By Kristel Cornejo
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Patient Initials: M.G.
Age: 62Y
Gender: M Race: African American
Admit Date: 2/4/15
Dx: Hemorrhagic CVA
PMH: Hypertension, Alcohol Abuse,
COPD, previous lumbar surgery
HPI: Recent fall, hitting his head. The next day,
patient called 911 and stated, “I’m about to pass
out”. Arrived in the ED with BP of 192/110 and
was started on Cardene drip.
CT scan revealed right side vermian hemorrhage
in middle cerebellum.
Presents with deficits in areas of mobility and self
care secondary to weakness.
• Widower – wife died in 1999
• Three children – 2 sons and a daughter
– Daughter lives 3 miles away
• Worked jobs in construction,
autoparts/junkyard, and demolition
• Currently retired
• 10th grade education level
• Patient Goal: “Get back on my feet and go
fishing”
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Lives alone
2nd floor Apartment Complex
Stairs (about 10 steps) with railings
No other stairs/steps in apartment
Shower with tub (no grab bars)
No wheelchair at home but has walker
Neuro: AAOx4,
Cooperative,
Speech clear
GI/GU: Continent, soft,
nontender abdomen,
solid stools,
clear/yellow urine
MS/UE:
MS/LE:
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Upper extremity function
Left arm weakness/numbness
Difficulty with extension and
flexion, limited ROM
Pain in L wrist r/t gout
Uses UE to navigate on
wheelchair
Fine motor skills intact
Practices safety techniques; puts
on breaks & uses UE to push up
from chair
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Nutrition: Cardiac Diet,
regular, thin liquids
Bilateral LE weakness
Pain in both feet r/t gout
Impaired gait, balance, and transfers
(moderate assist w/ verbal cueing)
Decreased flexion/extension of hips &
knees; flexed posture
Sitting balance independent; Standing
balance independent w/ assistive device
Ambulates using WC without using LE;
uses walker & cane during PT sessions
Eating: Complete
independence
Problem Solving:
• Does not make
appropriate decisions
Dressing:
to solve complex
Independent, uses
problems without
WC to gather
assistance
items, difficulty
putting on
• Difficulty sequencing
clothes
tasks
Vision: uses reading • Needs verbal cues
glasses,
when switching tasks
complains of
• Impaired memory
seeing dark
spider web like
recall
lines
Bathing: moderate
assist to reach
back and perineal
area
Grooming:
Independent but
uses extra time
Hearing:
Difficulty hearing
especially with
background noise
Activity Intolerance
•Assessing vital signs (HR, BP, Temp, O2 sat) to avoid dangers
of increase or decrease.
•Allow rest periods between activities
•Encourage fluid intake
•Administer multivitamin supplement
to provide extra energy
•Establish short term goals to
increase motivation
•Provide appropriate adaptive devices/equipment to complete
ADLs
Alternative Intervention
Autogenic Training
• Method of self-control therapy that uses specific phrases to
enter a state of deep relaxation and achieve healing.
•Used to decreased high blood pressure,
accelerated heart rate and other
Illnesses.
Ex:
“My heart is calm and regular”
“My lungs are breathing for me”
Impaired Physical Mobility
•Assess pt’s capabilities and areas of dependence
•Implement appropriate safety precautions
(Fall Precautions/Green Safety)
•Provide appropriate assistive devices for
mobility (wheelchair, walker, cane)
•Provide appropriate instructions for safe
transfer techniques
•Apply pressure relieving devices (SCDs)
to prevent venous stasis
•Encourage attending scheduled physical and
occupational therapy sessions
•Continue exercises that strengthen upper and lower extremities
Alternative Intervention
Applied Kinesiology
•Use of muscle testing techniques to identify weakened
muscles and other health problems.
•Treatments include various reflex procedures,
acupressure, and spinal/joint manipulation.
Alteration in Thought Processes
•Assess areas that need improvement
(recall, problem solving, sequencing)
•Continue therapy to improve cognitive
linguistic skills for safe participation in
ADLs
•Approach tasks in a slow and calm
manner
•Allow for adequate time to complete tasks
•Repeat instructions as necessary using
clear and simple language
•Recognize and support accomplishments in each task
Alternative Intervention
Electronic Devices/Personal Digital Assistant
Acute Pain
Self-Care Deficit
•Assess severity, quality and
location of pain
•Administer pain medications as
needed especially during acute
attacks
•Administer antigout
medications
•Apply cold packs to inflamed
joints
•Avoid purine rich foods
•Encourage adequate fluid
intake
•Assess ability to carry out
ADLs and determine deficits
•Provide necessary amount of
assistance to ensure safety
•Set short-range goals
•Provide appropriate
equipments needed to carry out
tasks and assistive devices for
mobility
•Encourage attendance to
therapy to address and improve
cognitive function
Sensory/Perceptual
Alterations
Ineffective Therapeutic
Regimen Management
•Report to physician visual
deficit acquired from stroke
•Provide reading glasses to
optimize vision
•Minimize
distraction/background noise
when talking to patient
•Continue to exercise
activities that improve spatial
awareness
•Assess pt’s ability to learn and
remember medication regimen
•Educate patient in benefits of
adherence to prescribed
medications
•Refer patient to community
resources
•Continue therapy to improve
cognitive function for safe and
effective medication
management
• Safety: Changed from Green to White Safety
• Grooming/Bathing/Dressing: Independent without assistance. Still
uses extra time to finish tasks.
• Improved UE strength: Arm Bike for 20 min without breaks and while
standing
• Improved flexion and extension of UE: can reach items from ground
and from above
• Improved balance and mobility function: Uses cane for ambulation at
a good pace; practices safe techniques and good posture
• Improved Activity Tolerance: Can ambulate longer distances without
stopping
• Cognition: Improved memory recall. Still presents difficulties and
inappropriate decisions in problem solving tasks. Still needs verbal
cues when switching tasks. Still has difficulties sequencing.
Success
Failures
•Independent premorbid
function
•Motivated to improve
•Upper extremity
function
•Pain at tolerable level
•Only been in rehab for
1 week, need more time
to exercise cognitive
skills
•Visual deficits from
stroke may be
interfering with ability to
complete written
exercises
• Destination: Going home to apartment complex
with daughter’s assistance
• Comprehensive Neuropsychological Evaluation
every 3-4 months
• Education:
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Sign and Symptoms of CVA (FAST)
Proper administration and compliance to medications
Address history of alcohol abuse
Benefits of joining support group of CVA survivors
• Anticipated Discharge Date: February 27
Title: A Randomized Controlled Trial of the Effectiveness of Handheld
Computers for Improving Everyday Memory Functioning in Patients with
Memory Impairments After Acquired Brain Injury
Subjects: Adults who were assessed as having functional memory
impairment from a brain injury. Intervention group received occupational
therapy with electronic aid. Control group received occupational therapy with
non-electronic memory aids.
Results: Intervention group achieved greater functional memory goals than
control group.
Implications: The use of electronic aids along with occupational therapy is
more beneficial in improving cognitive skills especially memory function
compared to a standard rehabilitation.
Avramut, M. P. (2012). Autogenic training. Salem Press Encyclopedia
Of Health
Benson, A. P. (2012). Applied kinesiology. Salem Press Encyclopedia
Of Health
Gulanick, Meg and Myers, Judith L. (2011). Nursing Care Plans:
Diagnoses, Interventions and Outcomes.
Lannin, N., Carr, B., Allaous, J., Mackenzie, B., Falcon, A., & Tate, R.
(2014). A randomized controlled trial of the effectiveness of
handheld computers for improving everyday memory functioning in
patients with memory impairments after acquired brain
injury. Clinical Rehabilitation, 28(5), 470-481