INTRODUCTION

Cerebrovascular Accident (Ischemic)

Ischemic stroke is focal brain infarction that produces sudden neurologic deficits persisting > 1 h.
Common causes are (from most to least common) nonthrombotic occlusion of small, deep cortical
arteries (lacunar infarction) ; cardiogenic embolism; arterial thrombosis that decreases cerebral
blood flow; and artery-to-artery embolism. Diagnosis is clinical, but CT or MRI is done to exclude
hemorrhage and confirm the presence and extent of stroke. Thrombolytic therapy may be useful
acutely in certain patients. Depending on the cause of stroke, carotid endarterectomy, antiplatelet
drugs, or warfarin may help reduce risk of subsequent strokes.

Ischemia usually results from thrombi or emboli. Even infarcts classified as lacunar based on
clinical criteria (morphology, size, and location) often involve small thrombi or emboli.

Thrombosis: Atheromas, particularly if ulcerated, predispose to thrombi. Atheromas can occur in

any major cerebral artery and are common at areas of turbulent flow, particularly at the carotid
bifurcation. Partial or complete thrombotic occlusion occurs most often at the main trunk of the
middle cerebral artery and its branches but is also common in the large arteries at the base of the
brain, in deep perforating arteries, and in small cortical branches. The basilar artery and the
segment of the internal carotid artery between the cavernous sinus and supraclinoid process are
often occluded. Less common causes of thrombosis include vascular inflammation secondary to
disorders such as acute or chronic meningitis, vasculitic disorders, and syphilis; dissection of
intracranial arteries or the aorta; hypercoagulability disorders (eg, antiphospholipid syndrome,
hyperhomocysteinemia); hyperviscosity disorders (eg, polycythemia, thrombocytosis,
hemoglobinopathies, plasma cell disorders); and rare disorders (eg, moyamoya disease,
Binswanger's disease). Older oral contraceptive formulations increase risk of thrombosis.

Embolism: Emboli may lodge anywhere in the cerebral arterial tree. Emboli may originate as
cardiac thrombi, especially in the following conditions:

* Atrial fibrillation

* Rheumatic heart disease (usually mitral stenosis)

* Post-MI

* Vegetations on heart valves in bacterial or marantic endocarditis

* Prosthetic heart valves

Other sources include clots that form after open-heart surgery and atheromas in neck arteries or
in the aortic arch. Rarely, emboli consist of fat (from fractured long bones), air (in decompression
sickness), or venous clots that pass from the right to the left side of the heart through a patent
foramen ovale with shunt (paradoxical emboli). Emboli may dislodge spontaneously or after
invasive cardiovascular procedures (eg, catheterization). Rarely, thrombosis of the subclavian
artery results in embolic stroke in the vertebral artery or its branches.

Lacunar infarcts: Ischemic stroke can also result from lacunar infarcts. These small (≤ 1.5 cm)
infarcts result from nonatherothrombotic obstruction of small, perforating arteries that supply
deep cortical structures; the usual cause is lipohyalinosis (degeneration of the media of small
arteries and replacement by lipids and collagen).
Diabetes

Diabetes is a metabolic disorder characterized by a relative or absolute lack of the hormone insulin
or insulin resistance, or both, which is impaired use of carbohydrates and altered metabolism of
fats and protein. The word diabetes, from the Greek meaning “a siphon”, suggests urine
formation, the word mellitus, from the Greek meaning “honey”, suggests sweetness. Type 2
diabetes was formerly known by a variety of partially misleading names, including “adult-onset
diabetes,” obesity-related diabetes”, or non-insulin-dependent diabetes” (NIDDM). It is
characterized by “insulin resistance” as body cells do not respond appropriately when insulin is
present. This is more complex problem than type 1, but it is sometimes easier to treat, since
insulin is still in many, especially in the initial years. Type 2 may go unnoticed for years in a
patient before diagnosis, since the symptoms are typically milder and can be sporadic. The 3
cardinal signs of Type 2 DM are polyphagia (excessive hunger), polydipsia (excessive thirst), and
polyuria (excessive urination). Other signs and symptoms of this disease are weight loss or gain,
blurred vision, headaches lethargy, impotence, vaginal discharge, increased vaginal infection,
increased wound healing time, orthostatic hypertension, decreased pedal pulses, paresthesics,
and decreased sensations (extremities). If these signs and symptoms were not given proper or
enough attention, it may lead to the following complications” diabetic neurophatics (low of
sensation in extremities), Charcot’s syndrome, Retinopathy, kidney failure, Atherosclerosis of the
heart and large vessels and amputation.

In 2004, according to the World Health Organization, more than 150 million people
worldwide suffer from diabetes. Its incidence is increasing rapidly, and it is estimated that by the
year 2025 this number will double. Diabetes mellitus occurs throughout the world, but it is
common (especially Type 2) in the more developed countries. In 2002 there were about 18.2
million diabetics in the United States alone. Diabetes is in the top 10, and perhaps the top 5, of the
most significant disease in the developed world, and is gaining insignificance. For at least 20
years, diabetes rates in North America have been increasing substantially. The Centers for Disease
Control has termed the change an epidemic. The National Diabetes Information Clearing house
estimates that diabetes costs $132 billion in the United States alone every year.

Hypertension

Hypertension is a common clinical problem faced by both primary care clinicians and specialists.
While the exact prevalence of resistant hypertension is unknown, clinical trials suggest that it is
not rare, involving perhaps 20% to 30% of study participants. As older age and obesity are 2 of the
strongest risk factors for uncontrolled hypertension, the incidence of resistant hypertension will
likely increase as the population becomes more elderly and heavier. The prognosis of resistant
hypertension is unknown, but cardiovascular risk is undoubtedly increased as patients often have a
history of long-standing, severe hypertension complicated by multiple other cardiovascular risk
factors such as obesity, sleep apnea, diabetes, and chronic kidney disease. The diagnosis of
resistant hypertension requires use of good blood pressure technique to confirm persistently
elevated blood pressure levels. Pseudoresistance, including lack of blood pressure control
secondary to poor medication adherence or white coat hypertension, must be excluded. Resistant
hypertension is almost always multifactorial in etiology. Successful treatment requires
identification and reversal of lifestyle factors contributing to treatment resistance; diagnosis and
appropriate treatment of secondary causes of hypertension; and use of effective multidrug
regimens. As a subgroup, patients with resistant hypertension have not been widely studied.
Observational assessments have allowed for identification of demographic and lifestyle
characteristics associated with resistant hypertension, and the role of secondary causes of
hypertension in promoting treatment resistance is well documented; however, identification of
broader mechanisms of treatment resistance is lacking. In particular, attempts to elucidate
potential genetic causes of resistant hypertension have been limited. Recommendations for the
pharmacological treatment of resistant hypertension remain largely empiric due to the lack of
systematic assessments of 3 or 4 drug combinations. Studies of resistant hypertension are limited
by the high cardiovascular risk of patients within this subgroup, which generally precludes safe
withdrawal of medications; the presence of multiple disease processes (eg, sleep apnea, diabetes,
chronic kidney disease, and atherosclerotic disease) and their associated medical therapies, which
confound interpretation of study results; and the difficulty in enrolling large numbers of study
participants. Expanding our understanding of the causes of resistant hypertension and thereby
potentially allowing for more effective prevention and/or treatment will be essential to improve the
long-term clinical management of this disorder.

NURSING OBJECTIVES

After 6 days of Nurse-Patient Interaction the student nurse will be able to:
Cognitive:

• Identify specific theoretical causes and clinical manifestations, and trace the
pathophysiology of the involved disease entity;
• Identify nursing problems and construct nursing care plans specifically;
• Understand the normal anatomy and physiology of the affected organs that are affected by
the underlying disease condition;
Affective:

• describe predisposing and precipitating factors that could possibly contribute to the
occurrence of the disease;
Psychomotor:

• Accurately gather nursing history

• Enumerate ways of preventing the occurrence of the disease or problem

ANATOMY AND PHYSIOLOGY

The Cardiovascular System

The heart and circulatory system make up the cardiovascular system. The heart works as a pump
that pushes blood to the organs, tissues, and cells of the body. Blood delivers oxygen and
nutrients to every cell and removes the carbon dioxide and waste products made by those cells.
Blood is carried from the heart to the rest of the body through a complex network of arteries,
arterioles, and capillaries. Blood is returned to the heart through venules and veins.

The one-way circulatory system carries blood to all parts of the body. This process of blood flow
within the body is called circulation. Arteries carry oxygen-rich blood away from the heart, and
veins carry oxygen-poor blood back to the heart. In pulmonary circulation, though, the roles are
switched. It is the pulmonary artery that brings oxygen-poor blood into the lungs and the
pulmonary vein that brings oxygen-rich blood back to the heart.

Twenty major arteries make a path through the tissues, where they branch into smaller vessels
called arterioles. Arterioles further branch into capillaries, the true deliverers of oxygen and
nutrients to the cells. Most capillaries are thinner than a hair. In fact, many are so tiny, only one
blood cell can move through them at a time. Once the capillaries deliver oxygen and nutrients and
pick up carbon dioxide and other waste, they move the blood back through wider vessels called
venules. Venules eventually join to form veins, which deliver the blood back to the heart to pick up
oxygen.

Vasoconstriction or the spasm of smooth muscles around the blood vessels causes and decrease
in blood flow but an increase in pressure. In vasodilation, the lumen of the blood vessel increase in
diameter thereby allowing increase in blood flow. There is no tension on the walls of the vessels
therefore, there is lower pressure.

Various external factors also cause changes in blood pressure and pulse rate. An elevation or
decline may be detrimental to health. Changes may also be caused or aggravated by other
disease conditions existing in other parts of the body.

The blood is part of the circulatory system. Whole blood contains three types of blood cells,
including: red blood cells, white blood cells and platelets.

These three types of blood cells are mostly manufactured in the bone marrow of the vertebrae,
ribs, pelvis, skull, and sternum. These cells travel through the circulatory system suspended in a
yellowish fluid called plasma. Plasma is 90% water and contains nutrients, proteins, hormones,
and waste products. Whole blood is a mixture of blood cells and plasma.

Red blood cells (also called erythrocytes) are shaped like slightly indented, flattened disks. Red
blood cells contain an iron-rich protein called hemoglobin. Blood gets its bright red color when
hemoglobin in red blood cells picks up oxygen in the lungs. As the blood travels through the body,
the hemoglobin releases oxygen to the tissues. The body contains more red blood cells than any
other type of cell, and each red blood cell has a life span of about 4 months. Each day, the body
produces new red blood cells to replace those that die or are lost from the body.

White blood cells (also called leukocytes) are a key part of the body's system for defending itself
against infection. They can move in and out of the bloodstream to reach affected tissues. The
blood contains far fewer white blood cells than red cells, although the body can increase
production of white blood cells to fight infection. There are several types of white blood cells, and
their life spans vary from a few days to months. New cells are constantly being formed in the bone
marrow.

Several different parts of blood are involved in fighting infection. White blood cells called
granulocytes and lymphocytes travel along the walls of blood vessels. They fight bacteria and
viruses and may also attempt to destroy cells that have become infected or have changed into
cancer cells.

Certain types of white blood cells produce antibodies, special proteins that recognize foreign
materials and help the body destroy or neutralize them. When a person has an infection, his or her
white cell count often is higher than when he or she is well because more white blood cells are
being produced or are entering the bloodstream to battle the infection. After the body has been
challenged by some infections, lymphocytes remember how to make the specific antibodies that
will quickly attack the same germ if it enters the body again.

Platelets (also called thrombocytes) are tiny oval-shaped cells made in the bone marrow. They
help in the clotting process. When a blood vessel breaks, platelets gather in the area and help seal
off the leak. Platelets survive only about 9 days in the bloodstream and are constantly being
replaced by new cells.

Blood also contains important proteins called clotting factors, which are critical to the clotting
process. Although platelets alone can plug small blood vessel leaks and temporarily stop or slow
bleeding, the action of clotting factors is needed to produce a strong, stable clot.

Platelets and clotting factors work together to form solid lumps to seal leaks, wounds, cuts, and
scratches and to prevent bleeding inside and on the surfaces of our bodies. The process of clotting
is like a puzzle with interlocking parts. When the last part is in place, the clot is formed.

When large blood vessels are cut the body may not be able to repair itself through clotting alone.
In these cases, dressings or stitches are used to help control bleeding.

In addition to the cells and clotting factors, blood contains other important substances, such as
nutrients from the food that has been processed by the digestive system. Blood also carries
hormones released by the endocrine glands and carries them to the body parts that need them.

Blood is essential for good health because the body depends on a steady supply of fuel and
oxygen to reach its billions of cells. Even the heart couldn't survive without blood flowing through
the vessels that bring nourishment to its muscular walls. Blood also carries carbon dioxide and
other waste materials to the lungs, kidneys, and digestive system, from where they are removed
from the body.

The Endocrine System

The endocrine system is made up of glands that produce and secrete hormones. These hormones
regulate the body’s growth, metabolism (the physical and chemical processes of the body), and
sexual development and function. The hormones are released into the bloodstream and may affect
one or several organs throughout the body.

The role of the endocrine system is to maintain the body in balance through the release of
hormones which transfer information and instructions from one set of cells to another. Many
different hormones move through the bloodstream, but each type of hormone is designed to affect
only certain cells.

Hormones are chemical messengers created by the body. They transfer information from one set
of cells to another to coordinate the functions of different parts of the body. Hormones can act on
some specific cells because they themselves do not actually cause an effect. It is only through
binding with a receptor (part of the cell specifically designed to recognize the hormone) like a key
into a lock - that causes a chain reaction to occur, changing the activity of the cells. If a cell does
not have a receptor for a hormone then there will be no effect. Also, there can be different
receptors for the same hormone, and so the same hormone can have different effects on different
cells.

The major glands of the endocrine system are the pituitary, thyroid, parathyroids, adrenals, pineal
body, thymus, and the reproductive organs (ovaries and testes). The pancreas is also a part of this
system; it has a role in hormone production as well as in digestion. A gland is a group of cells that
produces and secretes chemicals. A gland selects and removes materials from the blood,
processes them, and secretes the finished chemical product for use somewhere in the body. The
endocrine gland cells release a hormone into the blood stream for distribution throughout the
entire body. These hormones act as chemical messengers and can alter the activity of many
organs at once.

The hypothalamus controls all the processes undergone by the anterior and posterior pituitary
glands. It initiates the production of hormones by the APG. The APG is controlled by releasing
hormones which are chemical signals produced by the nerve cells of the hypothalamus, causing
either stimulation or inhibition of hormone production. Secretion of hormones by the PPG is
controlled by nervous system stimulation of nerve cells in the hypothalamus. Parathyroid glands
secrete parathyroid hormone which is essential for the regulation of blood calcium levels. Adrenal
glands produce epinephrine and norepinephrine which are fight-or-flight hormones that prepare
the body for vigorous physical activity. Testes and ovaries produce hormones that are responsible
for secondary sex characteristics, spermatogenesis, and oogenesis. The thymus gland secretes
thymosin which aids in the synthesis of WBC for fighting infection. This gland decreases in size in
some older adults. The pineal body releases melatonin that is thought to decrease the secretion of
LSH & FSH by decreasing the release of hypothalamic-releasing hormones. The thyroid gland,
located on either side of the trachea, is controlled by the thyroid stimulating hormone releases by
the anterior pituitary gland, which was initially stimulated by the TSH releasing hormone from the
hypothalamus.

The pancreas is also part of the body's hormone-secreting system, even though it is also
associated with the digestive system because it produces and secretes digestive enzymes. The
pancreas produces two important hormones, insulin and glucagon. They work together to maintain
a steady level of glucose, or sugar, in the blood and to keep the body supplied with fuel to produce
and maintain stores of energy. The pancreas completes the job of breaking down protein,
carbohydrates, and fats using digestive juices of pancreas combined with juices from the
intestines, secretes hormones that affect the level of sugar in the blood, and produces chemicals
that neutralize stomach acids that pass from the stomach into the small intestine by using
substances in pancreatic juice. It contains Islets of Langerhans, which are tiny groups of
specialized cells that are scattered throughout the organ.

In humans, the pancreas is a 15-25 cm (6-10 inch) elongated organ in the abdomen adjacent to
the small intestine and lies toward the back. It has three regions: a head (abuts a part of the
duodenum), body (at the level of L2 of the spine) and tail (extends toward the spleen).

The pancreatic duct (also called the duct of Wirsung) runs the length of the pancreas and empties
into the second part of the duodenum at the ampulla of Vater. The common bile duct usually joins
the pancreatic duct at or near this point. Many people also have a small accessory duct, the duct
of Santorini, which extends from the main duct more upstream (towards the tail) to the duodenum,
joining it more proximal than the ampulla of Vater.

The pancreas is supplied arterially by the Pancreaticoduodenal arteries and the splenic artery: the
splenic artery supplies the neck, body, and tail of the pancreas; the superior mesenteric artery
provides the inferior pancreaticoduodenal artery; and the gastroduodenal artery provides the
superior pancreaticoduodenal artery.

Venous drainage is via the pancreaticoduodenal veins which end up in the portal vein. The splenic
vein passes posterior to the pancreas but is said to not drain the pancreas itself. The portal vein is
formed by the union of the superior mesenteric vein and splenic vein posterior to the neck of the
pancreas. In some people (some books say 40% of people), the inferior mesenteric vein also joins
with the splenic vein behind the pancreas (in others it simply joins with the superior mesenteric
vein instead).

The pancreas is a compound gland in the sense that it is composed of both exocrine and endocrine
tissues. The exocrine function of the pancreas involves the synthesis and secretion of pancreatic
juices. The endocrine function resides in the million or so cellular islands (the islets of Langerhans)
embedded between the exocrine units of the pancreas. Beta cells of the islands secrete insulin,
which helps control carbohydrate metabolism. Alpha cells of the islets secrete glucagon that
counters the action of insulin.

There are four main types of cells in the islets of Langerhans. They are relatively difficult to
distinguish using standard staining techniques, but they can be classified by their secretion:

Name of cells Endocrine product % of islet cells Representative function

beta cells Insulin and Amylin 50-80% lower blood sugar

alpha cells Glucagon 15-20% raise blood sugar

delta cells Somatostatin 3-10% inhibit endocrine pancreas

PP cells Pancreatic polypeptide 1% inhibit exocrine pancreas

The islets are a compact collection of endocrine cells arranged in clusters and cords and are
crisscrossed by a dense network of capillaries. The capillaries of the islets are lined by layers of
endocrine cells in direct contact with vessels, and most endocrine cells are in direct contact with
blood vessels, by either cytoplasmic processes or by direct apposition.

There are two main types of exocrine pancreatic cells, responsible for two main classes of
secretions:

Name of cells Exocrine secretion Primary signal

Centroacinar cells bicarbonate ions Secretin

Basophilic cells digestive enzymes CCK

(pancreatic amylase, Pancreatic lipase,
trypsinogen, chymotrypsinogen, etc.)

Nursing Health History

BIOGRAPHIC DATA:
Client X is a 54 year old female who is currently residing at 506 41 St. Tawiran Extension
Santolan, Pasig City. She was born on April 21, 1956. She was the second among five siblings of
their parents. She was a roman catholic. She was currently married to his husband with their 3
 children. She was a former vendor in their community and now decided to be a housewife for the
meantime because of her condition and for her children. In healthcare financing her usual source
was is from children and her husband.
CHIEF COMPLAINT:
“Namamanhid ang kaliwang paa ko di ko maigalaw ng maayos parang paralisado”, as
verbalized by the client.
HEALTH HISTORY:
A. History of Present Illness
Two days prior to admission (PTC) the patient noted numbness, restlessness and weakness
of her left lower extremities associated with dizziness, positive slurring of speech and facial
asymmetry, no chest pain and difficulty of breathing, no consult done. The patient was
hypertensive since she was 40 years old.
Few hours prior to consultation (PTC) on November 10, 2010 at around 7:30 PM client noted
left side body weakness with numbness and episode of nonprojectile vomiting with slight difficulty
of breathing and chest pain. She was immediately rushed at the Emergency Room of Pasig City
General Hospital (PCGH) and was given prompt treatment. She has a working diagnosis of CVA,
possible infarct, HPN
30 minutes prior to admission (PTA), due to constant high BP, slurring of speech, left sided
body weakness with association of shortness of breath and possible stroke (infarct or bleed),
doctors decided to admit her on Female medicine ward under service of Dr. Custodio.
B. Past History
The client already had mumps but does not have chicken pox and measles during
childhood. She was also able to receive all immunizations during her childhood, as verbalized by
her. She doesn’t have any food, drug or environmental allergy.
As stated by the client, she doesn’t experience any accidents in the past and this is the
second time she was brought into the hospital after her previous CVA but she was immediately
discharged that time because of her fast recovery. Every time she had his flu it only last for a
maximum of 4 days and she medicate herself with OTC drugs, no consultation was ever made.
C. Family History
Client’s parents were already dead. They were five children in their family, two boys and
three girls. All of them were still alive. Client X stated that the most reason of death of some of her
relative was stroke due to hypertension. She also stated that her father does have stroke and
hypertension. In her mother side; she stated that they have cancer in their family.

D.Pain Assessment
1st DAY INTERVIEW (November 9, 2010) 3rd DAY INTERVIEW (November 16, 2010)
The client verbalized of having slight chest The client doesn’t verbalize any chest pain
pain with a difficulty of breathing. On a pain and difficulty of breathing. The pain scale is 0
scale of 1-10 with 10 being the worst; she out of 10. She now manages it well.
said that it was 7. She manages her pain by
changing her position from flat position into a
moderate high back rest and deep breathing.

FUNCTIONAL HEALTH PATTERNS

1. Health Perception and Health Management Pattern
The client stated that after her previous CVA her general health starts declining at the same time
she also stopped working. She is always at home caring for her children she also added that she
lack in exercise and sometimes she is insensitive of what food should she eat even though she is
aware of right choice of food that she must take. She believes that illness is a part of aging
process that everyone must be prepared and must be conscious to their health. She eats her
meal on a regular basis (breakfast, lunch and dinner). She even loves eating pork, rice and
vegetables. She often buys street foods such as isaw, chicken feet, ulo ng manok and balat ng
baboy. She used to drink a cup of coffee every morning. After her first CVA, client takes
medications such as Felodipine and Aspirin as his maintenance due to his high BP. The important
thing he keeps on his mind while he is in the hospital is that he needs to be aware on
communicable diseases that can be transmitted to him for she is aware of the other cases that
were admitted there. She also added that we can help her through continue monitoring of her
Vital Signs for her to be immediately recovered. She does believe in health customs such as
“Tawas and Hilot”.
2. Nutrition and Metabolic Pattern
BEFORE ADMISSION
The client usually eats pork and chicken as well as fish and vegetables for five meals
per day; around 8:00 in the morning, her breakfast comprises of 1 cup of rice and usual morning
meals such as hotdog, but she usually buy lugaw, pancit, sopas or champorado since a eatery is
close to their house. She paired it with one cup of coffee. During lunch time, she prepares a meal
comprises of dishes like pork sinigang. She used to eat bananacue and maruya during merienda
time. She consumes 1 cup of rice on the said meal. During dinner, she usually eats pork adobo
and adobong sitaw. She also consumes 1 cup of rice. She drinks 5 glasses of water a day,
approximately 1250 ml of water (1 cup= 250ml). She was not taking any supplements and
vitamins. There’s no change in her appetite and there’s no discomfort during eating or drinking.
The client doesn’t have any dentures. She also said that there is no food that she is allergic.
DURING CONFINEMENT
The client stated that in the hospital, she doesn’t eat a lot for his appetite decreased. It’s
because that as of now she was on NGT and she cannot eat the food she wants.
3. Elimination Pattern

BEFORE ADMISSION

The client’s bowel elimination pattern is twice a day-every morning and evening. The color
of her stool is from yellow to brown. She also said that she don’t have any difficulty in defecation.
 In the clients urine elimination pattern; she stated that she urinates for only 2x a day. The color
of her urine is yellowish one. She doesn’t have any difficulty in urination. She doesn’t have
excess perspiration.

DURING CONFINEMENT

The client’s bowel elimination and urine elimination does change. Since the patient is on FC-
UB, she cannot feel that she is urinating. She defecates 2-3 times a day since she was also
taking laxative (lactulose). The color of the urine is a yellowish one the color of her stool is dark
and it is formed in shape. She has excess perspiration and odor problems.

4. Activity and Exercise Pattern

BEFORE ADMISSION

The client said that she has a sufficient energy for completing desired required activities.
Since she retired from selling in the market; she was not engaged anymore with daily exercise
such as jogging. During her spare time, she used to watch TV as well as chatting with her
neighbors.

DURING CONFINEMENT

Due to the client’s condition, she has no sufficient energy for completing desired required
activities. She can’t do all things that she usually does when she is admitted in the hospital.

FIRST DAY INTERVIEW (November 9, 2010) THIRD DAY INTERVIEW (November 16, 2010))

She has perceived ability for: She has perceived ability for:

Feeding – 4 Feeding – 4
Grooming – 2 Grooming – 2
General Mobility – 3 General Mobility – 3
Toileting - 1 Toileting - 2
Cooking – N/A Cooking – N/A
Home maintenance – N/A Home maintenance – N/A
Dressing – 3 Dressing – 3
Shopping – N/A Shopping – N/A

NOTE:
Level 0: Full Self Care
Level 1: Requires use of equipment or
device
Level 2: Requires assistance or
supervisions from another person
Level 3: Requires assistance or supervision
from another person/or device
Level 4: Is dependent and does not
participate
N/A: Not Applicable

5. Sleep Rest Pattern

 BEFORE ADMISSION

The client stated that she has an intermittent sleep, which comprises of 5-8 hrs of sleep.
She’s not taking any nap during afternoon since she is fun of watching TV shows in the afternoon.
Her usual position in sleeping is side lying position. Even she doesn’t have a continuous sleep; she
doesn’t take any sleeping pills. She also added that’s she don’t feel any tiredness upon waking up.
She is fond of watching television and chatting with her friends and neighbors

DURING CONFINEMENT

Now that the client is in the hospital, her sleep is always interrupted due to frequent
monitoring of Vital Signs. Her sleep is also interrupted due to the environment in the hospital.
She’s sleeping in a supine position.

6. Cognitive Perceptual Pattern

The client verbalized that she’s not using any hearing aid even though she have hearing
difficulty in both ears. She also stated that she doesn’t wear any eyeglasses ever since even though
she knew that she cannot see things clearly. She doesn’t have any history of check- up in any
ophthalmologist. Her pupils are equally rounded and reactive to light and accommodation. There are
no changes in his memory lately. Client is oriented to time and person. The easiest way for the client
to learn things are through reading. She doesn’t have any difficulty in learning new things.

7. Self Perception and Self Concept Pattern

The client describes herself as a simple woman living in a simple way of life. She’s a happy
person and not irritable. Before the illness started, there is no hindrance for her to do any activity
without limitations. But she said that from 2008 until now, there was really lot of changes. She doesn’t
mind those people who make her angry for she is an optimist person. She used to just ignore it and
just continue with her own life. The thing that makes her cry is when her husband and children are
sick. She loves her husband so much and she can’t take seeing her husband suffering from any pain.

8. Role-Relationship Pattern

The client belongs to an nuclear family. She is living with his husband with their few
children. She doesn’t have problems that are difficult to handle. Her family does necessarily depend on
her and her husband when she was still working but she was financially supported by her husband and
some relatives.. Every time their family encounters a problem; they used to talk about it immediately
for them to not prolong their problem. The most common problem that they encounter is financial
problem. Her support system in time of stress is her family especially her husband. She doesn’t belong
to any social groups but she has lots of friends. She doesn’t feel alone frequently because she’s always
with another person in the house. She does not feel isolated in her neighborhood. Her daughter also
added that when her mother will be bringing back home; they will buy him cane or crutches to help
her in moving. Even though there is a health center in their community. She’s not seeking health care
in the said facility.

9. Sexually-Reproductive Pattern

The client admitted that she was active in sexual intercourse during her young age. She also
admitted that she was satisfied in terms of her sexual aspects. She and her husband are not using
any contraceptives during their sexual intercourse.

10. Coping Stress Tolerance Pattern

The client is not tense a lot of time. She used to relax herself by watching television or
simply doing household chores or chatting with her friends. Her major stressors are her problems
regarding money. In order for her to be ok, he’s expressing her feelings to her family. They are always
available for her. There are no changes in her life for the last 2 years except for the retirement on his
work and her present condition. When she’s suffering on a high level of stress or serious problems,
she’s solving it immediately.

11. Value-Belief Pattern

The client said that she is not a religious person. She seldom goes to church but she does
pray every night before she sleep. She also added that she usually pray every time she encounters
any problem. She knows that she can’t have everything that she wanted but she accepted that. The
most important thing in her life now is her family more than his health. On a scale of 1-10; 10 being
the highest she chose 10. That’s how much important her family is. She stated that her religious
beliefs and practices do interfere in the hospital.

Physical Examination

ANALYSIS and
AREA TECHNIQUE NORMS FINDINGS
INTERPRETATION

I. HEAD
1. Size, Inspection Rounded Rounded (normocephalic);Normal
shape and Palpation (normocephalic andsmooth skull contour
symmetry of symmetrical, with
the skull frontal, parietal, and
occipital
prominences);
Smooth skull contour
2. Presence Palpation Smooth, uniformHas no tenderness; noNormal
of nodules, Inspection consistence; absencemasses nor nodules
masses, and of nodules or masses
depressions
3. Facial Inspection Symmetric or slightlySymmetrical and palpebralNormal
Features Palpation asymmetric facialfissure equal in size,
features; palpebralnasolabial folds are
fissure equal to size;symmetrical.
symmetric nasolabial

4. Presence Inspection No edema andNo hollowness Normal

of edema hollowness
and
hollowness in
the eye.
II. HAIR
1. Evenness Inspection Evenly distributedHair evenly distributed Normal
of growth, Palpation and covers the
thickness, or whole scalp; maybe
thinness of thick or thin
hair
2. Texture Inspection Silky; resilient hair Silky; smooth and resilientNormal
and oiliness Palpation hair.
over the
scalp
3. Presence Inspection No infection andNo infection and infestation Normal
of infection Palpation infestation
and
infestation
III. FACE

Facial Inspection Symmetric orAsymmetrical facialAbnormal:

features, slightly features while talking andPossibly showing
symmetry of asymmetrical facialelevating the eyebrow. weakness on the
facial features; affected side of the
movements body (hemiparesis).
Due to loss of voluntary
control over motor
movements.
IV. EYES
A. EYEBROWS
Hair Inspection Symmetrical and inSymmetrical and alignedNormal
distribution, line with each other;with each other; black;
alignment, maybe black, brownevenly distributed,
skin quality or blond dependingmovements are
and on race; evenlysymmetrical.
movement distributed

B. EYELASHES
Evenness of Inspection Evenly distributed;Turned outward eyelashes:Normal
distribution Palpation turned outward hair equally distributed.
and direction
of curl
C. EYELIDS
Surface Inspection Upper eyelids coverAble to close the eyes andNormal
characteristi the small portion ofhas the ability to blink.
cs and the iris, cornea, and
position (in sclera when eyes
relation to open; eyelids meet
the cornea, completely when the
ability to eyes are closed;
blink, and symmetrical
frequency of
blinking)

D. CONJUNCTIVA
1. Color Inspection Pinkish or red inPinkish in color; no foreignNormal.
texture and Palpation color; with presencebodies, no ulcers.
the presence of small capillaries;
of lesions in moist; no foreign
the bulbar bodies; no ulcers
conjunctiva
2. Color, Inspection Pinkish or red inPinkish or red in color; withNormal.
texture, and Palpation color; with presencepresence of small capillaries
the presence of small capillaries;
of lesions in moist; no foreign
the bodies; no ulcers
palpebral
conjunctiva
E. SCLERA
Color and Inspection White in color;White sclera with some visibleNormal.
clarity clear; no yellowishcapillaries
discoloration; some
capillaries maybe
visible

F. CORNEA
Clarity and Inspection No irregularities onClear and smooth in texture. Normal
texture the surface; looks
smooth; clear or
transparent
G. IRIS
Shape and Inspection Anterior chamber isDark brown in color; transparentNormal
color transparent: noanterior chamber.
noted visible
materials; color
depends on the
person’s race
H. PUPILS
1. Color, Inspection Color depends on thePupil equally round. Normal.
shape, and person’s race; size
symmetry of ranges from 3-7 mm,
size and are equal in size;
equally round

2. Light Inspection Constrict Dilates when looking at farNormal

reaction and briskly/sluggishly objects and constrict when
accommodati when light islooking at near objects.
on directed to the eye,
both directly and
consensual

I. VISUAL ACUITY
1. Near Inspection Able to readPresbyopia (loss of elasticity ofAbnormal.
Vision newsprint the lens and thus loss of abilityPresbyopia is the
to see close object). decrease ability of
the eye to
accommodate for
near vision. This
occurs as a normal
part of aging and
the lens becomes
less flexible. The
average age of
onset of
presbyopia is the
midforties.
(Essentials of
Anatomy and
Physiology 6th
edition by Seeley,
et. Al page 256.
J. LACRIMAL GLAND
Palpability Palpation No edema orNo tenderness and edema. Normal.
and tenderness over
tenderness lacrimal gland
of lacrimal
gland
K. EXTRAOCULAR MUSCLE
Eye Inspection Both eyesEyed moves with parallelNormal.
alignment coordinated’ move inalignment.
and unison, with parallel
coordination alignment
L. VISUAL FIELDS
Peripheral Inspection When lookingLoss of peripheral vision Abnormal: stroke
visual fields straight ahead, client can result in visual-
can see objects in perceptual
the periphery dysfunctions
caused by
disturbances of the
primary sensory
pathways between
the eye and visual
cortex.
V. EARS
A. AURICLES
1. Color, Inspection Color same as facialSame color as the facial skin; tipNormal
symmetry of skin; symmetrical;of auricle aligned at the outer
size and auricle aligned withcanthus of the eye.
position outer canthus of eye,
about 10 degrees
from vertical
2. Texture, Palpation Mobile, firm, and notSmooth in texture, flexible andNormal
elasticity and tender; pinna recoilselastic pinna; no tenderness.
areas of after it is folded
tenderness
B. HEARING ACUITY TESTS

Client’s Inspection Normal voice tonesCan hear normal volume, tonesNormal.

response to audible or words.
normal voice
tones
VI. NOSE

1. Any Inspection Symmetric andSymmetric and straight; uniformNormal

deviation in straight; nocolor with no nasal flaring.
shape, size, discharge or flaring;
or color and uniform color
flaring or
discharge
from the
nares
2. Nasal Inspection Nasal septum intactNasal septum intact and inNormal
septum Palpation and in middle midline.
(between the
nasal
chambers)
3. Patency of Inspection Air moves freely asBoth nasal cavities are patent. Normal.
both nasal the client breathes
cavities through the nares

4. Palpation Not tender; noNo tenderness or lesions. Normal

Tenderness, lesions
masses and
displacement
s of bone and
cartilage
VII. SINUSES
Identification Palpation Not tender No tenderness present. Normal.
of the
sinuses and
for
tenderness
VIII. MOUTH
A. LIPS
Symmetry of Inspection Uniform pink color;Uniform pink color; soft, moist,Normal.
contour, Palpation soft, moist, smoothsmooth texture; ability to purse
color and texture; symmetry oflips
texture contour; ability to
purse lips
B. BUCCAL MUCOSA
Color, Inspection Uniform pink color;Uniform pink color; moist,Normal.
moisture, moist, smooth, soft,smooth, soft
texture, and glistening, and elastic
the presence texture
of lesions
C. TEETH
Color, Inspection 32 adult teeth;Intact dentures Normal.
number and smooth, white, shiny
condition tooth enamel;
and smooth, intact
presence of dentures
dentures
D. GUMS

Color and Inspection Pink gums; noPink gums. Normal.

condition retraction

E. TONGUE/ FLOOR OF THE MOUTH

1. Color and Inspection Pink color; moist;Pink color; moist; thin whitishNormal.
texture of slightly rough; thincoating; moves freely; no
the mouth whitish coating;tenderness.
floor and moves freely; no
frenulum tenderness
2. Position, Inspection Central position;Located and positioned in theNormal
color and pink color; smoothcenter.
texture, tongue base with
movement prominent veins
and base of
the tongue
3. Any Palpation Smooth with noNo tenderness or masses. Normal
nodules, Inspection palpable nodules,
lumps or lumps, or
excoriated excoriated areas
areas
F. PALATES and UVULA

1. Color, Inspection Light pink, smooth,Lighter hard palate; more irregularNormal

shape, Palpation soft palate, lightertexture
texture and pink hard palate,
the presence more irregular
of bony texture
prominences
2. Position of Inspection Positioned inPositioned at the center. Normal
the uvula midline of soft
and mobility palate
(while
examining
the palates)
G. OROPHARYNX and TONSILS

1. Color and Inspection Pink and smoothPink and smooth. Normal.

texture posterior wall
2. Size, Inspection Pink and smooth;Pink and smooth; no discharge; ofNormal.
color, and no discharge; ofnormal size
discharge of normal size
the tonsils
3. Gag reflex Inspection Present Present Normal

IX. THORAX

A. ANTERIOR THORAX
1.Breathing Inspection Quiet, rhythmic, andNormal breathing pattern.Normal.
pattern effortless respirations Symmetrical chest expansions,
no retractions
2. Temperature, Palpation Skin intact; uniformHas intact skin; has equalNormal
tenderness, temperature; chestwarmth on both sides. No
masses wall intact; nomasses.
tenderness; no
masses
3. Anterior Auscultation Bronchovesicular andAbsence of crackles. ClearNormal.
thorax vesicular breathbreath sounds.
auscultation sounds
B. POSTERIOR THORAX
1.Shape, Inspection Anteroposterior toSymmetrical chest. Normal
symmetry, and Palpation transverse diameter
comparison of in ratio 1:2; chest
anteroposterior symmetric
thorax to
transverse
diameter

2.Spinal Inspection Spine verticallySpine vertically aligned Normal.

alignment aligned
3. Temperature, Palpation Skin intact; uniformNo masses nor tenderness: hasNormal
tenderness, temperature; chestequal warmth on each side
masses wall intact; no
tenderness; no
masses
4. Posterior Auscultation Vesicular andAbsence of crackles. Normal.
thorax bronchovesicular
auscultation breath sounds
XI. CARDIOVASCULAR

A. AORTIC and Auscultation No pulsations No pulsations felt Normal

PULMONIC
AREAS
B. TRICUSPID Auscultation No pulsations; no liftNo pulsations felt Normal
AREA or heave
C. APICAL AREA Auscultation Pulsation visible inHas full pulsation Normal
50% of adults and
palpable in most PMI
in 5th LICS at or
medial to MCL
D. EPIGASTRIC Auscultation Aortic pulsations Has pulsation Normal
AREA
E. Auscultation S1: Usually heard atHas full and rapid pulsation, 75Abnormal.
CARDIOVASCU all sites bpm. Blood
LAR AREAS Usually louder at theSounds on the aortic andpressure
AUSCULTATIO apical area pulmonic areas; has a lub soundindicates
N S2: Usually heard aton the apex and dub sounds onhypertension.
all sites the tricuspid area.
Usually louder at theBlood pressure is 180/80 mmHg
base of heart
Systole: silent
interval; slightly
shorter duration than
diastole at normal
heart rate (60 to 90
bpm)
Diastole: silent
interval; slightly
longer duration than
systole at normal
heart rates.
S3: in children and
young adults
S4: in many older
adults
XII. CAROTID ARTERIES
1. Carotid Palpation Symmetric pulseHas full pulsation. SymmetricalNormal.
artery palpation volumes; fullpulse volume.
pulsations, thrusting
quality; quality
remains same when
the client breathes,
turns head, and
changes from sitting
to supine position;
elastic arterial wall
XII. AXILLAE

1. Axillary, Inspection No tenderness,No tenderness, masses, orNormal.

subclavicular, masses, or nodules nodules
and
supraclavicular
lymph nodes
XIII. ABDOMEN
1. Skin integrity Inspection Unblemished skin;Uniform color. Normal.
uniform color
2. Abdominal Inspection Flat, roundedHas a flat and concave abdomen Normal
contour (convex), or scaphoid
(concave)
3. Enlargement Inspection No evidence ofNo enlargement of the spleenNormal
of liver or enlargement of liverand liver seen.
spleen or speen
4. Symmetry of Inspection Symmetric contour Has a symmetrical abdominalNormal
contour contour.
5. Abdominal Inspection Symmetric Abdominal movements notedNormal
movements movements causedwhen inhaling.
associated with by respiration; visible
respirations, peristalsis in very
peristalsis or lean people; aortic
aortic pulsations in thin
pulsations persons at epigastric
area
6. Vascular Inspection No visible vascularHas no blood vessel visible. Normal
pattern pattern
XIV. MUSCULOSKELETAL SYSTEM
A. MUSCLES
1. Muscle size Inspection Proportionate to theProportionate to the body; inNormal.
and body: even in bothboth sides.
comparison sides
on the other
side
2. Inspection No fasciculation andNo tremors. Normal.
Fasciculation tremors
and tremors
in the
muscles
3. Muscle Palpation Even and firm muscleFirm muscle tone Normal.
tonicity tone
4. Muscle Palpation Has equal muscularUnequal muscular strength Abnormal.
strength strength on both Patient is
sides experiencing
weakness on
the left side of
his body.
B. JOINTS

1. Joint swelling Inspection No swelling, noAbsence of swelling, pain orNormal.

warmth, no redness,redness.
no pain, no crepitus
EXTREMETIES Inspection No swelling, noAbsence of swelling, redness orNormal.
Palpation warmth, no redness,pain.
no pain.

Neurological Assessment

Category Normal Findings Actual Findings Analysis and

Interpretation

Mental Status Alert Alert Patient was able to

response in motor and
Level of Oriented Oriented to person, time and verbal activities.
Consciousness place
Coherent Patient was oriented.
Orientation Coherent

Language test Able to state what happened

Able to remember to him in the past
Recall

Cranial Nerves

Category Normal Findings Actual Findings Analysis and Interpretation

CN1 Able to smell and Able to smell Able to recognize alcohol in cotton
recognize stimuli alcohol in cotton. merely smelling.
Olfactory

CNII 20x20 vision, able Presbyopia(loss Abnormal. Presbyopia is the

to read newsprint of elasticity of the decrease ability of the eye to
Optic lens and thus loss accommodate for near vision. This
of ability to see occurs as a normal part of aging and
close object) the lens becomes less flexible. The
average age of onset of presbiopia is
the midforties.

CN III,IV, VI (+) Extraocular Pupils react to The patient has a normal eye
Movement (EOM); light. There is movement; pupils react to light and
Occulomotor Lateral Upward and constriction and able to move his eyes in any
Trochlear Downward; pupils consensual direction.
reactive to light accommodation.
Abducens Able to move the
eyes in any
direction in
unison.

CN V Able to feel and Able to feel the Patient response in the test and has
clearly identify tip of the reflex a normal sense of touch.
Trigeminal stimulus, with hammer while
bilateral facial covering his eyes
sensation, with and able to open
active corneal mouth against
reflex and
 mastication resistance

CN VII Facial symmetry (+) Facial Able to do facial expression

and muscle symmetry according to his feelings
Facial movement,
salivation and Able to taste; no
tearing, taste and difficulty in
sensation in the swallowing.
ear.

CN VIII Able to hear Cannot maintain Weakness present on left side thus,
clearly, can balance cannot maintain balance.
Vestibulocochlear maintain balance

CN IX, X (+) gag reflex, Present gag Patient was able to identify the taste
uvula at the center, reflex, able to of the food.
Glossopharyngeal soft palate rises swallow and able
Vagus to identify the
taste of the food

CN XI Able to shrug Cannot able to Patient was able to move or turn his
shoulders against shrug shoulders head from right to left and but
Accessory (Spinal) resistance and able against unable to shrug his left shoulder
to turn the head resistance and against resistance.
side and against can turn the head
resistance. from right to left

CN XII Able to move Able to protrude Patient able to move tongue without
tongue from side to tongue and move difficulty.
Hypoglossal side it side to side

Muscle Strength

Category Normal Findings Actual Findings Analysis and Interpretation

Right Arm 100% of normal 100% of normal Patient able to move on his
strength; active motion strength; full muscle right arm with full muscle
against full resistance movement against movement without difficulty.
gravity; with support.

Left Arm 100% of normal 25% of normal Patient not able to move on
strength; active motion strength; full muscle his left arm with full muscle
against full resistance movement against movement without difficulty.
gravity

Right Leg 100% of normal 100% of normal Patient able to move on his
strength; active motion strength; full muscle right leg with full muscle
against full resistance movement against movement without difficulty.
gravity; with support.
Left Leg 100% of normal 25% of normal Patient not able to move on
strength; active motion strength; full muscle his left leg with full muscle
against full resistance movement against movement without difficulty.
gravity