!!!!! The Researchers
CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II
Page 1
BSN3- SECTION2-GROUP C TABLE OF CONTENTS
NCM 103
1ST SEM
SY 2013-2014
Pages I. INTRODUCTION . . . . . II. STATEMENT OF OBJECTIVES . . . III. GENERAL PROFILE/INFORMATION . . IV. CHIEF COMPLAINT . . . . V. PRESENT HISTORY OF THE ILLNESS . . VI. PAST HISTORY OF THE ILLNESS . . . VII. SOCIAL AND ENVIRONMENTAL HISTORY . VIII. FAMILY HEALTH HISTORY . . . IX. HEALTH-PERCEPTION/HEALTH MANAGEMENT PATTERN X. PHYSICAL EXAMINATION Head to Toe . . . . . 13 Areas of Assessment . . . a. Psychosocial Status. b. Environmental Status c. Mental and Emotional Status d. Sensory Status e. Motor Status f. Nutritional Status g. Elimination Status h. Fluid and Electrolytes i. Circulatory Status j. Respiratory Status k. Temperature Status l. Integumentary Status m. Comfort Status XI. DIAGNOSTIC PROCEDURES a. Hematology. . . . . . b. Blood Chemistry. . . . . c. Chest AP . . . . . d. Urinalysis. . . . . . e. Cranial CT-Scan . . . . XII. TREATMENT /MANAGEMENT a) IV Fluids . . . . . b) Drugs . . . . . . XIII. COMPREHENSIVE PATHOPHYSIOLOGY . . XIV. NURSING CARE PLANS a) Prioritization of Problems . . . b) Basis of Prioritization . . . . c) Nursing Care Plans 1. Actual . . . . . 2. Potential . . . . XV. DISCHARGE PLANS . . . . . XVI. CONCLUSIONS AND RECOMMENDATIONS . XVII. LIST OF REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 .4 .4 .5 .5 .5 .6 .6 .7 .8-16 .16-20
. . . . . . . . . . . . . . .
. . . . . . . . . . . . . . .
. . . . . . . . . . . . . . .
. . . . . . . . . . . . . . .
.21 .22 .22 .23 .23 .28 .24-27 .29 .30 .30 .32-37 .38-40 .41 .42 .43
Page 2
BSN3- SECTION2-GROUP C I. INTRODUCTION
NCM 103
1ST SEM
SY 2013-2014
The BSN3-Section 2-Group C was given the opportunity to have a hospital exposure last August 5-7, 2013 at 7-3 shift and on the said dates found a commendable case reasonable to be presented for the case study as agreed by the group. This study hopefully would become one of the bases for innovation of the Philippine health care system especially in the Medical Surgical setting. The same study aims to be a means of research practice for the studied profession. Readers of the study are expectedly to be educated in the course of taking care of patients. This also targets to document the event which by the demand of time can be used for review or recall about the subject event. In our part, this is essential for our realization of the said experience and which would make us a subject of ourselves for improvement. A Cerebrovascular Accident or stroke is infarction of a specific portion of the brain due to insufficient blood supply. It can occur from an occlusion of one of the major vessels feeding the brain, a partial or complete obstruction of a major intracranial vessel, or it can also be a hemorrhage within the brain. The blood vessels affected determines the area and extent of infarction. There are risk factors prior to the recurrence of CVA such as hypertension, hypercholesterolemia, smoking, oral contraceptives use, emotional stress, obesity, family history of stroke and age. This condition may alter the original circulation of blood, then leads to stroke. In line with this, as we all know almost all of the illicit drugs, alcohol and nicotine found in cigarettes are one of the potent vasoconstrictor. Stroke depends primarily on the location of the lesion or infracted tissue. If the brain stem is affected, blood pressure fluctuations altered respiratory patterns and cardiac dysrythmias are all possible. Coma can follow stroke from various causes; strokes due to occlusal disease (thrombus, embolus) rarely caused sudden death. When sudden death thus occurs it is usually due to heart failure. Respiratory infection and brain stem failure are two primary causes of death with stroke. According to the Philippine Nurses Association, the top 5 of the clinical disease entities frequently studied were Cerebrovascular Disease, infectious disease, neuromuscular diseases, epilepsy and demyelinating disease. For the past 10 years, there has been an increasing trend in the number of studies dealing with Cerebrovascular Disease. The group chose Patient X as their subject primarily because his case posed as a very intricate case requiring due understanding and knowledge. The group recognizes their partial knowledge about CVA and the surgical procedures involved in such condition, thus making this case a good avenue to broaden the proponents knowledge about the disease and the surgical pr ocedures involved. Having awareness and gaining more knowledge about CVA would enhance our skills and attitudes in handling patients suffering from this disease. This case serves as a challenge for us student-nurses to be committed and dedicated health professionals for in the next days, we will take care of the health of the citizens.
Page 3
BSN3- SECTION2-GROUP C II. STATEMENT OF OBJECTIVES A. General Objectives
NCM 103
1ST SEM
SY 2013-2014
The main goal of the group is to be able to present the case study of our chosen client that would provide a comprehensive discussion of the pathological mechanism of the disease to yield significant information for the case study. B. Specific Objectives This case analysis aims to: a) Illustrate the pathophysiology of CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II and in relation to the signs and symptoms specially observed in the clients. b) Discuss the medical intervention for the management of CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II. c) Formulate appropriate nursing care plans suited for the client based on the assessment findings. d) Identify care measures to be given to the patient and family to promote continuity of care and independence after discharge. III. GENERAL PROFILE / INFORMATION Name: X Age: 74 years old Sex: Male Civil Status: Married Hospital Number: 716217 Date of Birth: January 11, 1939 Place of Birth: Mankayan, Benguet Nationality: Filipino Address: Abatan, Buguias Benguet Occupation: Retired Lawyer Religious Affiliation: Roman Catholic Admitting Diagnosis: HPN- II T/C CVA Admitting Physician: Dr. Joel B. Bongotan MD Final Diagnosis: CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II Hospital: Baguio General Hospital and Medical Center Hospital Area: Stroke Unit Medical Ward Date Admitted: August 1, 2013
Page 4
BSN3- SECTION2-GROUP C Time Admitted: 5:55 PM Health Care Financing: PhilHealth and SSS IV. CHIEF COMPLAINT
NCM 103
1ST SEM
SY 2013-2014
Nape pain (right side), right sided body weakness with dizziness V. PRESENT HISTORY OF ILLNESS This was the patients first admission in a hospital in his entire life as he can remember. Two days prior to admission at around 1:00 PM on July 29, 2013, the patient had sudden onset of dizziness causing him to fell down to the floor, fatigability, right sided body weakness where in his hand and feet movement became imprecise and speech became incomprehensible these happened while he is fetching a pale of water from a spring 30 feet away from their house. He was drinking an alcoholic beverage of 3 bottles of San Mig Light before the symptoms manifested. His wife immediately placed him on bed in a high Fowlers position. She called her neighbor and brought 3 tablets of Neobloc 30 mg to the patient. The patient had taken the medication and relieved of his dizziness. He had a sound sleep that night. The morning after, he still experienced same symptoms meanwhile a midwife visited him and advised him to be admitted to a hospital and she also emphasized that it would be better to take the medication that is prescribed by the physician also to avoid other complications because Neobloc that was taken by the patient was unprescribed and was only recommended by their neighbor since he is also hypertensive. The SO was alarmed and decided to rush patient X at Buguias Emergency Hospital. One day prior to admission, no noted improvement hence, opted to transfer to Baguio General Hospital and Medical Center for further management and was admitted on August 1, 2013 at around 5:55 PM. VI. PAST HISTORY OF ILLNESS Hes heredo-familial disease is hypertension and 1 died with heart attack in their family. During his teenager, mid-adult years (mid 40s) and the recent years , he had been eating many fatty foods such as fried chicken, fried fish and pinikpikan and cholesterol rich foods such as fried egg. He also loves to eat salty foods. He also claimed that he had no known food and drug allergy nor experience any accidents or injuries. He has no previous illness for the past six months. He did not recall having been admitted in a hospital in his life. He hasnt experienced any surgery. He also hasnt experience blood transfusion. Patient had no known food and drug allergies. He was also an herbalist, believing in the effectiveness of herbs as a health treatment when having minor illness at home. He claimed that he didnt ever try smoking in his entire life. He admitted that he drank alcohol occasionally during her teenage years up to present.
Page 5
BSN3- SECTION2-GROUP C VII. SOCIAL AND ENVIRONMENT HISTORY
NCM 103
1ST SEM
SY 2013-2014
Patient X is a College graduate in the course of Law in University of the Cordilleras; he took his bar exam and passed. He worked as a lawyer for almost 10 years in Baguio City. He is married to a High school teacher major in English at the age of 28. His family used to reside at Buguias Benguet. He lives together with his wife and grandchildren. They had their children grown there and their ethnic affiliation is Kankana-ey. Each one of them had finished their studies and now working abroad. Their 1st Child is an architecture in Iran for 4 years, the 2nd child worked as a Mechanical Engineer in Switzerland for 1 year while the 3rd Child is working as a seaman in Abu Dhabi for almost 5 months. According to SOs propositions, He do attends church in regular basis but has no known devotion to Sto. Nio maybe. Noticeably, he as a father was bonded significantly to his 3 sons, when they were still a children they used to be in his bedside. She added that he is really close to his grandchildren and feels in deep sadness whenever one of them leaves for attending school here in Baguio. They usually visit him during sembreak, summer, holidays and special occasions. They used to live in a 3 storey house and is made of concrete and has 5 bedrooms, one bathroom, a kitchen, and a living room which is just enough or adequate for their living space. The location of the house is away to any possible accident hazards. The house appears to be durable and able to resist typhoons. Every member of the family has their own bedrooms. Mr. and Mrs. X share bedrooms while the siblings have their own rooms. The Laundry area outside the house, kitchen sink cabinet and the garbage cans are the resting sites of vectors of disease such as flies, mosquitoes and cockroaches present in the house. Their foods are stored in closed door cabinets and the refrigerator. Their water supply comes from spring. The water coming from the spring is used for washing, cleaning, and bathing and for drinking purposes. Their bathroom is near the kitchen and is kept clean everyday by his wife. Their way of disposing garbage is through a closed compost pit only for the biodegradable while for the plastic trashes they used to burn it. They have three garbage cans inside the house, one is in the kitchen, the other, is in the bathroom and lastly, near the bedroom. Their neighborhood is not congested, there is still room for trees and plants to grow and place to play and hang-out. They have their own telephone line and every family has their own cell phones. They also have a family van for their transportation facility. VIII. FAMILY HEALTH HISTORY According to the SO, Patient Xs father side only has a Hypertension and 1 died with heart attack in their family. XI. HEALTH PERCEPTION / HEALTH MANAGEMENT PATTERN Presently, the family is in good condition. The family members undergone complete immunization when they are still young. Mr. X makes sure that his family will not lead to any diseases. He is very sensitive to the health of his sons when they were still young. CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II Page 6
NCM 103
1ST SEM
SY 2013-2014
He eats three times a day. His food preferences are more often meat, fruits, vegetables and less sea foods. The members of the family (except his wife) have the habit of drinking liquors occasionally. His healthy lifestyle practices is walking, badminton, stretching which takes 6-10 minutes and eating fruits most specifically oranges. Because he is too old, he did not exercise everyday. He has enough of sleep about 8 hours a day he feel complete when he has sufficient rest a day. Resting and listening to radio drama serves as his relaxation and stress management activities. X. PHYSICAL ASSESSMENT A. Head to toe Assessment Date Assessed: August 7, 2013, 8:15 AM Vital Signs: BP: 140/100 mmHg PR: 92 BPM RR: 23 CPM T: 36.8 C Proportionate varies to body built, height, and weight in relation to the client's age, lifestyle, and health. Height- 58 Weight- 75 kgs Minor body odor and foul breathe odor relative to self care deficit. Cooperative; quantity and quality of speech are slightly understandable; exhibits thought through association of body gestures in communicating. Relevance and organization of thoughts logically sequence and makes sense of reality Patient is lying on bed, awake, coherent, and afebrile with oxygen inhalation at 10 LPM via face mask with ongoing IVF of PNSS 1L x 20 gtts/minute at 500 cc level hooked at left metacarpal vein patent and infusing well; intact NGT; With intact and patent IFC connected to a urine bag draining to amber colored urine; Needs full assistance to ADL and with signs of distress noted. Used adult diaper for defecation. General Survey:
General Appearance:
AREAS ASSESSED 1. INTEGUMENTARY A. SKIN 1. Skin color
ACTUAL FINDINGS
Pale
Page 7
NCM 103
1ST SEM
SY 2013-2014
3. Presence of edema
No edema
4. Existence of lesions
Freckles, some birthmarks, some flat and raised nevi, no abrasions or other lesions
5. Skin moisture
Dry
6. Skin temperature
Uniform; within normal range
7. Skin turgor
Sagged Wrinkled
8. Skin texture B. NAILS 1. Fingernail plate shape (its curvature and angle)
Convex curvature; angle of nail plate about 160
2. Fingernail and toenail bed color
Pallor
3. Fingernail and toenail texture
Smooth texture
4. Presence of tissues surrounding nails 5. Blanch test result of capillary refill 2. HEAD A. SKULL 1. Size, shpae and symmetry of the skull 2. Presence of nodules, masses, and depressions B. HAIR 1. Evenness of growth, thickness or thinness of hair 2. Color
Intact epidermis Delayed 4 seconds
Rounded (normecephalic and symmetrical, with frontal, parietal, and occipital prominences); Smooth skull contour Smooth, uniform consistence; absence of nodules or masses
Thin hairs not evenly distributed Black with white hairs
Page 8
BSN3- SECTION2-GROUP C C. FACE Facial features, symmetry of facial movements 3. EYES A. EYEBROWS Hair distribution, alignment, skin quality and movement B. EYELASHES Evenness of distribution and direction of curl C. EYELIDS Surface characteristics and position (in relation to the cornea, ability to blink, and frequency of blinking) D. CONJUNCTIVA 1. Color, texture, and tine presence of lesions in the bulbar conjunctiva
NCM 103
1ST SEM
SY 2013-2014
slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds
Symmetrical and in line with each other, black and evenly distributed
Evenly distributed and turned outward
Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are open; eyelids meet completely when the eyes are closed; symmetrical
Pale in color, with presence of small capillaries; moist; no foreigh bodies; no ulcers
2. Color, texture, and the presence of lesions in the palbebral conjunctiva E. SCLERA Color and clarity F. CORNEA Clarity and texture G. IRIS Shape and color
Pale in color, with presence of small capillaries; moist; no foreigh bodies; no ulcers
White in color, clear, no yellowish discoloration; some capillaries maybe visible
No irregularities on the surface; looks smooth; clear or transarent
Anterior chamber is transparent; no noted visible materials; color depends on the person's race
H. PUPILS Color depends on the person's race; size ranges from 3-7 mm, and are equal in size; equally round
1. Color, shape, and symmetry of size
Page 9
NCM 103
1ST SEM
SY 2013-2014
2. Light reaction and accommodation
Constrict briskly/sluggishly when light is directed to the eye, both directly and consensual Absence of blink in the right eye
3. Ability to blink I. VISUAL ACUITY 1. Near vision
Difficulty in reading newspaper not unless using his eye glass. 9/20' vision on Snellen chart
2. Distance vision J. LACRIMAL GLAND Palpability and tenderness of the lacrimal gland K. EXTRAOCULAR MUSCLES Eye alignment and coordination L. VISUAL FIELDS Peripheral visual fields 4. EARS A. AURICLES 1. Color, symmetry of size, and position
No edema or tenderness over lacrimal gland
Both eyes coordinated, move in unison, with parallel alignment
When looking straight ahead, client can see objects in the periphery
Color same as facial skin; symmetrical; auricle aligned with outer canthus of eye, about 10 degrees from vertical Mobile, firm, and not tender, pinna recoils after it is folded
2. Texture, elasticity and areas of tenderness B. HEARING ACUITY TESTS 1. Client's response to normal voice tones
Normal voice tones audible
2. Watch tick test result
Able to hear ticking in both ears Sound is heard in both ears or is localized at the center of the head
3. Weber's test result
Page 10
NCM 103
1ST SEM
SY 2013-2014
4. Rinne test result 5. NOSE
Air-conducted (AC) hearing is greater than boneconducted (BC) hearing
1. Any deviations in shape, size, or color and flaring or discharge from the nares
Symmetric and straight; no discharge or flaring; Uniform color
2. Presence of redness, swelling, growths and discharge in the nasal cavities
Mucosa pink; clear, watery discharge; no lesions
3. Nasal septum (between the nasal chambers)
Nasal septum intact and in midline
4. Patency of both nasal cavities
Air moves freely as the client breathes through the nares
5. Tenderness, masses, and displacements of bone and cartilage 6. SINUSES Identification of the sinuses and for tenderness 7. MOUTH A. LIPS
Not tender; no lesions
Not tender
Symmetry of contour color and texture
Pale in color, dry, rough in texture due to cracking; symmetry of contour, ability to purse lips
B. BUCCAL MUCOSA Color, moisture, texture and the presence of lesions C. TEETH Color, number and condition and presence of dentures 32 adult teeth; smooth white, shiny tooth enamel, smooth, intact dentures Uniform pink color, moist smooth, soft, glistening, and elastic texture
Page 11
BSN3- SECTION2-GROUP C D. GUMS Color and condition
NCM 103
1ST SEM
SY 2013-2014
Pink gums; no retraction
E. TONGUE/FLOOR OF THE MOUTH 1. Color and texture of the mouth floor and frenulum Pink color; moist; slightly rough; thin whitish coating; moves freely; no tenderness
2. Position, color and texture, movement and base of the tongue
Central position; pink color; smooth tongue base with prominent veins
3. Any nodules, lumps, or excoriated areas
Smooth with no palbable nodules, lumps, or excoriated areas
F. PALATES and UVULA 1. Color, shape, texture and the presence of bony prominences Light pink, smooth, soft palate; lighter pink hard palate, more irregular texture
2. Position of the uvula and mobility (while examining the palates) G. OROPHARYNX and TONSILS 1. Color and texture
Positioned in midline of soft palate
Pink and smooth posterior wall
2. Size, color, and discharge of the tonsils
Pink and smooth; no discharge; of normal size
3. Gag reflex 8.. NECK and LYMPH NODES A. NECK MUSCLES Inspection of neck muscle and head movement. A. LYMPH NODES
Dificiency
Muscles equal in size, coordinated head movement without discomfort
Page 12
NCM 103
1ST SEM
SY 2013-2014
Identification of Lymph nodes and for tenderness B. TRACHEA
Not palpable
Placement of the Trachea
Central placement in midline of neck; spaces are equal on both sides
C. THYROID GLAND
1. Symmetry and visible masses
Not visible on inspection
2. Smoothness and areas of enlargement, masses or nodules 9. THORAX A. POSTERIOR THORAX 1. Shape, symmetry, and comparison of anteroposterior thorax to transverse diamter
Lobes may not be palpated
Anteroposterior to transverse diameter in ratio 1:2; Chest symmetric
2. Spinal alignment
Spine vertically aligned
3. Temperature, tenderness, and masses
Skin intact; uniform temperature; chest wall intact; no tenderness; no masses
4. Respiratory excursion assessment
Full and symmetric chest expansion
5. Vocal fremitus palpation
Bilateral symmetry of vocal fremitus; Fremitus is heard most clearly at the apex of the lungs
6. Posterior thorax percussion
Percussion notes resonate except over scapula; Lowest point of resonance is at the diaphragm; percussion on a rib normally elicits dullness
7. Posterior thorax auscultation B. ANTERIOR THORAX
Vesicular and bronchovesicular breath sounds
Page 13
NCM 103
1ST SEM
SY 2013-2014
1. Breathing patterns
Quiet, rhythmic, and increase respiratory rate
2. Temperature, tenderness, masses
Skin intact; uniform temperature; chest wall intact; no tenderness; no masses Full symmetric excursion; thumbs normally separate 3 to 5 cm Bilateral symmetry of vocal fremitus; Fremitus is normally decreased over heart and breast tissue. Percussion notes resonate down to the sixth rib at the level of the diaphragm but are flat over areas of heavy muscle and bone, dull on areas over heart and the liver, and tympanic over the underlying stomach Bronchial and tubular breath sounds Bronchovesicular and vesicular breath sound
3. Respiratory excursion assessment
4. Vocal Fremitus palpation
5. Anterior thorax percussion
6. Trachea auscultation 7. Anterior thorax auscultation 10. CAROTID ARTERIES
1. Carotid artery palpation
Symmetric pulse volumes; full pulsations, thrusting quality; quality remains same when the client breathes, turns head, and changes from sitting to supine position; elastic arterial wall No sound heard on auscultation
2. Carotid arteries auscultation 11. JUGULAR VEINS Jugular veins inspection 12. BREAST and AXILLAE 1. Breast's size symmetry, and contour or shape
No sound heard on auscultation
Rounded Shape; slightly unequal in size; generally symmetric
2. Localized discolorations or hyperpigmentation, retraction or dimpling, localized hypervascular areas, swelling or edema in the skin of the breast
Skin uniform in color; skin smooth and intact; no major discolorations
Page 14
NCM 103
1ST SEM
SY 2013-2014
3. Areola's size, shape, symmetry color, discharge, and lesions
Round or oval and bilaterally the same; color varies widely, from light pink to dark brown; irregular placement of sebaceous glands on the surface of the areola irregular placement of sebaceous glands on the surface of the areola Round, everted, and equal in size; similar in color; soft and smooth; both nipples point in the same direction; no discharge, except from pregnant or breast-feeding females; inversion of one or both nipples that is present from puberty
4. Nipple's size, shape, position, color, discharge, and lesions
5. Axillary, subclavicular, and supraclavicular lymph nodes 6. Masses, tenderness, and any discharge from the nipples 13. ABDOMEN 1. Abdominal contour
No tenderness, masses, or nodules
No tenderness, masses, or nodules, or nipple discharge
Flat rounded (convex), or scaphoid (concave)
2. Enlargement of liver of spleen
No evidence of enlargement of liver or spleen
3. Symmetry of contour
Symmetric Contour Symmetric movements caused by respiration; visible peristalsis in very lean people; aortic pulsations in thin persons at epigastric area Audible bowel sounds; Absence of arterial bruits; absence of friction rub Tympany over the stomach and gas-filled bowels; dullness, especially over the liver and spleen, or a full bladder No tenderness; relaxed abdomen with smooth, consistent tension
4. Abdominal movements associated with respirations, peristalsis or aortic pulsations
5. Bowel sounds, vascular sounds, and peritoneal friction rubs 6. Several abdominal areas of the four quadrants
7. Light palpation in the four quadrants 14. MUSCULOSKELETAL SYSTEM A. MUSCLES 1. Muscle size and comparison on the other side 2. Contractures in the muscles and tendons
Proportionable to the body even in both sides No contractures
Page 15
NCM 103
1ST SEM
SY 2013-2014
3. Fasciculations and tremors in the muscles 4. Muscle tonicity 5. Muscle strength B. BONES 1. Normal structures and deformities in the skeleton 2. Areas of edema or tenderness in the bones C. JOINTS 1. Joint swelling
No fasciculation and tremors Even and firm muscle tone 60% muscle strength at the left side of the body. Whereas the right side is poor on muscle strength due to right sided body weakness
No deformities Absence of edema or tenderness in bones
No joint swelling, no warmth, redness
2. Tenderness, smoothness of movement, swelling, crepitation and presence of nodules
No tenderness, swelling and nodules: smooth movements: minimal crepitus may be present but there should be no pronounced crepitation
B. 13 Areas Assessment ***The mode in communicating between students and patient is through the help of the SO since they both know how to understand sign language. 1. Psychosocial Status According to Erik-eriksons 8 stages of development the client is under the Ego integrity vs. Despair (65 to death). This stage occurs during late adulthood from age 65 through the end of life. According to him, he did fulfill his career and was able to raise their children well, he didnt also regret every moment of his life. 2. Environmental Status Mr. X used to live in a 3 storey house and is made of concrete and has 5 bedrooms, one bathroom, a kitchen, and a living room which is just enough or adequate for their living space. The location of the house is away to any possible accident hazards. The house appears to be durable and able to resist typhoons. Every member of the family has their own bedrooms. Mr. and Mrs. X share bedrooms while the siblings have their own rooms. The Laundry area outside the house, kitchen sink cabinet and the garbage cans are the resting sites of vectors of disease such as flies, mosquitoes and cockroaches present in the house. Their foods are stored in closed door cabinets and the refrigerator. Their water supply comes from spring. The water coming from the spring is used for washing, cleaning, and bathing and for drinking purposes. They have their own bathroom and toilet. Their bathroom is near the kitchen and is kept clean everyday by his wife. Their way of disposing garbage is through a closed compost pit only for the biodegradable while for the plastic trashes they used to burn it. They CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II Page 16
NCM 103
1ST SEM
SY 2013-2014
have three garbage cans inside the house, one is in the kitchen, the other, is in the bathroom and lastly, near the bedroom. Their neighborhood is not congested, there is still room for trees and plants to grow and a place to play and hangout. They have their own telephone line and every family has their own cell phones. They also have a family van for their transportation facility. 3. Mental and Emotional Status The patient responds to stimuli by means of rubbing his sternum for him to wake up. The patient needs to be oriented with the time and date though he is aware that he is currently admitted in the hospital. He is responsive (through gestures), coherent, and can relate to conversations. He even smiles with jokes and wave his hands when someone he used to see visited him. He is aware regarding his condition. His hospitalization merely affected his status. He is able to write his name without difficulty since he is left handed and he could differentiate the objects shown to him (i.e. differentiating banana from an apple.) Through sign language and hand gestures. His ability to read and write matches his educational level. The patient was also able to respond to questions asked of him and was able to identify objects presented to him. The patient was able to evaluate and act appropriately in situations requiring his judgment. 4. Sensory Status Sense of sight
Mr. X is positioned in High Fowlers position and asked to face the Snellens chart at the distance of 20 feet occluding the other eye. The client had 9/20 visual acuity on the right eye, the same with the left. With the use of penlight the following were observed: 5. Motor Status Prior to admission, Mr. X was able to do daily routines without difficulty such as walking from one place to another, sit and change position in bed without difficulties. During admission, Mr. Xs gait was assessed using the head to toe method. Obviously, he cant able to stand on his own and balance himself since the patient is in total bed rest. He complains difficulty when turning him from side to side however; he states that he likes to move rather than flat in bed for a longer period of time. Assessment of the range of motion of the patient was done through instructions which include the ability of the patient to bend his shoulder apart. He has difficulty in moving his right shoulder laterally CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II Page 17 Pupils constrict when struck by light Patients eyes are symmetrical and round Sclera is white in color Eyes are symmetrical in moving.
NCM 103
1ST SEM
SY 2013-2014
and medially as well as rotating in the same manner. He has difficulty bending his right elbow however at the left elbow it can and farther apart or rotate it laterally to face upward and extending beyond the neutral position. The patient can also flex and extend his left knee of his ankle and left foot, so he cant tilt his right foot inward and move it toward and away the midline of his body. His neck is symmetrical with his head in central position. Movements through a full range of motion can be done with several discomforts.
0/5 5/5
0/5
5/5
6. Nutritional Status Mr. X was put into NPO upon admission to facilitate test and for observation of his general condition. With intubation, a Nasogastric tube was also inserted thus allowing the patient to take only liquid foods. After the patient was extubated he was then allowed to take soft foods minimally to practice her to go back to a full diet but still during this moment, he still has NGT feedings so as to his medications. His BMI is 30.00 Kg/m2(Obese) Obtained BMI Height: 58 ft/in Weight: 75 Kg BMI=30.00 Kg/m2 BMI Ranges ----Kg/m2 <18.5(Underweight) 18.5-24.9(Normal) 25-29.9 (Overweight) 30.0-39.9(Obese) 7. Elimination Status Before admission, he usually urinates for about 3-4 times a day and defecates twice or thrice. During admission, the urine output approximately ranges from 600-1350 cc per shift characterized by amber in light yellow in color. He defecates regularly 2-3 times a day using the adult diaper and the characteristics of his stool are slightly yellow in color, sticky and foul odor. August 5, 2013 Intake Time 7-3 3-11 Oral 830 1030 Parenteral 550 700 Others Total 1380 1730 Total: 3100 Urine 1350 600 Output Drainage Others Total 1350 600 Total: 1950
August 6, 2013 Intake Time Oral Parenteral Others Total Urine Output Drainage Others Total Page 18
BSN3- SECTION2-GROUP C 7-3 3-11 1030 600 600 450 1630 1050 Total: 2680 1630 1050
NCM 103
1ST SEM 1630 1050 Total: 2680
SY 2013-2014
August 7, 2013 Intake Time 7-3 3-11 Oral 860 1250 Parenteral 475 400 Others Total 1335 1650 Total: 1800 Urine 600 1250 Output Drainage Others Total 600 1250
Total: 2985
8. Fluid and electrolytes Prior to admission, Mr. X drinks 2 glasses of water every after meal. He usually drinks a cup of coffee during breakfast and during afternoon snack. According to the SO, he drinks carbonated drinks rarely and drinks alcoholic beverages occasionally. During admission, through NGT feeding he was able to drink water and take his medication after we pound and dissolved it in water. Mr. X was ordered to have an ongoing IVF of PNNS 1 L and regulated at 20 gtts/min. He has no restriction on his fluid intake. There was no edema present but there is dry skin noted. He was able to urinate 3-4 times within the shift by following the bladder training. 9. Circulatory Status A. Pulse Rate Data Time Pulse Rate 08/05/13 10 am 110 BPM 08/05/13 2 pm 115 BPM 08/06/13 10 am 115 BPM 08/06/13 2 pm 118 BPM 08/07/13 10 am 111 BPM 08/07/13 2 am 119 BPM His pulse was obtained from radial artery. The pulse rate ranges from 110-135 BPM which is above the normal range of 60-100 BPM hence it is classified as Tachycardia. His capillary refills returns within 4 seconds and it was taken from left forefinger. Pulse scale is 2 + which is easily palpable. B. Blood Pressure Data Time BP 08/05/13 10 am 180/100 mm Hg 08/05/13 2 pm 170/100 mm Hg 08/06/13 10 am 140/100 mm Hg 08/06/13 2 pm 120/100 mm Hg 08/07/13 10 am 150/100 mm Hg 08/07/13 2 am 140/100 mm Hg His BP was obtained from brachial artery. His BP ranges from 120-180/100 mm Hg and is classified as Stage 2 HPN ranging from 140-150/100-110 mm Hg.
Page 19
BSN3- SECTION2-GROUP C 10. Respiratory Status
NCM 103
1ST SEM
SY 2013-2014
Data Time Respiratory Rate 08/05/13 10 am 26 CPM 08/05/13 2 pm 28 CPM 08/06/13 10 am 25 CPM 08/06/13 2 pm 29 CPM 08/07/13 10 pm 25 CPM 08/07/13 2 pm 27 CPM His respiratory status ranges from 25-29, which is above the normal range of 16-20 CPM thus, it is classified as Tachypnea. Nasal Flaring noted at times. When auscultated, his breath sounds are normal, no cough but have difficulty in breathing is noted. His SPO2 is ranging from 97 to 99%. 11. Temperature Status Data Time Temperature 08/05/13 10 am 36.5 C 08/05/13 2 pm 36.8 C 08/05/13 10 am 37.0 C 08/05/13 2 pm 36.5 C 08/05/13 10 am 36.7 C 08/05/13 2 pm 36.8 C Mr. Xs temperature was obtained by the use of axillary thermometer placed on his axilla. His temperature status is normal, ranges from 36.5-37.0 C. 12. Integumentary Status Skin is pale in color, with the presence of edema, freckles and some birthmarks are noted. Skin moisture is dry, afebrile, sagged in turgor, skin texture is wrinkled. Fingernail and toenail are pallor, convex curvature and angle of the nail plate is about 160, smooth in texture, capillary refill is delayed for 4 seconds. Thin hairs not evenly distributed and black in color with white hairs 13. Comfort Status Before admission, Mr. X usually sleeps between 8:00PM 9:00PM and wakes up around 5:00AM and naps every afternoon. Now that he is admitted, he could hardly sleep because of his condition. His vital signs need to be monitored hourly. He sleeps irregularly because of the occurrence of sudden chestpain during the night, uncomfortable, irritability and restlessness.
Page 20
NCM 103
1ST SEM
SY 2013-2014
DIAGNOSTIC PROCEDURES: 1. HEMATOLOGY Data: Complete Blood Count Date of Examination: August 1, 2013 Time of Examination: 3:05 PM Description: A complete blood count is usually a series of tests in which the numbers of red blood cells and platelets in a given volume of blood are counted. The CBC also measures the hemoglobin content and the packaged cell volume (hematocrit) of the red blood cells, assesses the size and the shape of red blood cell, and determines the types and percentages of the white blood cells. Significance: Provides valuable information about the blood and blood forming tissues, as well as other body system. Abnormal results can indicate the presence of a variety of conditions sometimes before the patient experiences symptoms of disease. Reference/ Normal Findings RBC Male Female WBC Male Female HCT Male Female PLT Male Female 4.7-6.1 10/L 4.2-5.9 10/L Findings RBC-5.36x10/L WBC- Within NORMAL range HCT- Within NORMAL range 4.5-11.0 x10 9 /L WBC-5.9x109/L PLT- Within NORMAL range *** 40.7%-50.3% 36.1%-44.3% HCT-49.0% Interpretation and Analysis RBC- Within NORMAL range
150,000 -450,000 x 10-6/L
PLT-162x10-6/L
Data: Differential Count Reference/ Normal Findings Neutrophil Male Female Lymphocytes Male Female Monocytes Male Female Eosinophils Male Female Findings Neutrophil - 49 % 48-73 % Lymphocytes 39% Eosinophils - Within NORMAL range Basophils- Within NORMAL range 00-10 % Monocytes 09% Lymphocytes - Within NORMAL range Monocytes - Within NORMAL range 20-45 % Interpretation and Analysis Neutrophil - Within NORMAL range
Eosinophils 1% 00-05 % Basophils- 0%
Basophils Male 00-02 % Female
Page 21
NCM 103
1ST SEM
SY 2013-2014
3. Chest AP Chest X- Ray Anteroposterior View Date of Examination: August 1, 2013 Time of Examination: 4:40 PM Description: - a chest radiograph, commonly called a chest X-ray (CXR) or chest film, is a projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are among the most common films taken, being diagnostic of many conditions. Significance: Chest radiographs are used to diagnose many conditions involving the chest wall, including its bones, and also structures contained within the thoracic cavity including the lungs, heart, and great vessels. Pneumonia and congestive heart failure are very commonly diagnosed by chest radiograph. Reference/ Normal Findings: Results are considered normal if the organs and structures being examined are normal in appearance. Results: -Haziness is noted in the left paracardiac area. -Heart is enlarged. -Aorta isclerotic. -Diaphragm in normal in position and contour. -Included bones are intact. Impression: Cardiomegaly Atherosclerotic aorta 2. Blood Chemistry Data: Serum Electrolytes Date of Examination: August 1, 2013 Time of Examination: 03:15 PM Description: Electrolyte tests are performed from routine blood tests. Electrolyte tests are typically conducted on blood plasma or serum, urine, and diarrheal fluids. Significance: Serum electrolytes are taken in order to know whether the patient has electrolyte imbalance (excess or deficit in the plasma level of a specific ion). It is important to keep a balance of electrolytes in the body, because they affect the amount of water in our body, blood acidity (pH), muscle action, and other important processes. Reference/ Normal Findings Constituents Results 3.856.05 mmol/L 3.9-5.1 mmol/L Actual Results Constituents Results Interpretation and Analysis Glucose (Fasting)- Within NORMAL range Total Cholesterol ABNORMAL HIGH; Too much cholesterol in the blood, however, can cause deposits of cholesterol inside arteries. These plaques can narrow the artery enough to block blood flow. This process known as atherosclerosis commonly occurs in the coronary arteries which nourish the heart. For this case, an increase in the Total Cholesterol is just a proof supporting the atherosclerotic aorta. Blood Urea Nitrogen - Within NORMAL range Serum Creatinine - Within NORMAL range
Glucose (Fasting)
Glucose (Fasting)
4.56 mmol/L
Total Cholesterol
Total Cholesterol
8.3 mmol/L
Blood Urea Nitrogen
1.7-9.3 mmol/L
Blood Urea Nitrogen
4.9 mmol/L
Serum Creatinine
53-106 mmol/L
Serum Creatinine
55 mmol/L
Page 22
Data: Urine BSN3SECTION2-GROUP C NCM 103 1ST SEM SY 2013-2014 Date of Examination: August 1, 2013 Time of Examination: 4:09 PM Description: Urinalysis is a diagnostic physical, chemical, and microscopic examination of urine sample (specimen). Specimens can be obtained by normal emptying of the bladder (voiding) or by a hospital procedure called catheterization. Significance: It is a useful screening tool for diseases such as urinary tract infections, renal disease, and other disease of the body which result in the formation of compounds that can be detected in the urine at abnormal levels. Reference/ Normal Results Interpretation and Analysis Findings Physical Results Physical Results Physical Color Light Color Amber Color- Normal YellowTransparency- Normal Amber Transparency Slightly Appearance- Normal Transparency Slightly hazy hazy Appearance Clear Appearance Clear Chemical pH level Specific Gravity Protein Glucose Albumin Microscopic RBC WBC Epithelial cells Results 5-8 ph 1.010-1.030 Negative Negative Negative Results 0 0 0 Chemical pH level Specific gravity Protein Glucose Albumin Microscopic RBC WBC Epithelial cells Results 7.5 ph 1.010 Negative Negative Negative Results 0 0 0 Chemical pH level- Within normal range Specific Gravity- Within normal range; ***Kidneys are able to concentrate urine Protein- Normal Glucose- Normal Albumin- Normal finding, indicates normal glomerular permeability and adequate reabsorption function of the kidneys. Microscopic RBC- Normal WBC- Normal Epithelial Cells- Normal
Page 23
NCM 103
1ST SEM
SY 2013-2014
5. Cranial- CT Scan Date of Examination: August 1, 2013 Time of Examination: 4:30 PM Description: - is a medical imaging method employing tomography. Digital geometry processing is used to generate a three-dimensional image of the inside of an object from a large series of two dimensional x-ray images taken around a single axis of rotation. Significance: CT Scanning of the head is typically used to detect: Bleeding, brain injury and skin fractures, brain Tumors, blood clot or Bleeding, enlarged brain cavities, etc... Reference/ Normal Findings: Results are considered normal if the organs and structures being examined are normal in appearance. Results: -There is an ill defined curvilinear hypodensity noted on the posterior and anterior limb of the left external capsule. -Likewise a well marginated area of low density is seen on the right occipital lobe with adjacent dilatation of the right occipital horn. -The thalami, centrum semi-ovale, and pineal body are not usual. -The pons, medulla, cerebellum and CPA area are undisturbed. -The sella, parasellar regions, petromastoids and basophenorals are intact. -Cranial vault is intact. Impression: Acute vessel infarct, Left external capsule Gliosis, Right occipital lobe
Page 24
NCM 103
1ST SEM
SY 2013-2014
Page 25
NCM 103
1ST SEM
SY 2013-2014
TREATMENT AND MANAGEMENT: a. Drugs: NAME OF THE DRUG MANNITOL Brand Name: Osmitrol, Resectisol Classification: Osmotic Diuretic ACTION DOSAGE/ FREQUENC Y 100 cc every 4 hours INDICATION CONTRAINDICATI ON ADVERSE EFFECTS -Dehydration -Headache -Blurred vision -Nausea and vomiting -Volume expansion -Chest pain -Thirst -Tachycardia NURSING RESPONSIBILITIES Assessment: >Obtain patients medical history. >Assess patients condition >Monitor Vital Signs (BP, PR, RR) >Assess for allergic reactions like GI disturbances. Planning: >Direct IV administration should be very slowly to prevent episodes of hypotension. Health teaching: >Teach patient to gain benefits & not to miss any dose >Instruct patient to take only prescribed medicines.
Increases osmotic pressure of plasma in glomerular filtrate, inhibiting tubular reabsorption of water and electrolytes (including sodium and potassium). These actions enhance water flow from various tissues and ultimately decrease intracranial and intraocular pressures.
Indications 1. Increased intracranial pressure (IC P) 2. Intraocular pressure (IOP)
Active intracranial bleeding (except during craniotomy), anuria secondary to severe renal disease, progressive heart failure, pulmonary congestion, renal damage, or renal dysfunction after mannitol therapy begins, severe pulmonary congestion or pulmonary edema, and severe dehydration.
NAME OF THE DRUG
ACTION
DOSAGE/ FREQUENCY
INDICATION
CONTRAINDICATION
ADVERSE EFFECTS
NURSING RESPONSIBILITIES Page 26
NCM 103
1ST SEM
SY 2013-2014
Amlodipine Classification: Calciumchannel Blockers
These medications block the transport of calcium into the smooth muscle cells lining the coronary arteries and other arteries of the body.
5mg OD
Headache and Treat high blood pressure or chest pain. Sick sinus syndrome, 2ndor 3rd-degree heart block, hypertension less than 90 mm Hg systolic, hypersensitivity edema (swelling) of the lower extremities, dizziness, flushing, fatigue, nausea, and palpitations
>Assess cardiac status: B/P, pulse, respiration, ECG >Teach pt. do not break, open, crush, or chew sust rel caps
NAME OF THE DRUG Generic Name: Citicoline Classification: CNS stimulant/ neurotonic
ACTION Increase blood flow and oxygen consumption in the brain. It increases the neurotransmission levels because it favors the synthesis and production speed of dopamine in the striatum, acting then as a dopaminergic agonist thru the inhibition of tyrosinehydroxylase ACTION
DOSAGE/ FREQUENCY 1 gm IV every 12 hours
INDICATION Treatment of cerebrovascular accident in acute and recovery phase. It was indicated for the patient to accelerate the recovery of consciousness and helps the patient to overcome motor deficit.
CONTRAINDICATION Hypertonia of the parasympathetic nervous system
ADVERSE EFFECTS Headache, nausea, vomiting, diarrhea, shock, hypersensitivity, hypotension, insomnia,
NURSING RESPONSIBILITIES Assessment: >Obtain patients medical history. >Assess patients condition >Monitor Vital Signs (BP, PR, RR) >Assess for allergic reactions like GI disturbances. Health teaching: >Teach patient to gain benefits & not to miss any dose >Instruct patient to
NAME OF THE DRUG
DOSAGE/ FREQUENCY
INDICATION
CONTRAINDICATION
ADVERSE EFFECTS
NURSING RESPONSIBILITIES
Page 27
NCM 103
1ST SEM
SY 2013-2014
LOSARTAN Brand Name: Lozargard Classification: Angiotensin II blocker
Selectively blocks the binding Angiotensin II to receptor sites in many tissues, especially the vascular smoot h muscles and adrenal glands. This prevents the vasoconstriction and aldosterone secreting effects of angiotensin II on these tissues.
35 mg BID
Treatment for Hypertension. Reduction of Cardio-Vascular morbidity and mortality in hypertensive patients.
Hyperkalemia Hypertonia of the parasympathetic nervous system
Fever and Insomnia hypersensitivity, hypotension, insomnia, excitement
Assess cardiac status: B/P, pulse, respiration, ECG Teach pt. do not break, open, crush, or chew sust rel caps
Page 28
NCM 103
1ST SEM
SY 2013-2014 NURSING MANAGEMENT Monitor patient frequently or: a. Signs of infiltration /sluggish flow b.signs of phlebitis/infection c. well time of catheter and need tobe replaced d. Condition of catheter dressing. Check the level of the IVF. a.Correct solution, medication and volume. b.Check and regulate the drop rate. c.Change the IVF solution if needed.
NAME OF DRUG Brand name: Plain NSS Other name: 0.9% Sodium Chloride Solution Form: IV fluid Route: Dose:1000 ml @25 gtts/min Frequency: CLASSICFICATION: Isotonic Intravenous Solution
INDICATIONS
ACTION
CONTRAINDICATION -Heart failure -Pulmonary edema -Renal impairment -Sodium retention
SIDE EFFECTS -hypotension
ADVERSE EFFECTS -febrile response, -infection at the site of injection, -venous thrombosis or phlebitis extending from the site of injection, -extravasation, -and hypervolemia.
Used because it -Normal Saline is a sterile, has little to no nonpyrogenic effect on the solution for fluid tissues and and electrolyte Make the replenishment. person feel hydrated -It contains no preventing antimicrobial agents. hypovolemic shock or -The pH is 5.0 (4.5 hypotension to 7.0). -It contains 9 g/L Sodium Chloride with an osmolarity of 308 mOsmol/L. -It contains 154 mEq/L Sodium and Chloride.
Page 29
NCM 103
1ST SEM
SY 2013-2014
COMPREHENSIVE PATHOPHYSIOLOGY:
Precipitating Factors: Predisposing Factors: Age: 76 years old Sex: Male Family history of CVD DIET: Increase lipid and fatty foods intake Sedentary Lifestyle Obesity: BMI: 30.00 Wt: 75 kg Height: 58 ft/in HPN II
HPN II Dislodgement of Clot Thrombotic Infarction CVA Stroke
Motor Cortex Area
Brocas Area
Postereoinferior Artery
Right Sided Body Weakness
Slurred Speech
Decrease Gag Reflex
Impaired Physical Mobility Impaired Verbal Communication Risk for Impaired Skin Integrity
Impaired Verbal Communication
Dysphagia Risk for Aspiration
Page 30
NCM 103
1ST SEM
SY 2013-2014
XIV. NURSING CARE PLANS A. Prioritizations of Problems Rank 1 2 3 4 5
Nursing Problem Self care deficit : hygiene, dressing and grooming related to Neuromuscular impairment secondary to CVA Impaired verbal communication related to alteration of motor speech area of the brain as manifested by slurring of speech Impaired Physical Mobility related to Musculoskeletal as manifested by needs of fully assistance in ADLs Risk for Aspiration Related To Impaired Swallowing Risk for Impaired Skin Integrity related to Prolonged Bed rest Secondary to Impaired Mobility
B. Basis of Prioritizations Problem 1. Self care deficit : hygiene, dressing and grooming, related to Neuromuscular impairment secondary to CVA
Justification This is the first prioritized nursing diagnosis because the Orems self-care deficit theory explains not only when nursing is needed but 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 caring for himself or herself. - This is the second prioritized nursing diagnosis because the disorder impairs the expression and understanding of language. So as we nurses prioritize this problem to improve a person's ability to communicate by helping him or her to use remaining language abilities, restore language abilities as much as possible, compensate for language problems, and learn other methods of communicating. This is the third prioritized nursing diagnosis because according to Maslows hierarchy of needs, physiologic needs should satisfy first, so that the client should satisfy this to satisfy his physiologic needs. Maslows contended that until our basic physiologic needs were met, human beings arent really able to focus on meeting their higher order needs such as safety, love, esteem and self actualization. Physical mobility is necessary for the health and well-being of all persons ,but is especially important in older adults because a variety of factors impinge upon mobility with aging. Hogue(1964)identified mobility as the most important functional ability that determines the degree of independence and health care needs among older persons .CVA directly affecting mobility includes acute or chronic conditions that affect the muscular, skeletal or neurological systems and limit the persons ability to move and those conditions that require restricted mobility as therapeutic Page 31
2. Impaired verbal communication related to alteration of motor speech area of the brain as manifested by slurring of speech 3. Impaired Physical Mobility related to Musculoskeletal as manifested by needs fully assistance
NCM 103
1ST SEM
SY 2013-2014
regime. Impaired physical mobility a nursing diagnosis approved by the North American Nursing Diagnosis Association defined as the state in which an individual has a limitation in independent, purposeful physical movement of the body or of one or more extremities. Related factors arising from within the person include pain or fear of discomfort, anxiety or depression and physical limitations due to neuromuscular or musculoskeletal impairment. External factors include enforced rest for therapeutic purposes, as in the case of immobilization of a fractured limb. The human body is designed for motion; hence, any restriction of movement will take its toll on every major anatomic system. 4. Risk for Aspiration Related To Impaired Swallowing This nursing diagnosis will received 4th prioritization because this may ability to swallow. Slightly less saliva is produced. As a result, food is softened (macerated) less well and is drier before it is swallowed. The muscles in the jaws and throat may weaken slightly, making chewing and swallowing less efficient. Also, older people are more likely to have conditions that make chewing and swallowing difficult. For example, they are more likely to have loose teeth or to wear dentures. With aging, the contractions that move food through the esophagus become weaker. This change is very slight and usually has little effect on moving food to the stomach. But if older people try to eat while lying down or lie down just after eating, food may not easily move to the stomach. If reflux develops, the aging esophagus may be slower to move refluxed stomach acid back into the stomach. Some older people have a hiatus hernia, which may contribute to reflux. The nursing diagnosis received the 5th prioritization due to significant impact on aging to the skin and its ability to retain moisture. Changes in aging skin (eg, decreases in production of lipids, desquamation rate, and dermal proteins; changes in lipid composition; and prolonged epidermal turnover) decrease the skins ability to retain moisture.
5. Impaired Skin Integrity related to Prolonged Bed rest Secondary to Impaired Mobility
Page 32
NCM 103
1ST SEM
SY 2013-2014
ASSESSMENT Subjective: Simula nung mastroke siya di na niya magawa kahit mga simpleng pansariling gawain. As verbalized by the SO Objective: >Unkempt, soiled clothing >Foul smelling odor >with unsatisfying appearance >with minimal sweating uncombed hair
EXPLANATION OF THE PROBLEM Hypertension Occlusion within vessels of the brain parenchyma Disruption of blood supply in the brain area Tissue and cell necrosis Destruction of Neuromuscular junctions Interruption in transportation of electrical impulses to the neuromuscular receptors
PLANNING SHORT TERM OBJECTIVE: After 4 hours of nursing interventions, the patient will be able >to identify personal resource that can provide assistance; > to verbalize knowledge of health care practices. > demonstrate techniques/lifestyle changes to meet self care needs.
NURSING INTERVENTIONS INDEPENDENT: >Assessed for type and severity of immobility impairment, muscle flaccidity, spasticity and coordination, ability to walk, sit, move in bed perform >Assessed presence of factors that affects clients capacity for self care. > Provided privacy during dressing > Provided frequent assistance as needed with dressing > Provided loosed clothing
RATIONALE
EVALUATION LONG TERM OBJECTIVE:
>Provides data regarding mobility and ability to perform activities with in limitations without injury or frustration >Impairment in these areas can alter clients ability for self-care. >To promote privacy. >To reduce energy expenditure
Goal Met After 4 hours of nursing interventions, the patient was able >to identify personal resource that can provide assistance; > to verbalize knowledge of health care practices. > demonstrate techniques/lifestyle changes to meet self care needs.
LONG-TERM GOAL: After 3 days of nursing intervention, the patient was able to maintain neatness and cleanliness.
LONG-TERM GOAL: After 3 days of nursing intervention, goal was met as evidenced by the patient maintained neatness and cleanliness.
>To ensure easier dressing and comfort > To protect the patients skin integrity maintaining his first line of defense against sickness and infection. >Clothing that is difficult to get in and out of may compromise a patients ability to be
>Changed the diaper as soon as patient defecated.
> Assisted in removing and replacing necessary clothing
Page 33
NCM 103 continent
1ST SEM
SY 2013-2014
>Increased daily activity level as client progresses.
>Adequate exercise increases muscle tone; consistency in daily routine stimulates bowel elimination. >Appearance affects how the client sees self. A disheveled appearance conveys sense of low self worth, whereas an attractive, well put together appearance conveys a positive sense of self to the client as well as to others.
>Emphasized personal appearance, encouraged dressing in clean clothes.
NURSING DIAGNOSIS: Self care deficit : hygiene, dressing and grooming, related to Neuromuscular impairment secondary to CVA
Page 34
NCM 103
1ST SEM
SY 2013-2014
ASSESSMENT Subjective: hindi ko maintindihan ang sinasabi niya as verbalized by the SO. Objective: >Difficulty when speaking >Slurring of speech >Disorientation to place and time >Irritable > GCS= 10 >restlessness noted -GCS: E= 4 V=2 M=5
EXPLANATION OF THE PROBLEM A CVD, which may be caused by, hemorrhage, thrombus, embolism or vasospasm, can result in a local area of cell death, called infarct. It is caused by a lack of blood supply which is then surrounded by an area of cells that are secondarily affected. Since symptoms depend on the location of the stroke and size of the infarct, it could involve the brains Broccas area, which is primary responsible for communicatio n through facial expressions and speech. By causing damage to this area, the patients communicatin g skills are greatly altered and affected.
PLANNING SHORT-TERM GOAL: >After 1 hour of effective nursing intervention the patient will relate findings of decreased frustration with communication.
NURSING INTERVENTIONS INDEPENDENT: 1 Dx: >Assessed level of impairment.
RATIONALE
EVALUATION SHORT-TERM GOAL:
>To determine absence or presence of impairment. >To evaluate the degree of impairment. >To assess client to establish of means of communication to express needs, ideas and questions.
LONG-TERM GOAL: After 3 days of nursing interventions, the client will establish method of communication in which needs can be expressed.
>Noted speech patterns and manner of communicating including gestures. >Validated client message by repeating aloud. >Facilitated hearing and vision examinations when needed. >Assisted client S/O (s) to learn therapeutic communication skills of acknowledgement . >Provided environmental stimuli as needed.
>After nursing intervention the patient was able to establish method of communicatio n in which needs can be expressed.
>To improve communication . >Improves general communication .
>To maintain contact with reality/ lessen anxiety that may worsen problem. >Individuals with expressive aphasia may talk more easily when they are rested, relaxed to one person at a time. >To clarify discrepancies between verbal
LONG-TERM GOAL: Goal met after 3 days of nursing interventions, the client has established method of communicatio n in which needs can be expressed as evidenced by : >Salamat as verbalized by the client. >Established eye contact while communicatin g with others >Used paper and pen to express needs
>Maintained a calm unhurried manner, provide sufficient time for client to respond.
>Used confrontation skills, CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II
Page 35
BSN3- SECTION2-GROUP C when appropriate, within an established nurseclient relationship. >Involves family/ so in plan of care as possible.Tx: 10. Encouraged the patient and S.O.s to avoid sedentary lifestyle such as drinking liquor, smoking, improper exercise and too much fatty foods.
NCM 103
1ST SEM
SY 2013-2014
and non-verbal cues. >Enhances participation and commitment to plan.
COLLABORATIVE: 1. Administer medications as ordered: - Citicoline 2 drops BID / 1gm IV q8 NURSING DIAGNOSIS: Impaired verbal communicatio n related to alteration of motor speech area of the brain as manifested by slurring of speech
Page 36
BSN3- SECTION2-GROUP C ASSESSMENT Subjective: Hindi daw siya gaanong makagalaw sa kanang bahagi ng katawan as verbalized by the SO. Objective: -Weak in appearance - in muscle strength: Arms: L= 5/5 R= 0/5 Legs: L= 5/5 R= 0/5 -GCS: E= 4 V= 2 M=5 -Unable to carry out activities without assistance such as changing clothes. -Limited ROM on the right hand and foot(only able to carry out passive ROM on this area) -Impaired ability to turn side to side; needs fully assistance -Level 3 physical mobility Deposition of fatty materials on vessel walls Plaque formation Narrowing of atherosclerosis plaque Deprivation of blood supply in the brain Cerebral defects in the motor area Impairment of gross and motor function of the brain Impaired physical mobility EXPLANATION OF THE PROBLEM PLANNING SHORT TERM OBJECTIVE: After 5 hours of nursing intervention, the patient will be able to: a) Participate in performing ADLs with minimal assistance from others b) Do active and passive ROM exercise on the right side of his body within physical limitations after hours of sleep. SO will be able to: a) Verbalize understanding of the situation /risk factors, individual therapeutic regimen and safety measures. b) Demonstrate techniques/ behaviors that will enable safe repositioning LONG-TERM OBJECTIVE: After 3 days of nursing intervention, the patient will be able to: a) Manifest an improved participation in performing ADLs with or without support. b) Maintain NURSING INTERVENTIONS INDEPENDENT: Dx: 1. Established rapport to the patient and SO.
NCM 103
1ST SEM
SY 2013-2014 EVALUATION
RATIONALE
-To gain the pts & S.O.s trust & cooperation during the nsg care & procedures. -To identify contributing factors that enable the nurse to focus on appropriate interventions -To assess functional ability
2. Assessed and determine factors that contribute to physical immobility
3. Determined degree of immobility & muscle strength Tx: 4. Assisted patient in comfortable position 5. Provided support on affected body parts such as pillow 6. Provided safety precautions by raising up the side rails. 7. Provided environment free from noise and disturbances
LONG TERM OBJECTIVE: After 5 hours of nursing intervention, goal was met as evidenced by: a) Patient participated in performing ADLs with minimal assistance b) Patient having an active and passive ROM exercise within physical limitations after hours of sleep SO was able to: a) Verbalized understanding of the situation /risk factors, individual therapeutic regimen and safety measures. b) Demonstrated techniques/ behaviors that will enable safe repositioning LONG-TERM OBJECTIVE: After 3 days of nursing intervention, goal was met as evidenced by: a) Patient has an improved participation in performing Page 37
-To promote optimal level of functioning -To maintain position of function and reduce discomfort -To prevent injury and fall
-To have a good atmosphere conducive to the recovery of the patient -To reduce risk of tissue ischemia or injury and to prevent pressure sores
8. Changed position every 2 hours and possibly more often if placed on the affected part
BSN3- SECTION2-GROUP C functional abilities of the right side of the body. c) Manifest an increase in muscle strength of both arms and legs of the patient. d) Improved physical mobility from level 3 to level 2 and improved GCS 9. Massaged pressure points after each position change 10. Assisted in performing ADL 11. Assisted in performing ROM exercise after hours of sleep & within physical limitations. Edx: 12. Encouraged the pt and S.O.s to avoid a sedentary lifestyle such as drinking liquor, smoking, improper exercise and too much fatty foods.
NCM 103
1ST SEM
SY 2013-2014
-To promote circulation and oxygen distribution -To promote optimal level of functioning -To minimize muscle atrophy and promote circulation
-These factors may affect them in developing various diseases as what like the patient is suffering now. -It restores the activity and functions of the brain. It improves neuromuscular function.
ADLs with or without support. b) Patient has an improved functional abilities of the right side of the body c) The patient has an increased muscle strength with a scale of: Arms L=5/5 R=2/5 Legs L=5/5 R=2/5 d) The patient is having level 3 physical mobility and a GCS scale of E=4, V=4, M=5.
NURSING DIAGNOSIS: Impaired Physical Mobility related to Musculoskeletal as manifested by needs full assistance in AD
Page 38
BSN3- SECTION2-GROUP C POTENTIAL NURSING CARE PLAN ASSESSMENT Subjective: Hindi siya makakain sa pagnguya, naka NGT siya at doon nila pinapasok ang pagkain niya Objective: -decrease ability to swallow EXPLANATION OF THE PROBLEM >(the misdirection of oropharyngeal secretions or gastric contents into the larynx and lower respiratory tract) is common in older adults with dysphagia and can lead to aspiration pneumonia. The older adult with one of these conditions is at even greater risk for aspiration because the dysphagia is superimposed on the slowed swallowing rate associated with normal aging. >When there is a blockage of vertebrobasilar artery there will be Cranial nerves affectations. CN V, VII, IX, XII blockage may result to dysphagia or difficulty of swallowing which thereby having high risk for aspiration. PLANNING SHORT TERM OBJECTIVE: After 6 hours of nursing intervention, the patient will be able to demonstrate measures to prevent aspiration.
NCM 103
1ST SEM
SY 2013-2014
NURSING INTERVENTIONS DX: >Assessed level of consciousness of surroundings, and cognitive impairment
RATIONALE > To assess if there is gag reflex or difficulty of swallowing. > Impaired swallowing may cause aspiration. >To aid breathing and promotes lung expansion. > To reduce secretions present in the mouth >Reduces the risk of aspiration by allowing secretions to drain. >To prevent blockage on the passage of food. >To impart health teaching >To impart health teaching > To promote commitment to plan, maximizing outcomes.
EVALUATION LONG TERM OBJECTIVE: After 6 hours of nursing intervention, goal was met as evidenced by he was able to demonstrate measures to prevent aspiration.
> Assessed swallowing reflex or gag reflex
>Auscultated lung sounds to determine presence of secretions
TX: >Suctioned mouth secretions as needed
>Elevated to SemiFowlers position when feeding via NGT
LONG-TERM GOAL: After 3 days of nursing intervention, the patient will be free from risks for aspiration.
>Placed on lateral position or changed the position. EDX: > Educated SO about the importance of oral suctioning. >Informed SO about the significance of precautionary measures to prevent aspiration >Involved client S/O in determining activity schedule
LONG-TERM GOAL: After 3 days of nursing intervention, goal was met as evidenced by: patient is free from risks for aspiration.
NURSING DIAGNOSIS: Risk for Aspiration Related To Impaired Swallowing
Page 39
NCM 103
1ST SEM
SY 2013-2014
ASSESSMENT Subjective: Namumula yung sa may pwetan niya. Siguro dahil sa matagal niyang pagkakahiga as verbalized by the SO Objective: -intact skin with presence of reddish few unruptured blisters in bony prominent area -Reddened skin surface in the buttocks -blisters is 3mm in diameter -Prolonged bed rest
EXPLANATION OF THE PROBLEM Pressure on soft tissues between bony prominences Compresses capillaries & occludes blood flow Pressure not relieved Microthrombi formation + occlusion in capillaries & blood flow Formation of blister Rupture of blister + open wound >Immobility, which leads to pressure, shear, and friction, is the factor most likely to put an individual at risk for altered skin integrity. Advanced age; the normal loss of elasticity; inadequate nutrition; environmental moisture, especially from incontinence; and vascular insufficiency potentiate the effects of pressure and hasten the development of skin breakdown. Groups of persons with the highest
PLANNING SHORT TERM OBJECTIVE: After 8 hours of nursing intervention, the patient will be able to: a) Reduce risk of further impairment of skin integrity b) SO will demonstrate understanding & skill in care of the wound
NURSING INTERVENTIONS INDEPENDENT Dx: 1. Assessed skin, skin color, turgor and sensation. Described and measured blister and observed changes 2. Assessed between folds of skin, remove anti embolic stockings or devices & use a mirror to see the heels. Also assess under oxygen tubing especially on the ears & the cheek, beneath splints and under medical devices. 3. Noted objective data of blisters
RATIONALE
EVALUATION LONG TERM OBJECTIVE: After 8 hours of nursing intervention, goal was met as evidenced by: a) Have reduced risk of further impairment of skin integrity b) SO demonstrates understanding & skill in care of the wound
-Establishes comparative baseline provides opportunity for timely intervention -Pressure ulcers under medical devices are commonly overlooked.
LONG-TERM GOAL: After 3 days of nursing intervention, the patient will be able to: Experience healing of blisters/regai n skin integrity Absence of Reddened skin in the bony prominences . Reduce risk for infection
-Reassessment of blisters, sooner if ulcer shows manifestations of deterioration. Analyses of the trends in healing are important step in assessment. -To disperse pressure over time or decreasing the tissue load -Heel covers do not relieve pressure, but they can reduce friction. -To prevent further occurrence of pressure ulcer.
LONG-TERM GOAL: After 3 days of nursing intervention, goal was met as evidenced by: Has experienced healing of blisters/regai n skin integrity Free from reddened skin in the bony prominences . Has reduced risk for infection
Tx: 4. Repositioned every 2 hours.
5. Elevated heels off the bed by using pillows or heel elevation botts. 6. Maintain head of bed @ the lowest elevation, , reposition to 30
Page 40
BSN3- SECTION2-GROUP C risk for altered skin integrity are the spinal cord injured, those who are confined to bed or wheelchair for prolonged periods of time, those with edema, and those who have altered sensation that triggers the normal protective weight shifting. Pressure relief and pressure reduction devices for the prevention of skin breakdown include a wide range of surfaces, specialty beds and mattresses ,and other devices. degree lateral position. Used seat cushions & assess sacral ulcers daily. Edx: 7. Instructed SO to maintain clean, dry clothes, preferably cotton fabric (any T-shirt).
NCM 103
1ST SEM
SY 2013-2014
-Skin friction caused by stiff or rough clothes leads to irritation of fragile skin and increases risk for infection. -Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to fragile skin. -Improved nutrition and hydration will improve skin condition. -Providing the family with an alternative solution assists them in optimal healing with less expensive resources.
8. Demonstrated good skin hygiene, e.g., wash thoroughly and pat dry carefully.
9. Emphasized importance of adequate nutrition and fluid intake. NURSING DIAGNOSIS: Risk for Impaired Skin Integrity related to Prolonged Bed rest Secondary to Impaired Mobility 10. Demonstrated to the SO on how to make a guava decoction to apply to the wound as alternative disinfectant.
Page 41
NCM 103
1ST SEM
SY 2013-2014
XIV. DISCHARGE PLANS Criteria A. Diet Health Teachings Patient was instructed to maintain the low salt and low fat diet. The low salt diet is designed to induce a loss of sodium and water from the body or avoid sodium retention. A 2000 mg low sodium diet is sufficient to control blood pressure. A low fat diet help lose weight to decrease risk of having CVA again. The patient is encouraged to lessen cholesterol and fatty food intake such as egg, bulalo and fried food, minimize salt intake 2 grams per day, increase serving of fruits and vegetables such as cabbage, carrots, banana, apple, orange, malunggay etc. and increase serving of carbohydrates to 2 serving of rice. B. Activities Patient is instructed that he should do active and passive range of motion exercise at the unaffected area. Do simple exercises such as moving forward and backward of hands with intervals alternately, stretching, breast walking in the morning at home for 20-30 mins and deep breathing to prevent recurrence of the disease. C. Medications Encouraged the patient and significant others to follow the medication that was prescribed in order to help maintain its good health condition. The following are prescribed by the doctor for home medications. And should take her medicine at the right time, right dose and right frequency. Insist physical therapy for improving strength and walking. Occupational therapy for regaining dexterity of the arms and hands. Should undergo speech therapy to learn talking and swallowing. Oxygen inhalation if necessary and if possible 3-4 liters per minute. D. Spirituality Allowed the patient and the family to pray if possible all the time to God and encourage them to have faith in God to provide optimistic approach toward his condition. E. Others The patient with her SO was advised to have a follow-up check-up, as indicated by the physician after discharge to the OPD at the nearest hospital. Instructed to call and seek physician help if BP does not lower within normal level with continuance of drug intake and report any chest pain immediately. Encourage to turn side every 2 hours with assistance of significant others as needed, relaxation technique and avoid being fatigue by adequate resting CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II Page 42
NCM 103
1ST SEM
SY 2013-2014
between work and instructed to avoid getting quickly upon arising on bed and sit on bed first before standing.
CONCLUSIONS AND RECOMMENDATIONS: A. Conclusions: In summary content and analysis of the study, the researchers were able to drive the following conclusions. The patients sedentary lifestyle greatly affects and aggravates the conditions itself. With the diet of high in fats and salty foods, this can cause hypertension and lipid deposition in the major vessel of the brain. On the latter part of this fat and lipid deposition is atherosclerosis. With the lifestyle of alcohol drinking and cigarette smoking, the patients susceptibility to this condition is increased. Alcohol and nicotine found in cigarettes are potent vasoconstrictor. As part of the nursing duties and responsibilities, health teachings like diet and lifestyle modification must be rendered to promote health. Certain restrictions should be emphasized and the threats of these if not followed. Furthermore the group imparted the important information as health teachings that would be useful to patients understanding of care regimen and n ature of her health condition and enhanced skills & knowledge as health care provider in the clinical setting. The group also had enhanced their primary nursing skills in this rotation. Teamwork was established and camaraderie developed between peers. Also through working together with this CP the group built friendship that made our work easier and smoother. Moreover, the significant other and the patient had acquired priceless information about the patients disease condition which is a plus factor in changing her negative lifestyle that could lead to a healthier living. Lastly, the group has developed a better working relationship with one another, especially through this challenges and demanding strength of our student life. Over-all the case study was enjoying and satisfying. B. Recommendations As this study proceeds, few lessons were learned and things discovered. One of the basic is education and awareness. This is believed to be the primary of all, for it all started from self. For this, we strongly suggest to strengthen and intensively increase the provision of basic health education as well as imparting it to the different sectors starting from the most basic unit of the community. This knowledge campaign would surely help the eradication of unawareness and promotion of health motives.
Page 43
NCM 103
1ST SEM
SY 2013-2014
LIST OF REFERENCES: o Smeltzer, Medical-Surgical Nursing, 11th Edition, U.S.A.: Lippincott Wilkins and Williams, pages 1670-1672, 1882-1184 o Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005 o o Einbach, Medical-Surgical Nursing, 2009; U.S.A.: Price Publshing, pages 500-501 Smeltzer, Bare, Hinkle, and Cheever; Brunner and Suddarths TEXTBOOK OF MEDICAL-SURGICAL NURSING; 11th ed. 2008 Wolters Kluwer and Lippincott Williams and Wilkins; PATHOPHYSIOLOGY MADE INCREADIBLY VISUAL; 2008 Marieb, E. et al: ESSENTIALS OF ANATOMY AND PHYSIOLOGY, 6th edition, Addison-Wesley Publishing Company Inc., America; 2005 Deluane and Landner et al: FUNDAMENTALS OF NURSING: Standards and Practice, 3rd edition, Delmar learning, a division of Thomson Learning; 2006 Giddens and Langford et al: MOSBYS NURSING PDQ, Elsevier PTE LTD Health Science Asia, 2004 Doenges, M. et al: NURSING CARE PLAN, 6th edition, F.A Davis Company, Philadelphia; 2005 Gulanink and Myers et al NURSING CARE PLANS: Diagnosis and Interventions, 6th edition, 3 Killiney Road #08-01 Winsland House Singapore 239519, 2007 Doenges, Moorhouse, Murr, et al: NURSES POCKET GUIDE: Diagnoses, Prioritized interventions, and rationales, 11th edition, F.A. Davis Company Philadelphia, Pennsylvania, 2008 Smith T. et al: THE HUMAN BODY: An Illustrated Guide to its Structure, Function and Disorders, Dorling Kindersley Limited, London. 2000 Mosby E. et al: Pocket Dictionary of Medicine, Nursing and Health Professions, 5th ed, 3 Killiney Road #08-01 Winsland House I Singapore 239519, 2006 Lippincott, William and Wilkins, et al: NURSING DRUG HANDBOOK, 23rd edition, Wolters Kluwer Company, Philadelphia; 2005 Spratto and Woods et al: NURSES DRUG HANDBOOK: The information standard for prescription drugs and nursing considerations, 2008 edition, Delmar learning, a division of Thomson Learning, 2008 Clayton, Stock and Harroun, et al: BASIC PHARMACOLOGY FOR NURSES, 14th edition, Mosby an imprint of Elsevier Inc. 2007
o o o
o o
Page 44
NCM 103
1ST SEM
SY 2013-2014
Page 45
Page 46
Page 47
Page 48

Bsn3-2c UC-BCF CVA Case Study

Enviado por

Dados do documento

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

Bsn3-2c UC-BCF CVA Case Study

Enviado por

Direitos autorais:

Formatos disponíveis

BSN3- SECTION2-GROUP C

CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II

BSN3- SECTION2-GROUP C TABLE OF CONTENTS

CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II

BSN3- SECTION2-GROUP C I. INTRODUCTION

CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II

BSN3- SECTION2-GROUP C II. STATEMENT OF OBJECTIVES A. General Objectives

CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II

CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II

BSN3- SECTION2-GROUP C VII. SOCIAL AND ENVIRONMENT HISTORY

AREAS ASSESSED 1. INTEGUMENTARY A. SKIN 1. Skin color

CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II

Uniform; within normal range

Convex curvature; angle of nail plate about 160

2. Fingernail and toenail bed color

3. Fingernail and toenail texture

Intact epidermis Delayed 4 seconds

Thin hairs not evenly distributed Black with white hairs

CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II

Evenly distributed and turned outward

White in color, clear, no yellowish discoloration; some capillaries maybe visible

No irregularities on the surface; looks smooth; clear or transarent

1. Color, shape, and symmetry of size

CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II

2. Light reaction and accommodation

3. Ability to blink I. VISUAL ACUITY 1. Near vision

No edema or tenderness over lacrimal gland

Both eyes coordinated, move in unison, with parallel alignment

Normal voice tones audible

2. Watch tick test result

3. Weber's test result

CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II

4. Rinne test result 5. NOSE

Air-conducted (AC) hearing is greater than boneconducted (BC) hearing

Symmetric and straight; no discharge or flaring; Uniform color

2. Presence of redness, swelling, growths and discharge in the nasal cavities

Mucosa pink; clear, watery discharge; no lesions

3. Nasal septum (between the nasal chambers)

Nasal septum intact and in midline

4. Patency of both nasal cavities

Air moves freely as the client breathes through the nares

Not tender; no lesions

Symmetry of contour color and texture

CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II

BSN3- SECTION2-GROUP C D. GUMS Color and condition

Pink gums; no retraction

2. Position, color and texture, movement and base of the tongue

3. Any nodules, lumps, or excoriated areas

Smooth with no palbable nodules, lumps, or excoriated areas

Positioned in midline of soft palate

Pink and smooth posterior wall

2. Size, color, and discharge of the tonsils

Pink and smooth; no discharge; of normal size

Muscles equal in size, coordinated head movement without discomfort

CVA, THROMBOTIC INFARCT, INFARCT L MID CEREBELAR ARTERY, HPN-II

Identification of Lymph nodes and for tenderness B. TRACHEA

Placement of the Trachea

Central placement in midline of neck; spaces are equal on both sides

1. Symmetry and visible masses

Not visible on inspection

Lobes may not be palpated

Anteroposterior to transverse diameter in ratio 1:2; Chest symmetric

Spine vertically aligned

3. Temperature, tenderness, and masses