HOLY ANGEL UNIVERSITY

ANGELES CITY
COLLEGE OF NURSING

TRANSIENT ISCHEMIC ATTACK

A CASE STUDY

March 5, 2009

1
 I. INTRODUCTION
1. Description of the disease
When an area of the brain loses its blood supply it stops working, the part of the
body it controls also stops working. This is what happens with a Transient Ischemic
Attack, better known as TIA.
When the brain loses blood supply, it tries to restore blood flow. If blood supply is
restored, function may return to the affected brain cells, permitting return of function to
the affected body part.
Transient ischemic attack is also known as a mini-stroke, a hemorrhagic stroke, or
an ischemic stroke. Some people call a TIA a mini-stroke, because the symptoms are like
those of a stroke but do not last long. Generally, a TIA happens when platelets in the
blood clump together in your arteries (a blood clot) making blood flow to a part of the
brain be blocked or reduced. After a short time, blood flows again and the symptoms go
away. Symptoms usually last only 10 - 15 minutes and clear up within 24 hours. With a
stroke, the blood flow stays blocked, and the brain has permanent damage. TIAs
sometimes happen before strokes, and they are considered a warning sign of stroke.
It is estimated that more than 300,000 TIAs occur each year in the United States.
The highest incidence for a second stroke is within the first seven days after a TIA. The
prevalence for cerebral infarct after TIA is 11% at the ages of 55 to 64, 22% between the
ages of 65 to 69, 28% at the ages of 70 to 74 years, 32% between 75 to 79 years and 40%
at ages 80 to 85 years. TIA’s are the precursor in 15% of all strokes and if unrecognized,
can represent the greatest morbidity and mortality for stroke patients in the first thirty-
ninety days after their first TIA.
Fifty-percent of patients who experience a TIA fail to notify their healthcare
provider. Approximately one-third of TIA’s would reveal as a true ischemic event by
diffusion-weighted magnetic resonance imaging. Within the first year of having their
first TIA, 25% of patients will die. It has been estimated that only 9% of the general
population is familiar with typical TIA symptoms, and as few as 22% of primary health
care workers even know the definition of a TIA. This education gap poses a great
challenge for health workers when eliciting a history from patients and families.

2
 While TIA itself has short term effects, the significance is that this can herald a
major stroke, which is why it requires timely and aggressive treatment to prevent death
and disability.
It has been shown that stroke and TIA patients alike decrease their secondary
stroke risk considerably by learning about their own cardiovascular health maintenance,
risk assessment and lifestyle behaviors.
TIA is a common marker of cerebrovascular disease which, when correctly
diagnosed and managed, can lead to the prevention of significant morbidity and mortality.
2. Nurse-Centered Objectives
Upon the completion of this case study, the student-nurses shall have:
 Described and explained what transient ischemic attack is.
 Reviewed the anatomy and physiology of the organs involved.
 Identified the risk factors contributing to the occurrence of the disease.
 Expounded on the laboratory and diagnostic procedures done with the
patient, their purposes, and specific nursing responsibilities before, during
and after the procedure.
 Enumerated the different medications administered for the disease their
indications, contraindications, side effects, and specific nursing
responsibilities.
 Formulated significant nursing diagnoses, with their significantly related
nursing care plans.

3
II. NURSING HISTORY
1. Personal History
a. Demographic Data
Mrs. Attack was born in Quezon City on February 17, 1980. She is 29 years old,
a Filipino citizen, married and has one child. She lives with her family, residing at
Pandan, Angeles City. She was admitted in a private hospital on February 22, 2009 at
12:05 in the morning with a chief complaint of syncope. She was discharged four days
after the admission.
b. Socio-Economic and Cultural Factors
Mrs. Attack finished her college degree at Republic Central Colleges with the
course Education. She has her job as a cashier in a casino. She and her family were
baptized as Roman Catholics. They regularly attend Sunday masses and novenas
together. With minor illnesses such as fever, cough and colds, self medication is applied.
Although they seek the advice of their physician, they also believe in the albularyo and
the manhihilot.
2. Family Health-Illness History
Mrs. Attack’s father had a cerebrovascular accident in the year 2000 and was then
bedridden for almost nine years. Also, one of her first degree relatives, her aunt (her
mother’s sister), had her cerebrovascular accident in the year 2001 and is suffering from
hypertension. Other than these incidents, there were no other reported illnesses within
her family and relatives.
3. History of Past Illness
Mrs. Attack was confined in the same hospital two years ago (year 2007) with a
diagnosis of Gastroenteritis and was healed and discharged after few days of
confinement. Other than that, there were no known related ailments and past illnesses
with the present one.
4. History of Present Illness
a. Chief Complaint: Syncope
b. Sequence of the appearance of signs and symptoms up to the time patient
was admitted.

4
 Before going to bed at almost before midnight, Mrs. Attack experienced sudden
chest pain and left-sided weakness followed by loss of consciousness. She was brought
to the hospital already awake and was admitted minutes after midnight.

5
III. PHYSICAL ASSESSMENT
1. Assessment done upon admission: February 22, 2009 (copied from chart)
EENT: anicteric sclerae, pink palpebral conjunctiva
Lungs: Clear BS, no rales
Heart: NRRR, no murmur, soft full equal pulses
Abdomen: flabby, NABS,
2. Cephalocaudal assessment: February 26, 2009

Head
 With long hair, black and equally distributed
 Without palpable lumps
 With ucombed hair

Skin
 Dry and warm to touch
 With fair skin complexion
 With good skin turgor

Eyes
 With dark brown iris
 With white sclera
 Pupils equally round and reactive to light accommodation (PERRLA)
 With pink palpebral conjunctiva

Ears
 Pinna recoils after folding
 Absence of discharge
 Without any obstructions
 With ear piercing

6
Nose and Sinuses
 With thick nasal hair
 Absence of scar
 Absence of discharge
 Positioned at the center/midline

Mouth and Throat

 With pinkish lips
 With complete number of teeth
 With pink gums
 Without halitosis

Neck
 Absence of palpable masses
 Absence of swelling
 Without stiffness present
 Without swollen lymph nodes

Breast
Symmetrical in shape

Abdomen
With presence of horizontal scar on the hypogastric region (from past caesarian
section incision)
With presence of striae
Flabby

Upper and Lower Extremities

 With long and polished toenails and fingernails
 With numbness and inability to move the left lower extremity

7
CRANIAL NERVES:
OLFACTORY: able to smell alcohol in cotton.
OPTIC: able to read the newspaper at a readable distance.
OCULOMOTOR: pupil equally round and reactive to light and
accommodation.
TROCHLEAR: able to follow the up and down movement of the pen.
TRIGEMINAL: able to open mouth against resistance.
ABDUCENS: able to follow the left and right movement of the pen.
FACIAL: able to taste; no difficulty in swallowing.
AUDITORY: able to repeat whispered words
GLOSSOPHARYNGEAL: able to move the tongue in all directions.
VAGUS: able to say “aaahh”; with gag reflex.
ACCESSORY: able to elevate the shoulders against resistance.
HYPOGLOSSAL: able to protrude tongue.

8
IV. DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic/ Indications or Date Results Normal Analysis and

Laboratory Purposes Ordered Values Interpretation
Procedure Date (Units of Results
Results used in
were the
released hospital)
Potassium To determine February 3.3 3.6-5.0 Decreased
the amount of 22, 2009 mmo/L levels of
Potassium potassium
present in the indicate
blood. hypokalemia.
Potassium is
an important
electrolyte that
helps regulate
the flow of
fluids in and
out of the cells
Creatinine The creatinine February 0.64 0.5-1.69 Normal
blood test is 22, 2009 mg/dl
usually
ordered along
with a BUN
(blood urea
nitrogen) test
to assess
kidney
function
Sodium The amount of February 141 137-145 Normal
Sodium 22, 2009 mmo/L -low level of
present in the blood sodium
blood. means you have
Sodium is an hyponatremia,
important which is usually
electrolyte that due to too much
helps regulate sodium loss,
the flow of too much water
fluids in and intake or
out of the retention, or to
cells. fluid
accumulation in
the body
(edema).
-high blood

9
 sodium level
means you have
hypernatremia,
almost always
due to
excessive loss
of water
(dehydration)
without enough
water intake.
Glucose: FBS Glucose, February 83.8 76-111 Normal
formed by 22, 2009 mg/ dl
digestion of
carbohydrates
and the
conversion of
glycogen by
the liver, is the
primary source
of energy for
most cells.
BUN The BUN test February 7.0 7-21 mg/dl Normal
is primarily 22, 2009 -Increased
used, along BUN levels
with the suggest
creatinine test, impaired
to evaluate kidney
kidney function. This
function under may be due to
a wide range acute or chronic
of kidney disease,
circumstances damage, or
and to monitor failure.
patients with -Low BUN
acute or levels are not
chronic kidney common and
dysfunction or are not usually
failure a cause for
concern. They
may be seen in
severe liver
disease,
malnutrition,
and sometimes
when a patient
is overhydrated

10
 (too much fluid
volume), but
the BUN test is
not usually used
to diagnose or
monitor these
conditions.
Uric Acid The uric acid February 5.07 2.5-7 Normal
test is used to 22, 2009 mg/dl - Higher than
learn whether normal uric
the body might acid levels
be breaking mean that the
down cells too body is not
quickly or not handling the
getting rid of breakdown of
uric acid purines well.
quickly The doctor will
enough. The have to learn
test also is whether the
used to cause is the
monitor levels over-production
of uric acid of uric acid, or
when a patient if the body is
has had unable to clear
chemotherapy away the uric
or radiation acid.
treatments. - Low levels of
uric acid in the
blood are seen
much less
commonly than
high levels and
are seldom
considered
cause for
concern.
Although low
values can be
associated with
some kinds of
liver or kidney
diseases,
exposure to
toxic
compounds,
and rarely as

11
 the result of an
inherited
metabolic
defect, these
conditions are
typically
identified by
other tests and
symptoms and
not by an
isolated low
uric acid result.

Cholesterol To determine February 187.9 up to 200 Normal

your 22, 2009 mg/dl
nutritional
status or to
screen for
certain liver
and kidney
disorders as
well as other
diseases
Triglycerides Blood tests for February 115.0 35-135 A normal level
triglycerides 22, 2009 mg/dl for fasting
are usually triglycerides is
part of a lipid less than 150
profile used to mg/dL (1.70
identify the mmol/L). It is
risk of unusual to have
developing high
heart disease. triglycerides
As part of a without also
lipid profile, it having high
may be used to cholesterol.
monitor those Most treatments
who have risk for heart
factors for disease risk will
heart disease, be aimed at
those who lowering LDL
have had a cholesterol.
heart attack, or However, the
those who are type of
being treated treatment used
for high lipid to lower LDL
and/or cholesterol may

12
 triglyceride differ
levels. depending on
whether
triglycerides are
high or normal.
SGOT/AST used to detect February 13 5-35 u/L Normal
liver damage. 22, 2009 Very high levels
of AST (more
than 10 times
the highest
normal level)
are usually due
to acute
hepatitis, often
due to a virus
infection.
SGPT/ ALT To detects February 9 7-56 u/L Normal
liver injury. 22, 2009 Very high levels
of ALT (more
than 10 times
the highest
normal level)
are usually due
to acute
hepatitis, often
due to a virus
infection. In
acute hepatitis,
ALT levels
usually stay
high for about
1–2 months, but
can take as long
as 3–6 months
to come back to
normal.
Potassium To determine February 3.7 3.6-5.0 Normal
the amount of 23, 2009 mmo/L -Increased
Potassium potassium
present in the levels indicate
blood. hyperkalemia.
Potassium is Decreased
an important levels of
electrolyte that potassium
helps regulate indicate
the flow of hypokalemia

13
 fluids in and -Decreased
out of the cells levels of
potassium
indicate
hypokalemia.

Diagnostic/ Indications Date Results Normal Analysis and

Laboratory or Purposes Ordered Values interpretation
Procedure Date (units used
Results in the
were hospital)
released

HCT Hematocrit February 36.9 37-47 Decreased

test measures 22, 2009 hematocrit
the amount of indicates
space anemia, such
(volume) as that caused
RBC take up by iron
in the blood. deficiency or
other
deficiencies
pH Blood gas February 343 140-440 Normal
measurements 22, 2009
are used to -Abnormal
evaluate your results of any
oxygenation of the blood
and acid/base gas
status. components
may mean that
your body is
not getting
enough
oxygen, is not

14
 getting rid of
enough carbon
dioxide, or
that there is a
problem with
kidney
function. If
left untreated,
these
conditions
create an
imbalance that
could
eventually be
life
threatening.
WBC Determines February 7.6 4.3-10.0 Normal
the number of 22, 2009
circulating -An elevated
WBCs per number of
cubic ml of white blood
whole blood. cells is called
It is an leukocytosis.
indicator of This can result
immune from bacterial
function and infections,
helps to inflammation,
determine leukemia,
infection or trauma,
inflammation intense
exercise, or

15
 stress.

A decreased
WBC count is
called
leukopenia. It
can result
from many
different
situations,
such as
chemotherapy,
radiation
therapy, or
diseases of the
immune
system.

Granulocytes Determines February 62 44.2-80.2 The result is

the level of 22, 2009 wihtion
granulocytes normal range
in the blood.
An elevated
level means
that there is
hgh bacterial
infection

(x10/1) 4.7 2.0-8.8

Lympho/ Small February 38 28-48 The result is
monocytes agranulocytic 22, 2009 within normal

16
 leukocytes range
originating
from fetal
stem cells. It
is especially
helpful in the
evaluation of
the patient
with
infection.
HGB Measures the February 11.2 12-16 Below-normal
amount of 22, 2009 hemoglobin
hemoglobin levels may
in blood and lead to anemia
is a good that can be the
measure of result of iron
the bloods deficiency
ability to
carry oxygen
throughout
the body.

Nursing Responsibilities for Blood Chemistry:

A. Before the procedure:
1. Check the Doctor’s order.
2. Identify the patient.
3. Check the vital signs.
4. Decrease patient’s anxiety by explaining the procedure and why it has
to be performed.

17
 5. For blood sample, instruct that the medical technician will perform
venipuncture to extract blood.
6. Acknowledge questions regarding the safety of the procedure.
B. During the procedure:
1. If the test is to be done at bedside, remain with the patient.
2. Assist with the collection of specimen if allowed.
C. After the procedure:
1. Check the site for bleeding, cyanosis, or swelling.
2. Apply pressure and warm compress.
3. Check vital signs for any changes.
4. Document the data (attach result in the chart).

Diagnostic/ Indications or Date Ordered Results Analysis and

Laboratory Purpose Date Results Interpretation
Procedure were released of Results
Urinalysis To obtain February 23, Macroscopic: The greater the
clinical 2009 Color: yellow concentration of
information, to Specific the abnormal
detect renal and Gravity:1.015 substance (such
metabolisc Sugar: negative as greatly
disease, Appearance: increased
diagnosis of slightly turbid amounts of
disease or Reaction: pH glucose,
disorder on 6.0 protein, or red
kidneys or Albumin: blood cells), the
urinary tract. negative more likely it
will be that
Microscopic: there is a
Pus cells: 1-2 problem that
Red Cells: 0-1 needs to be
Epithelial cells: addressed.
few
Mucus threads:
rare

Nursing Responsibilities for Urinalysis:

A. Before the Procedure
1. Explain the procedure to the patient’s significant other.
2. Obtain materials needed in the procedure.

18
 3. Advise the significant other to wash perineal area prior to collection of specimen.
B. During the Procedure
1. Collect a fresh urine specimen in a urine container.
2. Obtain clean catch midstream urine if possible.
C. After the Procedure
1. Transfer the urine specimen to the laboratory promptly.
2. Document the procedure.
3. Attach the result in the patient’s chart.

Diagnostic/ Indications or Date Ordered Results Analysis and

Laboratory Purpose Date Results Interpretation
Procedure were released of Results
Brain Scan To identify February 23. Lacunar Infarct, Plain multiple
structural 2009 subcortical axial views of
lesions whether portion, left the head reveals
vascular or parietal lobe a small,
tumors. hyperlucent
focus on the
subcortical
portion of the
left parietal
lobe. The
ventricles and
cistern are not
dilated. The
midline
structures are
not displaced.
The sella
turtica,
posterior fossae
and basal skull
structures are
intact.

Nursing Responsibilities for Brain Scan:

A. Before the procedure:
1. Explain the procedure to the pt and the SO.
2. Obtain the consent.
3. Restrict food and fluids.

19
B. During the procedure:
1. Stay with the patient.
C. After the procedure:
1. Document the procedure.
2. Attach the result in the patient’s chart

20
V. THE PATIENT AND HER ILLNESS

1. Anatomy and Physiology

The systems involved in giving

part to the development of TIA are the
circulatory system and the nervous
system.
The circulatory system is a
network that carries blood throughout
the body.
The human circulatory system
supplies the cells of the body with the
food and oxygen they need to survive.
At the same time, it carries carbon
dioxide and other wastes away from
the cells. The circulatory system also
helps regulate the temperature of the
body and carries substances that
protect the body from disease. In
addition, the system transports
chemical substances called hormones,
which help regulate the activities of
various parts of the body.
One of the parts of the circulatory system is the heart. It is a hollow, muscular
organ that pumps blood. It consists of two pumps that lie side by side. These pumps relax
when taking in blood and contract as they send out blood. The left side of the heart is a
stronger pump than the right side. The stronger pump receives blood from the lungs and
sends it to cells throughout the body. The weaker pump receives blood from the cells
throughout the body and sends the blood to the lungs.
Another of the parts of the circulatory system are the blood vessels. They form a
complicated system of connecting tubes throughout the body. There are three major types

21
of these vessels. Arteries carry blood from the heart. Veins return blood to the heart.
Capillaries are extremely tiny vessels that connect the arteries and the veins.
The blood consists chiefly of liquid called plasma, and three kinds of solid
particles known as formed elements. Plasma is made up mostly of water, but it also
contains proteins, minerals, and other substances. The three types of formed elements are
called red blood cells, white blood cells, and platelets. Red blood cells carry oxygen and
carbon dioxide throughout the body. White
blood cells help protect the body from
disease. Platelets release substances that
enable blood to clot. Platelets thus aid in
preventing the loss of blood from injured
vessels.
The nervous system is a very
complex system in the body. It has many,
many parts. The nervous system is divided
into two main systems, the central nervous
system (CNS) and the peripheral nervous
system. The spinal cord and the brain
make up the CNS. Its main job is to get
the information from the body and send
out instructions. The peripheral nervous
system is made up of all of the nerves and
the wiring. This system sends the
messages from the brain to the rest of the
body.
One of the parts of the CNS is the brain. It keeps the body in order. It helps to
control all of the body systems and organs, keeping them working like they should. The
brain also allows us to think, feel, remember and imagine. In general, the brain is what
makes us behave as human beings.

22
 The brain communicates with the rest of the body through the spinal cord and the
nerves. They tell the brain what is going on in the body at all times. This system also
gives instructions to all parts of the body about what to do and when to do it.
There are five main senses - touch, smell, taste, hearing and sight. These are the
external sensory system, because they tell you about the world outside your body. Your
senses tell you what is happening in the outside world. Your body's sense organs
constantly send signals about what is happening outside and inside it to your control
center - the brain.
The cerebrum is part of the forebrain. The cerebral cortex is the outer layer of the
cerebrum. Certain areas of the cerebral cortex are involved with certain functions.
Sensory areas such as touch, smell, taste, hearing and sight receive messages from
the skin, nose, mouth, ears and eyes. We feel, taste, hear and see when these messages are
received by the sensory parts of the brain.
The second main part of the nervous system is the peripheral nervous system.
The nervous system is made up of nerve cells or neurons that are "wired" together
throughout the body, somewhat like communication system. Neurons carry messages in
the form of electrical impulses. The messages move from one neuron to another to keep
the body functioning.
Neurons have a limited ability to repair themselves. Unlike other body tissues,
nerve cells cannot also be repaired if damaged due to injury or disease.

23
2. Pathophysiology
A. Book-Based
a. Schematic Diagram

Predisposing factors Precipitating factors

- age - cigarette smoking
- sex - Diabetes Mellitus
- history of TIA/stroke & HTN on the family - thromboembolism
- sedentary lifestyle - stress
- personal HTN

Decrease blood supply on the brain leads to hypoxia, thus

Ischemia occurs on the brain.

Short-term ischemia leads to temporary neurologic deficits or a TIA

If blood flow is restored,

brain tissue will
reverse the damage
within minutes

if blood flow is not restored, brain tissue sustains irreversible damage

of infarction w/in minutes

the extend of infarction depends on the location and size of the occluded artery

24
 and the adequacy of collateral circulation to the area it supplies.

Ischemia quickly alters cerebral metabolism thus decrease cerebral perfusion

leading to further damage to the brain.

Lead to damaging both hemispheres of the brain thus leading to paralysis of the body,
speech, and ECG changes of the heart

A cascades of biochemical processes occurs within minutes of cerebral ischemia,

thus membrane depolarization occurs

Results to influx of calcium and sodium

Leads to cytotoxic edema and cell death area The area of edema after ischemia may lead to
results; temporary neurologic deficits

Leads to secondary neuronal injury

If edema subsides, client may regain some function

25
b. Synthesis of the Disease
b.1. Definition of the Disease
The definition of TIA continues to evolve. Traditionally, TIA has been defined as
the presence of neurologic symptoms of vascular etiology in one area of the brain
lasting less than 24 hours. Implicit in this definition is neuronal injury that is not
permanent in nature. However, there are several problems with this definition. It is
now clear through newer diagnostic modalities such as diffusion-weighted magnetic
resonance imaging (MRI) that this time- and symptom-based definition can be
clinically misleading. It assumes a complete correlation between the resolution of
symptoms and normalization of tissue reperfusion, which often underestimates the
potential tissue damage detected by diffusion-weighted MRI. Nearly 50% of patients
who meet the classic definition of TIA have in fact suffered subclinical strokes with
detectable cerebrovascular infarction.
A more accurate definition of TIA has been proposed by the Transient Ischemic
Attack Working Group formed by Albers and Caplan: “a brief episode of neurologic
dysfunction caused by focal brain or retinal ischemia, with clinical symptoms
typically lasting less than one hour, and without evidence of acute infarction”.
b.2. Predisposing/Precipitating Factors
Predisposing Factors
Age: Advancing age is one of the most significant risk factors of stroke.
Sex: Stroke has higher incidence in men due to physical needs and built.
History of TIA/Stroke & HTN in the family: Genetic predisposition of
stroke.
Sedentary lifestyle: Persons with a sedentary life style are at higher risk
for stroke than those with active life styles.
History of HTN: High blood pressure increases the pressure inside
arteries, causing damage. Excessive pressure on the walls of
vessels speeds up hardening and narrowing of the arteries
(atherosclerosis).
Precipitating Factors

26
 Cigarette smoking: Smoking injures blood vessel walls and speeds up
hardening of the arteries (atherosclerosis). As a result, the heart
works harder, and blood pressure may increase. Heavy smokers are at
greater risk for TIA and stroke. Daily cigarette smoking can
increase the risk of stroke by 2½ times.
Diabetes Mellitus: People who have diabetes are at increased risk for
many serious health problems, including hardening of the arteries
(atherosclerosis) and heart problems, eye problems that can
lead to blindness, circulation and nerve problems, and kidney
disease and kidney failure.
Thromboembolism: A blood clot or other tissue in the blood (such as fat)
from a part of the body other than the brain can travel through blood
vessels and become wedged in a smaller brain artery. This free-roaming
clot or tissue is called an embolus (emboli is plural). Emboli often form in
the heart. They also commonly form in the neck arteries or within the
aorta.
Stress:
b.3. Signs and Symptoms with Rationale
Blurred vision in both eyes, brief blindness, or double vision
Parietal and temporal lobe strokes may interrupt visual fibers of the optic
tract and route to the occipital cortex and impair visual acuity.
Difficulty speaking
It is caused by cranial nerve dysfunction from a stroke in vertebrobasilar
artery or its branches. It may result from the weakness or paralysis of the muscles of
the lips, tongue, and larynx or form loss of sensation.
Weakness, sometimes on only one side of the body
The deficit is usually caused by a stroke in the anterior or middle cerebral
artery, leading to infarction of motor strip of the frontal cortex.
Vertigo (a whirling or spinning feeling), headache, confusion
They occur due to decreasing oxygen level or total oxygen deprivation.
Loss of consciousness

27
 It occurs due to impaired Oxygen absorption, altering or disturbing brain
cell metabolism and functioning.
Chest pain
Anything that compresses a nerve root (like a disc or multiple discs) due
to cardiac ischemia will hurt.

28
 B. Client-Centered
a. Schematic Diagram

Predisposing factors Precipitating factors

- history of HPN on Aunt (Mother’s side) - use of birth control pills
- history of stroke (Aunt and Father) - increased fatty food on diet
- stress

Fromation of Lacunar infarction Dx. Brain Scan (02-22-09)

Lacunar infarction, subcortical portion, left parietal lobe

Infarct causing decrease blood supply n the brain

Decrease blood supply leads to O2 and glucose supply

brain thus Hypoxia occurs

Hypoxia can cause Ischemia which may lead to temporary

neurologic deficits or a TIA Ischemia quickly alters cerebral
also known as Transient Ischemic Attack metabolism

29
 decrease cerebral perfusion

affects blood flow n the body

Leading to Hypoxia on the brain will cause further Leading to hypotension

damage if not be reversed and will
furtherresult to higher damaged to the brain

leading to syncope and chest pain, and left sided weakness of the body

Leading to Transient Ischemic Attack

30
B. Synthesis of the Disease
b.1. Predisposing/Precipitating Factors
Predisposing factors
History of HPN and stroke on Aunt (mother’s side) & history of
stroke on father: Genetic predisposition of stroke.
Precipitating Factors
Use of birth control pills: Taking birth control pills increases the risk for
TIA because they are said to interfere with peripheral blood flow most
especially when they are taken by cigarette smokers.
Increased fatty food on diet: Too much cholesterol in the blood is not
healthy because it can build up in the walls of arteries, narrowing and
hardening blood vessels (atherosclerosis).
Stress: A person with a stress reaction experiences symptoms of anxiety
when exposed to very stressful events. It is a factor in your environment
that causes your mind or body to be tense. You may react to the stress by
feeling tension, anxiety, fear, anger, frustration or depression and even loss
of body function.
b.2. Signs and Symptoms with Rationale
Weakness, left side of the body
The deficit is usually caused by a stroke in the anterior or middle cerebral
artery, leading to infarction of motor strip of the frontal cortex.
Loss of consciousness
Occur due to impaired Oxygen absorption, altering or disturbing brain cell
metabolism and functioning.
Chest pain
Anything that compresses a nerve root (like a disc or multiple discs) due
to cardiac ischemia will hurt.

31
 VI. THE PATIENT AND HER CARE

1. Medical Management

A. IVF

Medical General Indications/ Date ordered, Client’s response

Management description purpose date performed, to treatment
date changed or
D/C

IVF D5NM It is indicated for 02-21-09 The patient was

It is a sterile, parenteral able to maintain a
nonpyrogenic, maintenance of normal hydration
hypertonic routine daily fluid status.
solution of and electrolyte
balanced requirements with
maintenance minimal
electrolytes and carbohydrate
5% dextrose calories from
injection in water dextrose.
for injection. Magnesium in the
formula may help
The solution is to prevent
administered by iatrogenic
intravenous magnesium
infusion for deficiency in
parenteral patients receiving
maintenance of prolonged
routine daily fluid parenteral
and electrolyte therapy.
requirements with
minimal
carbohydrate
calories.

a. 1. Nursing responsibilities:
PRIOR TO INSERTION:
 When inserting an IV line to a patient, always prepare all the materials to
be used prior to the insertion.
 Wash hands thoroughly before performing the procedure.
 Identify the correct patient by checking the name on the chart or by asking

32
 directly the patient.
 Explain the procedure to the patient.
DURING ADMINISTRATION:
 Insert the IV catheter accordingly.
 Regulate and monitor infusion rate.
AFTER ADMINISTRATION:
 Monitor patient’s therapeutic response to treatment.
 Check the IV insertion site for signs of infiltration, bulging, heat, pain and
redness.

B. Drugs
Drugs Action Indication Date ordered, Client’s
date Response
performed,
date changed
or D/C
Generic Name: -Replaces -To prevent Date Ordered: The patient’s
Potassium potassium and hypokalemia 02-22-09 potassium
Chloride maintains level
Brand Name: potassium level returned to
Kalium Durule normal
range.

Generic Name: -increases the To increase There is

Citicoline neurotransmission brain improvement
Brand Name: levels because it metabolism in the
Somazine favors the synthesis affected
and production (paralyzed)
speed of dopamine areas.
in the striatum,
acting then as
dopominergic
agonist through the
inhibition of
tyrosine
hydroxilase.

Generic Name: -Increases osmotic -to prevent The patient’s

Mannitol pressure of oliguria or urinary
Brand Name: glomerular filtrate, acute renal function

33
Osmitrol inhibiting tubular failure returned to
reabsorption of normal.
water and
electrolytes; drug
elevates plasma
osmolality;
increasing water
flow into
extracellular fluid.

Generic Name: inhibits secretion of To prevent The patient

omeprazole gastric acid by gasto- did not
Brand Name: irreversibly esophageal experience
Risek blocking the reflux and reflux and
enzyme system of peptic ulcer. did not
hydrogen/potassium manifest
adenosine ulcerations.
triphosphate (H+/K+
ATPase), the proton
pump of the gastric
parietal cell.

Generic Name: - Inhibits the - to reduce 02-23-09 The patient’s

Clopidogrel binding of thrombotic blood
bisulfate adenosine events in circulation
Brand Name: diphosphate (ADP) patients with improved
Plavix to its platelet atherosclerotisis and was
receptor, impeding documented by increased.
ADP-mediated recent stroke,
activation and MI, or
subsequent platelet peripheral
aggregation, and arterial disease
irreversibly
modifies the
platelet ADP
receptor.

Generic Name: -increases the to increase 02-24-09 There is

Citicoline Na neurotransmission brain improvement
Brand Name: levels because it metabolism in the
Cholinerv favors the synthesis affected

34
 and production (paralyzed)
speed of dopamine areas.
in the striatum,
acting then as
dopominergic
agonist through the
inhibition of
tyrosine
hydroxilase.

b. 1. Nursing responsibilities:
BEFORE ADMINISTRATION:
 Check and clarify Doctors order
 Prepare equipments
 10 R’s of drugs
 Performed skin testing
 Check for the patient’s medication card and chart.
 Performed hand washing
DURING ADMINISTRATION:
 Read the name, amount, and expiration date three times
 Check for patient’s identification
 Explain the procedure to the client
AFTER ADMINISTRATION:
 Document
 Watch out for any side effects
D. Diet

Type of Diet General Indications Date Client’s

description /purpose ordered, date response
started, date and/or
changed or reaction to
D/C the diet

35
Low salt and To prevent the 02/22/09 - The patient
low fat problems that complied with
result from the the doctor’s
need to withhold order.
food.

c. 1. Nursing responsibilities:
PRIOR TO INITIATION OF DIET:
 Explain why diet is desired to client.
DURING INITIATION OF DIET:
 Instruct patient and SO to eat healthy foods to promote wellness except those
allergic to the patient.
AFTER INITIATION OF DIET:
 Explain to the patient foods that are good for fast recovery.
 Instruct SO to observe strictly the diet to improve the nutrition of the patient.

D. Activity
Type of General Indications Date Client’s
Exercise description /purpose ordered, date response
started, date and/or
changed or reaction to
D/C the activity

Turning Turning the To prevent 02/23/09 Compliance

exercise client side to side venous stasis,
on bed every 2 thrombophlebitis,
hours pressure ulcer
formation and
respiratory
complication.

36
Flexion- Flexion and To increase 02/24/09 Compliance
extension extension the muscle strength.
exercise unaffected
extremities.

d.1 Nursing Responsibilities prior to during and after start of the activity

1. Explain the significance of the activity.

2. Assist the patient and the SO in doing the procedure.

3. Place pillows to prevent falls.

37
VII. NURSING CARE PLAN
Problem No. 1
Cues Nursing Scientific Nursing Nursing Rationale Expected
Diagnosis Explanation Objectives interventions Outcome
S> Ø  Encourage  Enhance The pt’s
Ineffective Because there’s After 1 hour of early venous condition in
O> Body peripheral an decrease in NPI, pt’s ambulatio return circulation of
weakness tissue oxygen supply condition in n when the lower
 Paralysis perfusion r/t in our body it circulation of possible extremity shall
of left impaired fails to nourish the left lower have
lower transport of the the tissues at extremity will  Elevate  To increase progressed.
extremitie O2 across the capillary have progress. HOB at gravitation
s alveolar and level resulting night al blood
 BP of capillary to tissue flow
100/60 membrane perfusion
AEB paralysis  Heat
of left lower  Exercise increases
extremity caution in the
use hot metabolic
water demands
bottles or of already
heating pads compromis
ed tissue

 Encourage  Smoking
to minimize causes
places that vasoconstri
are high in ction and
smoke further
compromis
ed
perfusion
Problem No. 2

38
 CUES NURSING SCIENTIFIC NURSING NURSING RATIONALE EXPECTED
DIAGNOSIS EXPLANATION OBJECTIVE INTERVENTIONS OUTCOME

S > “Di ko Impaired Due to the After 1° of Assist in self-care To promote The pt. shall
magalaw physical impairment of nursing activities. independence have
‘tong left mobility r/t blood flow in the intervention, and participated in
foot ko… neuromuscular brain’s the pt. will be enhancement of ADL’s and
Wala ring impairment neurologic able to self-concept. with the
pakiramda AEB paralysis branches, participate in desired
m of the lower dysfunction ADL’s and Encourage energy- To prevent activities.
hanggang left extremity. occurs resulting with the conserving fatigue and
waist…” to ineffective desired techniques. overexertion.
impulses sent to activities.
O > The pt. different body Provide pt. with To provide time
manifeste parts specifically ample time to to rechannel
d the ff: the extremities. perform mobility- energy and to
Numbness and related tasks. prevent exertion
 with inability to move and
limited the affected area overexhaustion.
ability to occurs and
perform decreases the pt’s Place pillows on To promote
gross ability to perform the right side of the safety and to
motor desired and bed. prevent injury.
skills necessary
 with activities. Change lying To prevent
difficulty position every 2 stasis of blood
in turning hours. and to reduce
 with the risk of
slowed pressure ulcers.
movement
 needs Offer fluids and To aid in
assistance reinforce nutritious supplementing
upon foods. normal body

39
 ambulatio functions.
n
 with Reinforce low salt, To assure
paralysis low fat diet. compliance
of the left with daily diet
lower regimen and to
extremity provide a
 PR: continuous
54bpm recovery state.

Problem No. 3
NURSING SCIENTIFIC
CUES OBJECTIVE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS EXPLANATION

S–Ø Activity The patient is After 2 hours The pt shall

Intolerance suffering from of Nursing Assist with to protect client have
O – left related to Cerebrovascular intervention activities and from injury demonstrated
extremity neuromuscular Accident wherein the patient monitor c behaviors that
weakness impairment as there is a sudden will lient’s use of will improve her
- inability to evidenced by loss of brain demonstrate assistive present
move left sided function resulting behaviors that device condition.
purposefully weakness and from a disruption will improve
inability to of the blood her present Adjust activities to prevent
move without supply to a part of condition. overexertio
SO support the brain. As a Plan care with rest n
secondary to result, brain cells periods
disease are starved of between to reduce
process. oxygen causing activities fatigue
some cells to die
and leaving other Promote comfort
cells damaged. measures and
provide relief
Making the of pain to enhance

40
patient unable to ability to
move the left side participate
of her body most in activities
especially the left
side of the body.

Thus, the patient

was unable to turn
side to side, sit or
stand and move
on bed without
support

Leading the
patient to suffer
Activity
Intolerance.

41
VIII. DISCHARGE PLAN

OBJECTIVE CONTENT TIME ALLOTMENT TEACHING EXPECTED

STRATEGIES OUTCOME

After NPI, the pt. will Exercise 1 hour Lecture-discussion and The pt. shall have
be able to comply and Advise to: demonstration complied and have
verbalize Do deep breathing verbalized
understanding on exercises. understanding on
provided health Have ambulation with provided health
teachings and home assistance and support teachings and home
maintenance as tolerated. maintenance
management. Perform ADLs management.
involving hygiene and
self-care.

Treatment
Instruct to:
Comply strictly with
drug treatment
regimen.

Health Teachings
Demonstrate to:
Place pillows on bed
when asleep to prevent
injury and other
accident precautions.
Support the affected
part to prevent
development of
pressure ulcers.
Provide adequate rest

42
periods.
Provide energy
conservation
techniques.
Make up activities that
increase the well
being.

Out-Patient
Instruct to:
Return a week after
discharge as ordered
by the physician.

Diet
Reinforce to:
Maintain a low salt,
low fat diet.
Increase fluid, fruit
and vegetable intake.

43
IX. LEARNING DERIVED FROM THE STUDY

Confusions between Transient Ischemic Attack and Stroke were identified

by the student-nurses wherein TIA is a sign of a possible impending stroke. Proper diet
modification and increase in activities will reduce the risk of having an attack. Also,
health care workers have a great responsibility towards making the disease known to
patients and the population as a whole.
Taking care of an ill patient is our responsibilities being a nurse. We have
to give the proper care they need, identifying the problem to give appropriate
interventions in their disease.
We’ve encountered different kinds of diseases, behavior of each patient,
and knowing the causes of each diseases. Being a nurse is not that easy because we are
dealing in the life of the patient. Nurses must be competent or knowledgeable enough in
doing the care in a patient because one mistake of it can cause more complications or
death to the patient.
In this case study we’ve learned the causes, factors or signs and symptoms
of the disease, how it was started and what are the appropriate interventions and
medications given to the patient. We’ve learned and more appreciated the meaning of the
disease. This is the essence of being a nurse, though we are encountering some patients
quite not good to deal with.
Related learning experiences help us more to apply what we’ve learned
from the lectures and discussions within the four corners of the classroom. One can never
really appreciate what was learned until was experienced.

44