Capitol University College of Nursing Cagayan de Oro City

A CASE STUDY ON CEREBROVASCULAR DISEASE

Presented to : Mr. Ryan Manuel Nasol, RN Clinical Instructor Abao, Ruzzelyn R. Alondres, Rudyfer D. Amante, Elizabeth C. Amores, Amor Grace C. Amores, Raiza F. Apilan, Mariel Q. Arellano, Aileen Faye J. Bacsarsa, Flora Mae P. Bancale, Apple May L. Caberte, Kimberly Anne U Cabuya on , Honey Mae S. Cagaa -nan, Elma O.

INTRODUCTION
Cerebrovascular disease is a group of brain dysfunctions related to disease of the blood vessels supplying the brain.
Cerebrovascular disease is the leading cause of disability in adults and each year millions of stroke survivors has to adapt to a life with restrictions in activities of daily living as a consequence of cerebrovascular disease.
In 2001 it was estimated that cerebrovascular diseases (stroke) accounted for 5.5 million deaths worldwide, equivalent to 9.6 % of all deaths Two-thirds of these deaths occurred in people living in developing countries and 40% of the subjects were aged less than 70 years.

Cerebrovascular disease is the leading cause of disability in adults and each year millions of stroke survivors has to adapt to a life with restrictions in activities of daily living as a consequence of cerebrovascular disease.
The 1990 Global Burden of Disease (GBD) study provided the first global estimate on the burden of 135 diseases, and cerebrovascular diseases ranked as the second leading cause of death after ischemic heart disease.

SPECIFIC OBJECTIVES
At the end of the case presentation, the audience should be able to: Have a thorough understanding about the disease process of the case presented Identify and comprehend the signs and symptoms of the disease and the causes leading to such manifestations Learn, understand the purpose, and later on practice ideal management for cases similar to the case presented Have the necessary information about the treatment and other modalities in caring for a patient presenting similar manifestations as in the case presented Understand and have the proper behavior when caring for a patient presenting with the same neurological problems as in the case discussed Perform with/apply appropriate actions and/or manners when handling a patient with a related illness and when interacting with patients significant others

SCOPE AND LIMITATION

The case study includes:
The overview of the patient's health condition and its disease process. The priority nursing diagnoses identified and its corresponding nursing and medical interventions. The anatomy and physiology of the systems affected by the illness. The Pathophysiology of the disease. The list and the individual study on the different drugs of our patient as prescribed by the physician. The different diagnostic tests undergone by the patient at the time of our assessment with their results and interpretation

DEMOGRAPHIC DATA
This is a case of Client X, 77-year-old Filipino female who was born on October 5, 1934 and presently residing at Villanueva, Misamis Oriental. She is

a Roman Catholic, widower with 7 children. She is a elementary graduate and

used to work as a plain housekeeper . He weights 60kg but after series of hospitalizations his weight gradually decreased up to 5kg and stands 52. She was admitted at Northern Mindanao Medical Center last June 19, 2011 6:00 PM

at the female ward, due to change in sensurium, had sudden body malaise
with headache. She has an admitting blood pressure of 150/100 mmHg, respiratory rate of 24 cpm, pulse rate of 60 bpm and temperature of 36.8 degrees Celsius. She admitting and final diagnosis is Cerebrovascular Disease, probably hemorrhagic, hypertensive Cardiovascular Disease.

CLIENTS PROFILE

HISTORY OF PRESENT ILLNESS

Two days prior to admission, Client X had

sudden onset of body malaise, severe headache and

disoriented to time and place. Despite the medications taken, patient had a persistence of headache which leads him to seek for consultation.

CLIENTS PROFILE

HISTORY OF PAST ILLNESS

In her adult years, Client X has recurrences of high blood pressure but has not sought medical consultation.

She has no Diabetes mellitus, only have a high blood pressure especially when patient is stress in managing her poultry. At present, he maintains in drinking herbal medicine and herbal tea in treating his hypertension.

CLIENTS PROFILE

FAMILY HEALTH HISTORY

Clients father died and had hypertension. Her

mother was diagnosed of Acute Renal Failure (ARF) at the age of 28, and had developed hypertension, and died

at the age of 68 years from renal failure. Client X has one

sister and two brothers. Her sister, 68, is healthy and has no known illnesses at present. Her brothers, 78 and 72 are both hypertensive.

CLIENTS PROFILE

PYSCHO AND SOCIAL HISTORY

Client X, the youngest child among four, was born in Gingoog, Misamis Oriental. She spent majority of his childhood with his family. She is elementary graduate. Her husband died last 2009 and who is from Lanao del Norte. The couple married in the year 1973 and had a child. Client X is a Catholic, joining church services during Sundays but does not have any spiritual organization.

CLIENTS PROFILE

NUTRITIONAL AND LIFESTYLE PATTERN She has no history of food and drug allergies or hypersensitivities. She denies of having smoked but drinks alcoholic beverages occasionally. As she was diagnosed of Hypertension after series of routine blood pressure monitoring, clients physician advised her to avoid salty and fatty foods (Low-Salt and Low-Fat diet) which she still manages to strictly maintain and since the client cannot tolerate in eating via the mouth, client is being fed via NGT. She has a poor appetite.

CLIENTS PROFILE

ELIMINATION PATTERN

She voids 3-5 times a day (1000-1200/day) with yellowish urinee and usually defecates

2/day with brownish and sometimes a watery

stool but during her confinement he had difficulty in defecating.

CLIENTS PROFILE

Activity and Exercise Pattern

She does not have a regular exercise due to her age.

Sleep Rest Pattern She normally sleeps from 9 PM and wakes up at 3 AM. She also sleeps during afternoon time. She has difficulty of sleeping continuously and easily disturbed by the noises. She also felt discomfort during sleeping.

Role Relationship Pattern

She lives with his daughter and has a good relationship. Her daughter supports her always.

CLIENTS PROFILE

SEXUALITY AND REPRODUCTIVE PATTERN

Client X is not sexually active anymore because of her age and status. Before, when she was a teenager she always uses contraceptive method like pills is 100% safe to use. She has a regular menstrual period before menopausal stage. COGNITIVE AND PERCEPTUAL PATTERN Client X is not using any deviceslike auditory and visual. She is oriented to time, place, person and knows her reason for admission. She is not able to speak and strives to listen well. There is difficulty uttering words. There is difficulty of speech. Difficulty in expressing thoughts verbally COPING STRESS TOLERANCE PATTERN Client X is worried about her condition. She anticipates going home.

CLIENTS PROFILE

PHYSICAL ASSESSMENT
Decrease level of consciousness Hair not evenly distributed Discomfort in hyperextending neck Dark periorbital skin Dry, cracked, pales lips Wrinkled hands Wrinked feet Skin turgor: 2 sec. sternum Edema

Pale conjuctiva

Pale, dry & flaky

Pale Nails, capillary refill 3 sec. Skin turgor: 3sec. Clavicle, Wrinkled neck

ANATOMY
The Brain Three cavities, called the primary brain vesicles, form during the early embryonic development of the brain. These are the forebrain (prosencephalon), the midbrain (mesencephalon), and the hindbrain (rhombencephalon). The names of these vesicles and the major adult structures that develop from the vesicles. The telencephalon generates the cerebrum (which contains the cerebral cortex, white matter, and basal ganglia). The diencephalon generates the thalamus, hypothalamus, and pineal gland. The mesencephalon generates the midbrain portion of the brain stem. The metencephalon generates the pons portion of the brain stem and the cerebellum. The myelencephalon generates the medulla oblongata portion of the brain stem second method for classifying brain regions is by their organization in the adult brain. The following four divisions are recognized.

The cerebrum consists of two cerebral hemispheres connected by a bundle of nerve fibers, the corpus callosum. The largest and most visible part of the brain, the cerebrum, appears as folded ridges and grooves, called convolutions. The following terms are used to describe the convolutions: A gyrus (plural, gyri) is an elevated ridge among the convolutions. A sulcus (plural, sulci) is a shallow groove among the convolutions. A fissure is a deep groove among the convolutions. The deeper fissures divide the cerebrum into five lobes (most named after bordering skull bones)the frontal lobe, the parietal love, the temporal lobe, the occipital lobe, and the insula. All but the insula are visible from the outside surface of the brain. A cross section of the cerebrum shows three distinct layers of nervous tissue:

The cerebral cortex is a thin outer layer of gray matter. Such activities as speech, evaluation of stimuli, conscious thinking, and control of skeletal muscles occur here. These activities are grouped into motor areas, sensory areas, and association areas. The cerebral white matter underlies the cerebral cortex. It contains mostly myelinated axons that connect cerebral hemispheres (association fibers), connect gyri within hemispheres (commissural fibers), or connect the cerebrum to the spinal cord (projection fibers). The corpus callosum is a major assemblage of association fibers that forms a nerve tract that connects the two cerebral hemispheres.

Basal ganglia (basal nuclei) are several pockets of gray matter located deep inside the cerebral white matter. The major regions in the basal gangliathe caudate nuclei, the putamen, and the globus pallidusare involved in relaying and modifying nerve impulses passing from the cerebral cortex to the spinal cord. Arm swinging while walking, for example, is controlled here.

The diencephalon connects the cerebrum to the brain stem. It consists of the following major regions: The thalamus is a relay station for sensory nerve impulses traveling from the spinal cord to the cerebrum. Some nerve I mpulses are sorted and grouped here before being transmitted to t he cerebrum. Certain sensations, such as pain, pressure, and temperature, are evaluated here also. The epithalamus contains the pineal gland. The pineal gland s ecretes melatonin, a hormone that helps regulate the biological clock (sleep-wake cycles). The hypothalamus regulates numerous important body activities. It controls the autonomic nervous system and regulates emotion, behavior, hunger, thirst, body temperature, and the biological c lock. It also produces two hormones (ADH and oxytocin) and various releasing hormones that control hormone production in the anterior pituitary gland.

PATHOPHYSIOLOGY

LABORATORY RESULTS
CT SCAN REPORT

Multiple sequential axial tomography sections of the head from the skull base to the vertex without contrast reveal the following findings.
Punctuate hypo densities noted in the superior of the right external capsule and right frontal while matter. Tiny calcification is seen in the left globus pallidus. No mass or mass effect is seen. Both external carotic arteries are calcified. No evidence at intracerebral hemorrhage. No abnormal extra axial fluid collection or hematoma. Ventricles are within normal. No shifting of midline structures. Cerebellum and pons are not unusual. Sella, petromastcia, orbits and paranasal sinuses are intact.

Impression: 1. Lacunar infarcts, right external capsule and right frontal while matter. 2. Tiny calcification, left globus pallidus.

3. Calcified internal carotic arteries.

COMPLETE BLOOD COUNT

Exam

Normal Value 12.0 - 16.0

Result (12/14/10) 8.3 decreased 26.0 decreased 16.0 increased 2.98 decreased 9.4 decreased 85.1 high

Clinical Significance May indicate anemia, or polycythemia; may also indicate fluid imbalances in dehydration, or diarrhea. May indicate anemia, or polycythemia; may also indicate fluid imbalances in dehydration, or diarrhea.

Hmg

Hct

37.0 47.0

WBC

5.0 10.0

This shows presence of inflammation and infection. This indicates alteration in erythropoietin production secondary to renal malfunction. Patient is prone to immunosupression since his lymphocytes aresmall in number. indicates infection

RBC

4.2 5.4

Lymphocyte

17.4 48.2 43.4 76.2

Neutrophil

SERUM BUN, SERUM CREATININE AND SERUM POTASSIUM

Exam BLOOD UREA NITROGEN Normal Value 15.0 45.0 mg/dl Rationale The test that measures the amount of BUN per liter of blood The test measures the amount creatinine per liter of blood The test measures electrolyte level of Potassium in the blood The test measures electrolyrte level of Sodium in the blood The test measures the level of glucose in the blood Result (12/12/10) 54.6 mg/dL Increased Result (12/14/10) 64.48 mg/dL Increased Clinical Significance
Increased BUN levels suggest impaired kidney function

CREATININE

0.6 1.2 mg/dl

6.29 mg/dL increased

7.6 mg/dL increased

Result was abovenormal thus showing inability of the kidney to excrete nitrogenous waste product of protein leading to its accumulation in the blood.

POTASSIUM

3. 9 5.4 mg/dL

5.3 mmol/L Normal

5.34 mg/Dl normal

Normal

SODIUM

134 149 mg/dL

128.0 mg/dL decreased

Result was below normal thus showing the fluid and electrolyte imbalance.

GLUCOSE

59.9 110.1 mg/dL

94,8 mg/dL

normal

DRUG STUDY
DRUG ORDER Generic name: captopril Brand name: Capten Classifica tion: ACE inhibitor Dosage: 20 mg Route: NGT Frequenc y: OD MECHANI SM OF ACTION Blocks ACE from converting angiotensin 1 to angiotensin II, a powerful vasoconstri ctor, leading to decreaseB P, decrease aldosterone secretions a small increase of potassium levels and sodium and fluid loss; increased prostagland ins synthesis also may be involved in the antihyperte nsive action. INDICAT ION Treatme nt for hyperten sion alone or combinat ion with thiazide type diuretics CONTRAINDIC ATION With allergy to Captopril, history of angioedema, second or 3 rd trimester of pregnancy ADVERSE EFFECT CV: tanchycardia, angina pectoris, CHF, hypotension; DERMATOL OGIC : rash, pruritus, scaled mouth sensation, alopecia; GI: gastric irritation, peptic ulcer, jaundice, anorexia, constipation; GU: proteinuria, renal insufficiency, renal failure, polyuria; HEMATOLO GIC: Neutopenia, thrombocytop enia; OTHER : cough, malaise, dry mouth. NURSING RESPONSIBI LITIES Administer 1 hour before meal; Monitor patient for drop of blood pressure; report any unusualties

DRUG ORDER

MECHA NISM OF ACTION

INDICATION

CONTRAINDI CATION

ADVERSE EFFECT

NURSING RESPONSIBI LITIES

Generic name: simvastatin Brand name: Zocor Classificati on: Antihyperlipi demic HMG CoA

Inhibits HMG CoA reductas e, the enzyme that catalyzes the first step in the cholester ol synthesis pathway resulting in a

Diet in the treatment of elevated total cholesterol and LDLs cholesterol with primary hyperchole sterolemia

With allergy to this drug and fungal by product

CNS: Headache, asthesia, sleep disturbanc e GI: Flatulence, diarrhea, abdominal pain. Cramps, constipatio n, nausea, dyspepsia, heartburn, liver failure RESPIRAT ORY: Sinusitis, pharyngitis
-

Take this drug in the evening and do not drink grape juices while taking this drug Monitor the serum cholestero l level

Reductase Inhibitor Dosage: 40mg Route: NGT Frequency: HS

decrease in serum cholester ol, serum LDLs and either an increase or no change in serum HDLs

DRUG ORDER

MECHANI SM OF ACTION

INDICATI ON

CONTRAINDICA TION

ADVER SE EFFEC T

NURSING RESPONSIBILI TIES

Generic name: lactulose Brand name: Cephulac Classificati on: Laxatives ammonia reduction Dosage: 30cc Route: NGT Frequency: HS

Drug passes uncharged into the colon where break in down to organic acid that increases pressure in the colon and slightly acidify the colonic content, resulting in

Treatment for constipati on

With allergy to lactulose, low

GI: transient flatulenc e, abdomin al distensi on, intestina l cramps, belching , nausea, diarrhea , OTHER: acidbase imbalan ce

Monitor vital signs; intake & output

galactose diet

Do not use other laxatives while taking this drug

I nsure

that

the patient is readily accessible to the bathroom

increase in stool water content/sto ol softening. This also result in

migration of blood ammonia in the colon with subsequen t tapping and

DRUG ORDER

MECHANIS M OF ACTION

INDICATIO N

CONTRAINDIC ATION

ADVERS E EFFECT

NURSING RESPONSIBIL ITIES Monitor vital signs and intake and output as baseline of care; Taken with or without food; Provide safety measures

Generic name: ceticoline Brand name: Zynapse Classificat ion: Neuroprote ctive Dosage: 500 mg Route: NGT Frequency : TID

Activates the biosynthesis of structural phospholipi ds in the neural membrane, increase cerebral metabolism and increase level of various neurotrans mitter.

Treatment for cerebrovas cular disease; accelerates recovery of memory and overcoming motor deficit.

with parasympathetic hypertonia

GI: gastric disorders , nausea, vomiting; ALLERG IC REACTI ON: rash, itching or hives, swelling in face/han ds, mouth/thr oat, chest tightness, trouble breathing , low BP (dizzines s, faintness ) headach e

DRUG ORDER

MECHAN ISM OF ACTION

INDICA TION

CONTRAINDI CATION

ADVERSE EFFECT

NURSING RESPONSIBI LITIES

Generic name: metropolol Brand name: Lopressor Classifica tion: Antihypert ensive Beta adrenergic blocker Dosage: 50mg Route: Oral Frequenc y: OD

Acts in the CNS to reduce sympathe tic outflow and vasocons trictor

Hyperte nsion

Use cautiously With diabetes or COPD.

CNS: dizziness,headac he,fatigue ; GI: diarrhea, nausea,vomiting,a bdominal pain; GU: genital pruritus; Hematologic: neutropenia, thrombocytopenia ; Musculoskeletal: joint pain; Skin: erythematous rashes; Other: hypersensitivity reactions, serum sickness

*Ensure the patient to shallow the tablet. * Enumerate the side effects that the patient may experience * Report for any unusualities

DRUG ORDER

MECHANI SM OF ACTION

INDICATI ON

CONTRAINDICA TION

ADVER SE EFFEC T

NURSING RESPONSIBILI TIES

Generic name: sodium bicarbonate Brand name: Sodium bicarbonate Classificati on: Antacid Dosage: 250 Route: Oral Frequency: BID

Buffers excess hydrogen ion concentrati on, increases blood PH, neutralizes or reduces gastric acidity

Treatment for metabolic acidosis

Allergy: low serum chloride

GI: belching , gastric distentio n; Metaboli c: alkalosis , tetany; Skin: rashes, dry,tissu e damage ; Urogenit al: impaired kidney function

*Monitor ABG *Instruct the patient to shallow the tablet *explain the side effects and encourage patient to report any problems

DRUG ORDER

MECHAN ISM OF ACTION

INDICATI ON

CONTRAINDI CATION

ADVERSE EFFECT

NURSING RESPONSIB ILITIES

Generic name: omeprazo le Brand name: Losec Classific ation: Gastroint estinal agent, Proton Pump inhibitor Dosage: 40mg Route: Oral Frequenc y: BID

Suppressi on gastric acid secretion relieving gastrointe stinal distress and promoting ulcer healing.

Longterm treatment of pathologi c hypersec retory condition s such as multiple endocrin e adenoma , and systemic mastocyt osis

Long-term use for gastroesophag eal reflux disease, duodenal ulcers, lactation

CNS: dizziness,headac he,fatigue; GI: diarrhea, nausea,vomiting,a bdominal pain; GU: genital pruritus; Skin: rashes; Urogenital: hematuria; Other: hypersensitivity reactions, serum sickness

Monitor urinalysis *Report for severe diarrhea;drug may need to be discontinue *encourage patient to report for any health problems

DRUG ORDER

MECHA NISM OF ACTION

INDICA TION

CONTRAINDI CATION

ADVERSE EFFECT

NURSING RESPONSIBI LITIES

Generic name: essential amino acid Brand name: Ketosteril Classifica tion: Antihypert ensive agent, calcium channel blocker Dosage: 600mg Route:

Normaliz es metaboli c process recycling product exchang e. Reduces ion concentr ation of potassiu m, magnesi um and phosphat e

*Protein energy malnutrit ion *prevent ion and treatme nt of conditio n cause by modified or insufficie nt protein metaboli sm in chronic renal failure.

Allergy an hypersensitivit y to any content of this drug, Hypercalcemia , Disturded amino acid metabolism, Caution use for patient with phenylketonuri a

CNS: dizziness,headach e,fatigue; GI: diarrhea, nausea,vomiting,a bdominal pain; GU: genital pruritus; Hematologic: neutropenia, thrombocytopenia; Musculoskeletal: joint pain; Skin: erythematous rashes; Other: hypersensitivity reactions, serum

*evaluate for any contraindicati ons *take drug as prescribe o recognize about the possible side effects and how to recognize them. *give with food if GI upset occurs

DRUG ORDER

MECHANI SM OF ACTION

INDICATI ON

CONTRAINDICA TION

ADVERS E EFFECT

NURSING RESPONSIBILI TIES

M onitor BP very carefully M onitor Cardiac Rhythm regularly Administe r drug without regards to meals Provide safety (side rails up) Observe for any adverse effects and notify physician if there is any

Generic name:
amlodipine

Brand name: Aginal Classificati on:

Calcium Channel Blocker

Dosage: 10 mg Route: Oral Frequency : OD

Inhibits the movement of Calcium ion across the membranes of Cardiac and arterial muscle cells: inhibits the transmembr ane Calcium flow, which results in the depression of impulse formation in specialized cardiac pacemaker cells, slowing the velocity of conduction of the cardiac impulse, depression of myocardial contractility and dilation of coronary arteries and arterioles and peripheral arterioles: these effects lead to decrease cardiac work, decreased cardiac oxygen consumptio

Essential Hypertensi on

Allergy to Amlodipine Impaired Hepatic and Renal function Sick Sinus syndrome

CNS: dizziness, light headedne ss, headache asthenia, fatigue lethargy CV: Peripheral edema, arrythmias Dermatolo gic: flushing, Rash GI: Nausea, abdominal discomfort

NURSING CARE PLAN

ASSESSMENT DATA (Subjective & Objective Cues) Subjective Cues: dili siya makalihok pag NURSING DIAGNOSIS GOALS AND OBJECTIVES (Problem and Etiology) NURSING INTERVENTIONS AND RATIONALE EVALUATION

siya ra isa as verbalized by the daughter.

Activity Intolerance related to Loss of Muscle strength secondary to LeftSided Body Weakness

Within 8 hours of nursing interventions, the client will be able to:

Independent 1.

Evaluated clients actual and perceived limitation /degree of deficit in light usual status.
R: provides comparative baseline and provides information about needed education/interventions.

GOALS PARTIALLY MET.

Short term Objective Cues:

Impaired ability to turn to sides, move from supine to sitting position and to reposition self in bed noted Weakness noted Vital signs = 150/100 mmHg =60 bpm

Achieve improved activity tolerance in terms of turning to sides, and of changing positions Maintained position that allows improved function and skin integrity as evidenced by absence of contractures, decubitus ulcers and so forth

Turned dependent client frequently (every 2 hours), utilizing bed and mattress positioning settings to assist movements, reposition in good body alignment, using appropriate support R: to promote optimal level of function and to prevent complications. 3. Instructed client and caregivers aim for positions which is most comfortable to client R: To encourage client to achieve independence and improve comfort
2. 3.

At the end of 8 hours of nursing intervention, the client has achieved improved physical mobility in terms of turning to sides, but still cannot sit down on bed alone

Observed skin for reddened areas/shearing. Provided appropriate pressure relief to reduce friction, maintain safe skin and wick away moisture
R: Early identification of skin problems may alleviate further complications and avoid unnecessary discomfort to client Instructed SOS to limit the activities/exertion of the client R: to prevent overexertion Assisted in learning and demonstrating appropriate safety measures R: to prevent injuries Encouraged to have early ambulation R: to promote proper circulation of blood and venous return Encouraged to maintain positive attitude; suggest use of relaxation techniques. Such as visualization/guided imagery and deep breathing exercise R: to enhance w ell-being and reduce tension Explained to the client the importance od Range of motion exercises. R: for patients deeper understanding and to gain rapport and cooperation Assisted patient in doing Passive Range of Motion. R: to promote good circulation . Collaborative

maintained position that allows her comfort, demonstrated behaviors/techniqu es but still enable completion of Activities of Daily Living

Functional level classification = 2 (requires help from another person)

4.

Long term Demonstrate behaviors/technique s that enable completion of Activities of Daily Living such as toileting, eating, grooming, bathing and etc.
5.

6.

7.

8.

9.

ASSESSMENT DATA
(Subjective & Objective Cues)

NURSING DIAGNOSIS
(Problem and Etiology)

GOALS and OBJECTIVES After 4 hours of nursing intervention Short term:

NURSING INTERVENTIONS and RATIONALE

EVALUATION

Subjective: Maglisod gyud ni siya ug istorya. Murag wla bitaw mugawas na tingog sa iyang tilaok., as verbalized by the daughter. Objectives: There is difficulty uttering words. There is difficulty of speech. Difficulty in expressing thoughts verbally Difficulty in use of facial/body expression

Impaired verbal communication related to neuromuscular impairment

Independent The short term goals were partially met since the learned to develop eye to eye contact as a way of better communication. The client continued to manifest difficulty in uttering words.

1. Provided alternative methods of communication, like pictures or visual cues, gestures or demonstration. a. The client will be R: Provide communication needs or desires based able to on individual situation or underlying deficit. communicate by 2. Anticipated and provided for Clients needs. writing or sign R: Helpful in decreasing frustration when dependent on others and unable to communicate desires. language b. The patient will 3. Talked directly to patient. Speaking slowly and establish method of directly. Use yes or no question to begin with. communication in R: It reduces confusion or anxiety and having to which needs can process and respond to large amount of information at one time. be expressed. 4. Spoke in normal tones and avoid talking too Long term: fast. Give patient ample time to respond. R: Patient is not necessary hearing impaired and raising voice may irritate or anger the patient. After 4 days of 5. Encouraged family members and visitors to nursing intervention persist efforts to communicate with the patient. the client will be able R: It is important for family members to continue to improve her communication skills talking to the patient to reduce patients isolation, and this will also promote establishment of effective communication and maintain sense of connectedness or bonding with the family.

The long term objective was partially met. The client manifested a development in nonverbal ways of communication.

ASSESSMENT DATA
(Subjective & Objective

NURSING DIAGNOSIS
(Problem and Etiology)

GOALS and OBJECTIVES Short-term:

NURSING INTERVENTIONS and RATIONALE Independent:

EVALUATION

Cues)

Subjective: Maglisod siya ug tulog mao ng mag problema mi usahay kay maghilak man gud siya dayon gusto na mo uli sa balay., as verbalized by the daughter. Sa tunga2x sa gabii mag mmmmmm lang na siya., as verbalized by the daughter.

Disturbed sleep pattern r/t presence of discomfort.

At the end of 8 hours of 1. Assisted the client into a comfortable nursing interventions, position. the client will be able to R: Comfortable position will facilitate a good nights sleep sleep and rest for at least 6-8 hours without 2. Provided patient with additional sleeping interruption aids like pillows/blankets. R: Facilitates sleep 3. Assisted patient to practice relaxation techniques. R: Relaxation techniques provide measures that relax the body systems, reducing pain and promoting sleep 4. Provided an environment conducive to sleep. R: Enhances comfort and promotes sleep 5. Restricted caffeine, alcohol, and other stimulating substances and avoid giving large meals a few hours before bedtime. R: These factors are known to disrupt sleep pattern.

The short term objective was partially met as evidence by a feeling of being relaxed after waking up as verbalized by the patient.

Long-term: After 3 days, the client will:

Objective: no of hours: 4-6 hours at night. (+) weakness (+) fatigue (+) irritable

a. report 6-8 hours of nights sleep without disturbance/awakening b. show no physical signs of sleep deprivation

The long term objectives were partially met since the Patient still manifest sleep deprivation due to hallucination as evidence by waking up at the middle of the night and is difficult to fall asleep again.

ASSESSMENT DATA
(Subjective & Objective Cues)

NURSING DIAGNOSIS

(Problem and Etiology) Subjective: Hopelessness related to deteriorating Ambot nalang gyud ni mama, gakawad-an man physiological gud siyag gana mabuhi condition usahay, kapoy na ba. as verbalized by daugher Uli nako., as verbalized by the patient. Objective: Anticipates going home lack of initative Dependent on performing ADLs passitivity, decreased verbalization decreased response to stimuli decreased sleep lack of involvement in care

GOALS and OBJECTIVES

Short term: After 8 hours of nursing intervention, the patient will: a. Communicate personal feelings of hopelessness

NURSING INTERVENTIONS and RATIONALE EVALUATION

Independent: 1. Establish a therapeutic and facilitative care with positive regard for the patient. R: Patient may feel safe to disclose feelings and feel understood or listened to. 2. Assist with self care needs R: To make the patient feel the support. 3. Provide quiet environment and emphasize importance of rest. R: Conserves energy and allows rest The short term goal was fully met since the patient participate in diversional activities such as watching TV and the patient was able to communicate feelings of hopelessness.

Long term: After 32 hours of nursing intervention, the patient will be able to:

4. Provide positive feedback for actions taken to deal with and overcome feelings of behavior.
R: Encourages continuation of desired behaviors

The long term goal was not met.

a. Communicate 5. Include client and SO in the plan of care and express feelings of wellness hope. or of being hopeful. R: Client may identify hope in own situation. b. Have SO be willing to listen to patients 6. Prevent situations that patient may feel isolated or out of concerns control of her own situation. R: To avoid further feelings of hopelessness Collaborative: 1. Refer to counselor or spiritual advisor R:To provide psychological, emotional and spiritual support.

ASSESSMENT DATA
(Subjective & Objective Cues)

NURSING DIAGNOSIS
(Problem and Etiology)

GOALS AND OBJECTIVES NURSING INTERVENTIONS and RATIONALE Independent: EVALUATION

Risk Factors: body weakness(right sided) unable to move herself to sides, from supine to sitting decreased ROM

Risk for impaired skin integrity related to decrease activity to move.

Within 8 hours of nursing management client will be able to:

1. Assessed skin routinely, noting moisture, color, and elasticity. R: this may indicate particular vulnerability. 2. Observed for reddened/blanched areas of skin R: this reduces likelihood of progression to skin breakdow n Instructed SOS the need/importance of massaging the bony prominences and the use of proper positioning, turning, lifting and transferring when moving client R: to prevent friction or shear injury 3. 4. Instructed and demonstrated change position in bed/chair on a regular schedule and encourage early ambulation, active and assistive range-of-motion R: to promote proper blood circulation 5. Instructed the importance of adequate clothing/covers; protect from drafts R: to prevent vasoconstriction 6. Kept bedclothes dry and wrinkle free, use nonirritating linens and provide protection by use of pillows R: to increase circulation and limit/eliminate excessive tissue pressure 7. Instructed SOS to change diapers frequently; cleanse perineal skin daily and after incontinence episode R: to minimize contact w ith irritants(urine, stool, excessive moisture) 8. Emphasize importance of adequate nutritional/fluid intake R: to maintain general good health and skin turgor. 9. Kept the nails short

Goals met At the end of 8 hours nursing management client was able to:

Short term: Client and significant (SOs) identify the risk factors Client and significant others (SOs) verbalize understanding of the importance of treatment/ therapy regimen. Maintain position that allows improved function and skin integrity as evidenced by absence of contractures, decubitus ulcers and so forth

Client and SOS identified the risk factors that could contribute to skin breakdown SOS verbalized understanding regarding the need of treatment to prevent from any additional complication Client maintained position that allow her improved her comfort and skin integrity Demonstrate behaviors in preventing skin breakdown

Long term: Demonstrate behaviors/techniques to prevent skin breakdown

Independent: Risk for impaired skin integrity related to decrease activity to move. Within 8 hours of nursing management client will be able to: 1. Assessed skin routinely, noting moisture, color, and elasticity. R: this may indicate particular vulnerability. 2. Observed for reddened/blanched areas of skin R: this reduces likelihood of progression to skin breakdow n Instructed SOS the need/importance of massaging the bony prominences and the use of proper positioning, turning, lifting and transferring when moving client R: to prevent friction or shear injury 3. 4. Instructed and demonstrated change position in bed/chair on a regular schedule and encourage early ambulation, active and assistive range-of-motion R: to promote proper blood circulation 5. Instructed the importance of adequate clothing/covers; protect from drafts R: to prevent vasoconstriction 6. Kept bedclothes dry and wrinkle free, use nonirritating linens and provide protection by use of pillows R: to increase circulation and limit/eliminate excessive tissue pressure 7. Instructed SOS to change diapers frequently; cleanse perineal skin daily and after incontinence episode R: to minimize contact w ith irritants(urine, stool, excessive moisture) 8. Emphasize importance of adequate nutritional/fluid intake R: to maintain general good health and skin turgor. 9. Kept the nails short R: to reduce risk of dermal injury w hen sever itching is present Collaborative: 1. Refer to dietitian as appropriate as the finances availability R: to identify nutritional needs. Goals met At the end of 8 hours nursing management client was able to:

Risk Factors: body weakness(right sided) unable to move herself to sides, from supine to sitting decreased ROM

Short term: Client and significant (SOs) identify the risk factors Client and significant others (SOs) verbalize understanding of the importance of treatment/ therapy regimen. Maintain position that allows improved function and skin integrity as evidenced by absence of contractures, decubitus ulcers and so forth

Client and SOS identified the risk factors that could contribute to skin breakdown SOS verbalized understanding regarding the need of treatment to prevent from any additional complication Client maintained position that allow her improved her comfort and skin integrity Demonstrate behaviors in preventing skin breakdown

Long term: Demonstrate behaviors/techniques to prevent skin breakdown

Independent: Within 8 hours of nursing management client will be able to: 1. Assessed skin routinely, noting moisture, color, and elasticity. R: this may indicate particular vulnerability. 2. Observed for reddened/blanched areas of skin R: this reduces likelihood of progression to skin breakdown Short term: Cli ent and significant (SOs) identify the risk factors Client and significant others (SOs) verbalize understanding of the importance of treatment/ therapy regimen. Maintain position that allows improved function and skin integrity as evidenced by absence of contractures, decubitus ulcers and so forth 3. Instructed SOS the need/importance of massaging the bony prominences and the use of proper positioning, turning, lifting and transferring when moving client R: to prevent friction or shear injury 4. Instructed and demonstrated change position in bed/chair on a regular schedule and encourage early ambulation, active and assistive range-of-motion R: to promote proper blood circulation 5. Instructed the importance of adequate clothing/covers; protect from drafts R: to prevent vasoconstriction 6. Kept bedclothes dry and wrinkle free, use nonirritating linens and provide protection by use of pillows R: to increase circulation and limit/eliminate excessive tissue pressure 7. Instructed SOS to change diapers frequently; cleanse perineal skin daily and after incontinence episode R: to minimize contact with irritants(urine, stool, excessive moisture) 8. Emphasize importance of adequate nutritional/fluid intake R: to maintain general good health and skin turgor. 9. Kept the nails short R: to reduce risk of dermal injury when sever itching is present Collaborative: 1. Refer to dietitian as appropriate as the finances availability R: to identify nutritional needs. Client and SOS identified the risk factors that could contribute to skin breakdown SOS verbalized understanding regarding the need of treatment to prevent from any additional complication Client maintained position that allow her improved her comfort and skin integrity Demonstrate behaviors in preventing skin breakdown Goals met At the end of 8 hours nursing management client was able to:

Long term: Demonstrate behaviors/techniques to prevent skin breakdown

ASSESSMENT DATA
(Subjective & Objective Cues)

NURSING DIAGNOSIS
(Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Risk factors: decreased LOC left sided weakness noted altered thought processes Extremes of

Risk of Injury related to Decreased ability to move secondary to Left-Sided Body Weakness

Within 8 hours of nursing intervention, the client will verbalize

INDEPENDENT 1. Assessed the person for factors known to increase injury risk such as history of falls, mental status changes and sensory deficits.

GOALS MET.

1.understanding of risk factors that contribute to possibility of injury, 2. demonstrate behaviors, lifestyle changes to reduce and protect from injury as well as to be free from injury.

R: Evidence indicates that a person who has

sustained one or more falls in the past year is more likely to fall again. 2. Assessed clients environment for factors known to increase fall risk such as unfamiliar setting and inadequate lighting.

Age : 62 years old

At the end of 8 hours of nursing intervention, client verbalized understanding on risk factors that may contribute to possibility of injury, demonstrated behaviors to be free from injury and that safety is ensured.

R: Patients who are not familiar with the placement of furniture and equipment in the room are more likely to experience a fall. 3. Performed thorough assessments regarding safety issues when planning for client care

R: Failure to accurately assess and intervene or refer these issues can place the client at needless risk and creates negligence issues for the health care practitioner. 4. Placed items used by the patient within easy reach and maintain bed/chair in lowest position with wheels locked.

R: Stretching to get items from bedside tables that are out of reach can disrupt the patients balance and contribute to falls 5. Kept the side rails of the raised.

R: To ensure safety

6.

Frequent skin inspections.

R: essential to note for manifestations to injury 7. Encouraged the patient to participate in a program of regular exercise

R: Evidence suggests that people who engage in regular exercise and activity will strengthen muscles. COLLABORATIVE

DISCHARGE PLAN
NURSING PRIORITIES Enhance comfort and general well-being. Prevent/minimize complications. Promote a positive emotional response. Provide information regarding Cerebro Vascular Disease DISCHARGE GOALS Physical/psychological needs being met Complications prevented/resolving Patient's Understanding about the condition will widen.

M- Medications

Instruct significant others to follow orders for take home medications of patient upon discharge as prescribed by physician.
Advice patient to continue taking medications needed to maintain a normal functioning of the body and maintain homeostasis. The treatment regimen ordered by the doctors must be followed strictly and should not be stopped to prevent the aggravation of the condition. The full course of antibiotics should be followed. Instruct significant others to follow right dose and timing of medications without consultation to physician Report any adverse effects and drug/food-drug interactions to the physician Compliance of medications as prescribed by the physician justifies the effectiveness of drugs.

E- Exercise

Passive ROM exercises which is to be assisted by significant others/caregivers in maintaining proper circulation especially in extremities
T- Treatment: Instruct patient to consult the physician first if what activities must he/she avoid or put into limits. Encourage patient to compliance of medication regimen to promote optimal health. Communication therapy instruct significant others to encourage patient to voice out feelings of helplessness and hopelessness.

H- Health Teachings: Importance of personal hygiene to prevent infection. Encourage patient to take a lot of rest and adequate sleep. Rest is as important of exercise in order for his body to relax and repair body tissues. Encourage patient to take a lot of rest and adequate sleep. Rest is as important of exercise in order for his body to relax and repair body tissues. Intake of nutritious foods like vegetables and fruits and intake of foods those are rich in protein such as meat, fish, egg, etc. to promote fast wound healing. compliance of medication regimen to promote wellness. Immediate report to the physician if unusualities occur. Explain to the Significant others about the precautions, patient's diet and S/Sx of the disease. Discouraged patient to participate in strenuous activities that might precipitate stress. Instructed Significant E- Exercise Passive ROM exercises which is to be assisted by significant others/caregivers in maintaining proper circulation especially in extremities

T- Treatment: Instruct patient to consult the physician first if what activities must he/she avoid or put into limits. Encourage patient to compliance of medication regimen to promote optimal health. Communication therapy instruct significant others to encourage patient to voice out feelings of helplessness and hopelessness. others to always remind the patient about his medications to be taken, to his diet and to always be observant about the signs and symptoms of CVD.

O- Out-Patient:
Return to OPD for further check-up if whether it is improving or not. Also, for early diagnosis of any other underlying conditions.

D- Diet Encourage client to eat nutritious or healthy foods such as fruits and vegetables and foods that are rich in proteins such as meat, fish, etc. Instructed to maintain the low salt and low fat diet. The low salt diet is designed to induce a loss of sodium and water from the body or avoid sodium retention. A 2000mg low sodium diet is sufficient to control blood pressure. A low fat diet lose weight decrease risk of having CVA again. S- Spiritual Encouraged pt to continue her habits in going to church every day and always seek God helps when ever problems occur