…………………………………………………………………………
…………..TABLE OF CONTENTS
TITLE
PAGE NO.
I.
Introduction
1-2
II.
Objectives
2-3
III.
Nursing Assessment
1. Personal History
1.1. Patient’s Profile
3-4
1.2. Family and Individual Information
4
1.3. Level of Growth and Development
IV.
1.3.1. Normal Development at Particular Stage
5-7
1.3.2. Ill Person at Particular Stage of Patient
8
2. Diagnostic Results
8-11
3. Present Profile of Functional Health Pattern
11-14
4. Pathophysiology and Rationale
14-22
Nursing Intervention
1. Care Guide of Patient
22-25
2. Actual Patient Care
2.1. Nursing Assessment
26-27
2.2. Nursing Care Plan
27-32
2.3. Drug Study
33-34
2.4. Health Teaching Plan
35-36
V.
Evaluation and Recommendation
36
VI.
Evaluation and Implication
36-37
VII.
Referral and Follow –up
37-38
VIII.
Bibliography
38-39
1
I. Introduction
“Cerebrovascular disorders” is an umbrella term that refers to any functional
abnormality of the central nervous system (CNS) that occurs when the normal blood
supply to the brain is disrupted. It also refers to any functional or structural abnormality
of the brain caused by a pathological condition of the cerebral vessels or of the entire
cerebrovascular system. This pathology either causes hemorrhage from a tear in the
vessel wall or impairs the cerebral circulation by a partial or complete occlusion of the
vessel lumen with transient or permanent effects. Stroke is the primary cerebrovascular
disorder and it is the third leading cause of death after heart disease and cancer and is the
leading cause of disability among nations.
Stroke is a term used to describe neurologic changes caused by an interruption in
the blood supply to a part of the brain. The most common vessels involved are the
carotid arteries and those of the vertebrobasilar system at the base of the brain. The two
major types of stroke are ischemic and hemorrhagic. Ischemic stroke is caused by a
thrombotic or embolic blockage of blood flow to the brain, with thrombosis being the
main cause of both CVA’s and transient ischemic attacks (TIAs). A thrombotic CVA
causes a slow evolution of symptoms, usually over several hours, and is “completed”
when the condition stabilizes. An embolic CVA occurs when a clot is carried into
cerebral circulation and causes a localized cerebral infarct. Ischemia may be transient
and resolve within 24 hours, reversible with resolution of symptoms over a period of 1
week (reversible ischemic neurologic deficit [RINDI]), or progress to cerebral infaction
with variable effects and degrees of recovery.
Bleeding into the brain tissue or the subarachnoid space causes a hemorrhagic
stroke. It is caused by other conditions such as a ruptured aneurysm, hypertension,
arteriovenous (AV) malformations, or other bleeding disorders. Symptoms depend on
distribution of the cerebral vessels involved.
Ischemic strokes account for
approximately 83% of all strokes. The remaining 17% of strokes are hemorrhagic.
2
Cerebrovascular disorder are the third leading cause of death in the United State.
And in the Philippine setting, it ranked as the second leading causes of mortality with a
62.3 rate per 100,000 population in both sexes and with a percentage of 12.5 by the year
2002. Therefore, giving emphasis in the study of this disease condition is very relevant.
Breakthroughs could happen and may help in the welfare of not just to Filipinos but to all
people at risk in this condition.
The advent of thrombolytic therapy for the treatment of acute ischemic stroke has
revolutionized the care of the client following a stroke. Before, health care professionals
could offer only supportive measures and rehabilitation
to stroke survivors.
New
therapies can now prevent or limit the extent of brain tissue damage caused by acute
ischemic stroke. Thrombolytic therapy must be administered as soon as possible after the
onset of the stroke; a treatment window of 3 hours from the onset of manifestations has
been established. To convey this sense of urgency regarding the evaluation and treatment
of stroke, health care professionals now refer to stroke as brain attack. Public education
is focused on prevention, recognition of manifestations, and early treatment of brain
attack.
II. Objectives
Student Nurse
General Objectives
After 2 days of giving holistic nursing care to the patient who have viral
meningitis, the nurse will be able to gain adequate knowledge, attitude and skills in
taking care of a patient who is suffering from this disease condition.
Specific Objectives
After 8 hours of giving holistic nursing care, the nurse will be able to:
1. relate the patients history and level of growth and development
2. explain the significance of the diagnostic results
3. review the anatomy and physiology of the brain
3
4. explain the disease process and organ involved
5. compare the chart in classical and clinical symptoms of the disease
process
6. formulated appropriate nursing care plan based on identified problem of
patient
7. impart health teachings to the patient and significant others on viral
meningitis
Patient and Family
General Objective
After 2 days of nurse- client interaction the client and family will be able
to acquire adequate knowledge, attitude and skills in the promotion of health and
prevention of injuries and disease as well as rehabilitation from the condition.
Specific Objective
After 8 hours of giving holistic nursing care, the patient and significant
others will be able to:
1. establish a trusting relationship with the nurse
2. verbalize feelings and thoughts to the nurse
3. share information about self and the family and life experiences to the
nurse
4. explain the disease process in their own level of understanding
5. show willingness in the implementation of planned nursing care
III. Nursing Assessment
1. Personal History
1.1Patient’s Profile
Name: Lee, George Ang
Age: 54 years Old
4
Sex: Male
Civil Status: Married
Religion: Buddhist
Date of Admission: January 2, 2006
Room number: 221
Complaints: Right sided weakness and slurred speech
Impression/Diagnosis: Cerebrovascular Accident (Bleed- left basal ganglia)
Physician: Dr. M. Lim, Dr. W. Briones, Dr. G. Lim, Dr. E. Hernandez
Hospital Number: 782349
1.2 Family and Individual Information, Social and Health History
A case of Mr. George Ang Lee, 54 year old, male, Filipino and Buddhist.
He is a businessman living at 515 MJ Cuenco Avenue, Cebu City.
Patient is a known hypertensive for many years already with a usual blood
pressure of 140/90.
He has a maintenance medication when systolic blood
pressure reaches to 170. He is non-diabetic and non-asthmatic. Inspite, his
condition, he has no previous hospitalization until January 2, 2006 when he
experienced a sudden onset of weakness at the right side of his body. Patient was
later noted to be on the floor with slurred speech and drowsiness, then was rushed
immediately to Chong Hua Hospital- Emergency Room and later transferred to
Cebu Doctor’s University Hospital after basic diagnostic procedures were taken.
CT Scan taken revealed 25 cc bleed at left basal ganglia with medial shift to the
right. BP was noted to be elevated with highest BP at 190/110 and captopril was
given.
The patient doesn’t smoke and drink alcoholic beverages. His usual diet
consist of vegetable and no meat.
He also has a regular exercise schedule
everyday but he has a strong heredofamilial disease of hypertension. His wife
shared that lately his husband was under stress due to increase sales in their
business on the month of December and missed to have his regular exercise and
only sleeps a lesser hour per night compared to his usual sleep.
5
1.3 Level of Growth and Development
1.3.1 Normal Development at Particular Stage
Physical
Appearance Changes
Hair begins to
thin, and gray hair appears.
Skin turgor and
moisture decreases, subcutaneous fat decreases and wrinkling occurs.
Fatty tissue is redistributed, resulting in fat deposits in the abdominal
area.
Cardiovascular Changes
Blood vessels lose elasticity and become thicker.
Gastrointestinal Changes
Gradual decrease in tone of large intestine may predispose the
individual to constipation.
Sensory Perception Changes
Visual acuity declines, often by the late forties, especially for near
vision (presbyopia).
Auditory acuity for high-frequency sounds
(presbycusis) also decreases, particularly in men. Taste sensation also
diminish.
Metabolism Changes
Metabolism slows, resulting in weight gain.
Urinary changes
Nephron units are lost during this time, and glomerular filtration
rate decreases.
Sexuality Changes
Hormonal changes takes place.
Musculoskeletal Changes
Skeletal muscle bulk decreases at about age 60. Thinning of the
intervertebral disks causes a decrease in height of about 1 inch. Calcium
loss from bone tissue may occur.
Muscle growth continues in
proportion to use.
6
Psychosocial
Erickson viewed the development tasks of middle-aged adult as
generativity versus stagnation. Generativity is defined as the concern
for establishing and guiding the nest generation. In other words, there is
concern about providing for the welfare of humankind that is equal to
the concern of providing for self. In middle age, the self seems more
altruistic, and concepts of service to others and love and compassion
gain prominence.
These concepts motivate charitable and altruistic
actions, such as church work, social work, political work, community
fund-raising drives, and cultural endeavors. Marriage partners have more
time for companionship and recreation; thus, marriage can be more
satisfying in the middle years of life. Generative middle-aged persons
are able to feel a sense of comfort in their life-style and receive
gratification form charitable endeavors.
Erickson believes that persons who are unable to expand their
interests at this time and who do not assume the responsibility of middle
age suffer a sense of boredom and impoverishment, that is, stagnation.
These persons have difficulty accepting their aging bodies and become
withdrawn and isolated. They are preoccupied with self and unable to
give to others. Some may regress to younger patterns of behavior.
Cognitive
The middle-aged adult’s cognitive and intellectual abilities change
very little. Cognitive processes include reaction time that stays much
the same or diminishes during the later part of the middle years,
perception, learning that continues and can be enhanced by increased
motivation oat the time in life, memory and problem solving that are
maintained through middle adulthood, and creativity.
Middle-aged adults are able to carry out all the strategies described
in Piaget’s phase of formal operations.
operations
strategies
to
assist
Some may use post-formal
them
in
understanding
the
7
contraindications that exist in both personal and physical aspects of
reality. The experiences of the professional, social and personal life of
middle-aged persons will be reflected in their cognitive performance.
Thus, approaches to problem solving and task completion will vary
considerably in a middle-aged group.
The middle-aged adult can
“reflect on the past and current experiences and can imagine, anticipate,
plan and hope”
Moral
According to Kohlberg, the adult can move beyond the
conventional level to the postconventional level. Kohlberg believes that
extensive experience of personal moral choice and responsibility is
required before people can reach to postconventional level. Kohlberg
found that few of his subjects achieved that highest level of moral
reasoning. To move from stage 4, a law and order orientation, to stage
5, a social contract orientation, requires that the individual move to a
stage in which rights of others take precedence. People in stage 5 take
steps to support another’s right.
Spiritual
Not all adults progress through Fowler’s stages to the fifth, called
the paradoxical-consolidative stage. At this stage, the individual can
view the “truth” from a number of viewpoints. Fowler’s fifth stage
corresponds to Kohlberg’s fifth stage of moral development. Fowler
believes that only some individuals after the age of 30 years reach this
stage.
In middle age, people tend to be less dogmatic about religious
beliefs, and religion often offers more comfort to the middle-aged person
than it did previously. People in this age group often rely on spiritual
beliefs to help them deal with illness, death and tragedy.
8
1.3.2 The Ill Person at a Particular Stage of Patient
The three most common causes of death in older adults are heart
disease, cancer and stroke. Other frequently reported causes of death are lung
disease, accidents/falls, diabetes, kidney disease, and liver disease. Heart
disease is the leading cause of death in older adults. Common cardiovascular
disorders are hypertension and coronary artery disease. Cancer or malignant
neoplasms are the second most common cause of death among older adults.
Cerebrovascular accidents, the third leading cause of death, occurring as brain
ischemia or brain hemorrhage. Cigarette smoking has been recognized as a risk
factor in the four most common cause of death for older adults: heart disease,
cancer, stroke and lung disease. Dental carries, gingivitis, broken or missing
teeth and ill-fitting or missing dentures may affect nutritional adequacy, cause
pain, and lead to infection.
2. Diagnostic Results
Diagnostic Test
Normal Values
Patient’s
Significance
Result
Hematology
Hemoglobin
11.5-16 g/dl
11.5 g/dl
Normal
Hematocrit
35-49 vol %
35 vol %
Normal
4.5-5.3x10^6/dl
4.73x10^6/dl
Normal
RBC
Elevated
WBC
4.5-15.0x10^3/dl
12.2x10^3/dl
in
acute
disease.
Source: Brunner and Suddarth’s
Textbook of Medical –
Surgical Nursing, 9th Ed.
Smeltzer, Suzanne C.
Bare, Brenda G., p.1954
MCV
72-98 fl.
91 fl.
Normal
MCH
25-35 pg
30.3 pg
Normal
MCHC
30-37 g/dl
33.3 g/dl
Normal
9
Platelets
150,000-450000
361,000 cu/mm
Normal
84%
Elevated
cu/mm
Segmenters
54-62%
in
acute
disease.
Source: Brunner and Suddarth’s
Textbook of Medical –
Surgical Nursing, 9th Ed.
Smeltzer, Suzanne C.
Bare, Brenda G., 1953
Eosinophils
1-3%
01%
Normal
25-33%
10%
Normal
Yellow
Yellow
Normal
Clear
Slightly cloudy
5.5-7.5
6.0
Normal
1.001-1.045
1.020
Normal
Protein
Negative
Trace
Not normal
Glucose
Negative
Negative
Normal
Ketones
Negative
Negative
Normal
Blood
Negative
Negative
Normal
RBC
<3 RBC’s/HFF
0-1
Normal
WBC
0-5 WBC/ HPF
3-5
Normal
Epithelial Cells
Rare
Few
Normal
Mucus Threads
Rare
Rare
Normal
Bacteria
None
Negative
Normal
Leukocytes
Negative
Negative
Normal
Nitrites
Negative
Negative
Normal
Trace
Normal
Normal
Negative
Negative
Normal
Lymphocytes
Urinalysis
Macroscopic
Color
Appearance
Reaction
Specific gravity
Not normal
Macroscopic
Urobilinogen
Bilirubin
10
Serum
Glucose
65-110
142
Increased in infections
Source: Brunner and Suddarth’s
Textbook of Medical –
Surgical Nursing, 9th Ed.
Smeltzer, Suzanne C.
Bare, Brenda G., 1960
Creatinine
.7-1.5
.9
Normal
Sodium
137-145
137
Normal
Potassium
3.6-5.0
4.6
Normal
Chloride
98-107
103
Normal
Calcium
8.4-10.2
8.8
Normal
ELECTROCARDIOGRAPHIC REPORT
Atrial Rate:
120/min.
Ventricular:
120/min.
PR Interval:
0.14 sec.
QRS Complex:
Transition zone in V3-V4
ST Segment:
Isoelectric
T-wave:
Upright
QRS:
0.08 sec.
AXIS:
0 degree
P-wave:
upright
Interpretation:
Sinus tachycardia with non specific ST-T wave changes
ECHOCARDIOGRAPHY REPORT
1. Quality of study-
Optimal
2. Sinus Tachycardia-
107 beats/ min
3. Cardiac Measurements-
IVSd= 1.05 cm
LVIDd= 5.75 cm
LVPWd= 1.67 cm
LVIDs= 3.89 cm
11
Ejection Fraction= 61%
Ao rest= 2.97 cm
LA diameter= 3.40 cm
4. Cardiac Values:
normal
5. Color and Doppler exam- Normal Pulmonic Valve/ Aortic/ left ventricular outflow
tract velocities. Normal mitral inflow pattern.
6. Left Ventricular Systolic Function- preserved global and regional with visual ejection
fraction estimate 70%.
7. Right Ventricular Systolic Function- preserved
8. No pericardial Effusion
CONCLUSION:
1. Well preserved biventricular systolic function.
2. Left ventricular hypertrophy.
3. Mild diastolic dysfunction.
CT SCAN
IMPRESSION: (as compared to the previous study done January 6, 2006.)
1. Further interval decrease in volume and density of the intraparenchymal
(hemorrhage in the left putamen/ left external capsule now measuring
approximately 34cc in volume (previous was 39cc), as described above.
2. Slight further decrease in the small amount of intraventricular hemorrhage
(extension) within the lateral ventricular.
3. No change in the subfalcine deviation (midline shift) to the right, still by 0.6 cm.
4. Chronic lacunar infarct in the right thalamus.
3. Present Profile of Functional Health Patterns
3.1 Health perceptions/ Health management
According to Mr. Lee’s wife, his husband take a great deal with regards to
his health. He disciplined his self well to achieve an optimum health cause he
12
believes in the saying “health is wealth”. He values it well enough since it’s
something that gives him greater favor in his business.
Whenever he
experiences sickness he manages it using Chinese herbal medications. Mrs. Lee
believes that her husband will recover gradually because he is a determined and
disciplined person who strongly value his health. As of the moment, the family
religiously follows the doctor’s instruction in restoring Mr. Lee’s health.
3.2 Nutritional/Metabolic pattern
According to Mrs. Lee, prior to admission, patient usually eats 3 meals a
day which usually consist of vegetables and fruits, rice, and less meat but more
on fish. He usually drinks tea every after meal or whenever he feels drinking.
He has no allergies to foods. His water consumption is replaced with tea. He has
Chinese drug supplements and has a maintenance medication for his
hypertension. Currently, he is on nasogastric tube feeding (blenderized) with
1800 calories in 1800 u volume. He is also allowed to take sip of water with
strict aspiration precaution.
3.3 Elimination Patterns
According to Mrs. Lee, before her husband’s admission, Mr. Lee voids
and defecates normally and has no problems/complaints in defecating and
urinating. He defecated about once a day usually at the morning. In the hospital
he is on diaper and lactulose is given to soften his stool. His skin is dry and
rough because he can’t take a bath but lotion is given to prevent further dryness.
3.4 Activity/ Exercise Pattern
According to Mrs. Lee, before her husband’s admission, his usual activity
is managing and supervising his own wholesale business of different stuffs. He
helps in transferring boxes from the truck to the stock rooms, without any
complaint of dyspnea or fatigue after. Every morning he takes time to go to his
13
gym and exercise. And during breakfast he reads newspaper or watch news
from television. Currently, in the hospital passive exercise is done by Mrs. Lee
or the Private Nurse.
Turning on the television whenever he is awake is
recommended by the doctor to rehabilitate his senses.
3.5 Cognitive/Perceptual Pattern
According to Mrs. Lee, her husband manages to read newspaper without
the aid of eye glasses, he still has a 20/20 vision and can also hear clearly prior
to admission. He was also able to comprehend well. But at the moment, he
doesn’t respond to any questions asked of him, he can’t speak yet. But he can
show some facial expressions like grimacing his face whenever he feels pain at
some parts of his body.
3.6 Rest/ Sleep Pattern
According to Mrs. Lee, he sleeps about 7 hours a day, usually goes to bed
early around 9 PM and arises early as well around 4 AM. He has no problems
or difficulty in sleeping. Before sleeping he usually pray with his Buddha beads.
In the hospital he sleeps most of the time, waking up occasionally. He is
drowsy.
3.7 Self- Perception Pattern
According to Mrs. Lee, he is a very responsible father to his children as
well as a good husband to her. She believes that Mr. Lee is also cooperating for
his quick recovery since he is looking forward to visit his relatives in China as
soon as he gets well.
3.8 Roles- Relationship Pattern
According to Mrs. Lee, he speaks Bisaya and Mandarin. He can’t speak at
the moment yet. He has 3 children. The two has a family of their own already
14
and is presently residing in China. One son ,the eldest who is still single, is left
in Cebu with them who’ll take care of him at the hospital. In time of needs he
usually turns to his wife
3.10 Coping- Stress Management Pattern
According to Mrs. Lee, whenever problems occur especially with business
matters, both of them are solving it but most of the time his decision influenced
a lot. He also have his friends and relatives who’ll listen and advices him. He
also has a strong faith that he always pray whenever he has problems. Mrs. Lee
decided to have a private nurse to monitor his husband closely.
3.11 Values- Belief System
According to Mrs. Lee, they are Buddhist. They are religious in the
practices and faith of the Buddhist. Most spare time of Mr. Lee is spend in
prayers. They have their prayer room at the house. They are also active in their
temple activities and tries not to miss it. In the hospital they requested to play a
Buddhist chant which they believe could help him recover early. They also
have incenses that can soothe or make him sleep well.
4. Pathophysiology and Rationale
4.1 Normal Anatomy and Physiology of Organ System Affected
The Nervous system is the body’s most organized and complex
structural and functional system. It profoundly affects both psychological and
physiologic function.
The brain is the largest and most complex part of the nervous
system. It is composed of more than 100 billion neurons and associated
fibers. The brain tissues have a gelatin-like consistency. This semi-solid
organ weighs about 1400 g in the adult. It is divided into three major areas:
15
the cerebrum, the brain stem and the cerebellum. The cerebrum is composed
of two hemispheres, the thalamus, the hypothalamus and the basal ganglia and
connections of the olfactory and optic nerves. The brain stem includes the
midbrain, pons, medulla, and connections of cranial nerve II, IV and VII. The
cerebellum is located under the cerebrum and behind the brain stem.
The BASAL GANGLIA consist of several structures of subcortical
gray matter buried deep in the cerebral hemisphere. These structures include
the caudate nucleus, putamen, globus pallidus, substantia nigra, and
subthalamic nucleus. The basal ganglia serve a processing stations linking the
cerebral cortex to thalamic nuclei. Almost all the motor and sensory fibers
connecting the cerebral cortex and the spinal cord travel through the white
matter pathways near the caudate nucleus and putamen ganglia.
These
pathways are known as the internal capsule. The basal ganglia, along with the
corticospinal tract, is important in controlling complex motor activity.
CEREBRAL CIRCULATION. The cerebral circulation receives
approximately 15% of the cardiac output, or 750 ml per minute. The brain
does not store nutrients and has a high metabolic demand that requires the
high blood flow. The brain’s blood pathway is unique because it flows
against gravity; it’s arteries fill from below and the veins drain from
above. In contrast to other organs that may tolerate decreases in blood
flow because of their adequate collateral circulation, the brain lacks
additional collateral blood flow, which may result in irreversible tissue
damage when blood flow is occluded for even short periods of time.
16
Brain: Basal ganglia
Coronal slices of human brain showing the basal ganglia, globus pallidus: external segment (GPe),
subthalamic nucleus (STN), globus pallidus: internal segment (GPi), and substantia nigra (SN).
Coronal section of brain immediately in front of pons. (Not all basal ganglia are visible, but caudate nucleus
and substantia nigra are labeled. Subthalamic nucleus would be between thalamus and internal capsule.)
4.2 Schematic Drawing on Pathophysiology of Disease
17
Predisposing Factors
Precipitating Factors
Heredity
Age – 54 years old
History of stroke
Stress
High sodium diet
High blood pressure
Etiology
Plaque formation
Thrombi formation
Bloodstream is loaded
High blood pressure
Dislodgment of thrombi
Emboli
Occlusion of cerebral vessels and
Rupture of arteriosclerotic hypertensive vessels
Hemorrhage
Cerebral anoxia
CVA
Clinical symptoms
Facial asymmetry
Slurring of speech
Aphasia
Hemiparesis
Classical symptoms
Facial asymmetry
Slurring of speech
Aphasia
Hemiparesis
Apraxia
Hemiplegia
Confusion
18
4.3 Disease process and Effects on Different Organ System
Stroke, ischemic damage of the brain owing to a blockage in blood flow,
or to a hemorrhage of blood vessels in the brain. Without blood, sections of brain
tissue quickly deteriorate or die, resulting in paralysis of limbs or organs controlled
by the affected brain area. Most strokes are associated with high blood pressure
(hypertension), atherosclerosis (development of fatty plaques in artery walls), or both.
Some of the signs of major stroke are facial weakness, inability to talk, loss of
bladder control, difficulty in breathing and swallowing, and paralysis or weakness,
particularly on one side of the body. Stroke is also called cerebral apoplexy and
cerebrovascular accident.
The majority of stroke cases are due to arterial blockage caused by either
thrombosis or embolism. Thrombosis involves the clotting of the surface of an
atherosclerotic plaque, in a branch of one or more of the four main arteries leading to
the brain. As these arteries become narrowed, a potential stroke victim often
experiences recurrent warnings, which take the form of transient paralysis (such as in
one arm or leg or on one side of the face), or discovers impairments in speech, vision,
or other motor functions. At this stage, deposits in the linings of the cerebral arteries
can often be treated by surgical removal or bypass of blockages.
Embolism occurs when a cerebral artery suddenly becomes blocked by
material—such as clotted blood, air, or fat—coming from another part of the
bloodstream. Such masses, known as emboli, often form as clots in a diseased or
malfunctioning heart, but can also come from dislodged fragments of atherosclerotic
plaque or even an air bubble. Treatment is largely preventive, consisting of
monitoring of the diet, and, if possible, use of anticoagulants.
Hemorrhaging of cerebral blood vessels, a less frequent but usually more
serious cause of stroke, can occur where aneurysms, or blister-like bulges, develop on
the forks of large cerebral arteries on the brain surface. The rupture of aneurysms
causes brain damage, owing to the seepage of blood into brain tissue or to the reduced
flow of blood to the brain beyond the point of rupture.
19
4.4 Comparative Chart
Classical Symptom
Clinical Symptom
Rationale
a. Motor changes:
contralateral hemiparesis or
hemiplegia
hemiplegia;
- affectation in the middle
cerebral artery
Sensory changes: contralateral contralateral hemisensory
hemisensory alterations;
alterations
neglect of involved
extremities;
Visual changes:
homonymous hemianopia;
inability to turn eyes toward
the affected side;
Speech changes: dyslexia,
Dysphagia, aphasia
dysgraphia, aphasia;
Others: vomiting may occur
b. Motor changes:
contralateral hemiparesis, foot
Footdrop, contralateral
- affectation in the anterior
and leg deficits greater than
hemiparesis
cerebral artery
arm, footdrop gait
disturbances;
Sensory changes: contralateral Contralateral
hemisensory alterations;
hemisensory alteration
Visual changes: deviation of
eyes toward affected side;
Speech changes: expressive
Expressive aphasia
aphasia;
Mental changes: confusion,
Amnesia, shortened
amnesia; flat affect, apathy;
attention span
shortened attention span; loss
20
of mental acuity;
Others: apraxia (inability to
carry out purposeful
movements in nonaffected
areas)
c. Motor changes: mild
contralateral hemiparesis (with
Memory deficit
thalamic or subthalamic
- affectation of the
posterior cerebral artery
involvement); intention
tremor;
Sensory changes: diffuse
sensoryloss (thalamic);
Visual changes: papillary
dysfunction (brain stem); loss
of conjugate gaze, nystagmus;
loss of depth perception;
cortical blindness;
homonymous hemianopia;
Speech changes:
perseveration; dyslexia;
Mental changes: memory
deficits;
Others: visual hallucinations
d. Motor changes:
contralateral hemiparesis with
Contralateral hemiparesis
- affectation of the internal
facial asymmetry;
dysarthia; dysphagia
carotid artery
Sensory changes: contralateral
sensory alterations;
Visual changes: hemianopia;
ipsilateral periods of blindness
21
(amaurosis fugax);
Speech changes: dysphagis;
Others: mild Horner’s
syndrome; carotid bruits
e. Motor changes: alternating
Dysarthia, dysphagia,
- affectation of the
motor weaknesses; ataxic gait,
temporary memory loss,
vertebral – basilar system
dysmetria (uncoordinated
disorientation
actions);
Sensory changes: numbness
of the tongue;
Visual changes: double
vision; homonymous
hemianopis; nystagmus,
conjugate gaze paralysis;
Speech changes: dysarthia;
dysphagia;
Mental changes: memory
loss; disorientation;
Others: drop attacks; tinnitus,
hearing loss
f. Motor changes: Ipsilateral
None
- affectation of the
ataxia; facial paralysis;
anteroinferior cerebellar
Sensory changes: ipsilateral
(lateral pontine)
loss of sensation in face,
sensation changes on trunks
and limbs;
Visual changes: nystagmus;
Others: Horner’s syndrome;
tinnitus, hearing loss
22
g. Motor changes: ataxia;
Dysarthia, dysphagia,
- affectation of the
paralysis of larynx and soft
coughing, hiccoughs.
posteroinferior cerebellar
palate;
Sensory changes: ipsilateral
loss of sensation on face,
contralateral on body;
Visual changes: nystagmus;
Speech changes: dysarthia;
dysphagia; dysphonia; Others:
Horner’s syndrome; hiccoughs
and coughing
IV. Nursing Interventions
1. Care Guide of Patient with Disease Condition
IDENTIFY STROKE EARLY. A critical factor in the early intervention
and treatment of stroke is the proper identification of stroke manifestations.
The initial assessment of the client who is thought to have had a stroke includes
level of consciousness, papillary response to light, visual fields, movement of
extremities, speech, sensation, reflexes, ataxia, and vital signs. This data are
recorded and scored on the Glasgow Coma Scale. Intracranial pressure is also
monitored, the baseline pressure values and waveforms should be noted.
MAINTAIN CEREBRAL OXYGENATION. Always maintain a patent
airway.
The client should be turned on the affected side if he or she is
unconscious, to promote drainage of saliva in the airway. The collar of the shift
should be loosened to facilitate venous return. The head should be elevated, but
the neck should not be flexed. Oxygen should be supplied an if the client
demonstrates poor ventilatory effort, intubation and mechanical ventilation may
be required to prevent hypoxia and increased cerebral ischemia.
ECG is
performed and blood pressure is evaluated, and hypertension may be reduced
with vasodilators.
Caution is exercised when treating blood pressure, as
23
lowering the blood pressure too far may lower cerebral perfusion pressure and
increase cerebral ischemia.
Laboratory test for hematology, chemistry and
coagulation are obtained to rule out stroke-mimicking conditions and to detect
bleeding disorders that would increase the risk of bleeding during thrombolytic
therapy.
PREVENT COMPLICATION. Such as bleeding, cerebral edema, stroke
recurrence, aspiration and other potential complication.
REHABILITATION AFTER STROKE. Early premobilization efforts are
aimed at preventing the complications of neurologic deficit and immobility.
Relearning can take place even though damage in the CNS is irreversible. It is
extremely important that relearning take place as soon as possible after the
injury.
An interdisciplinary rehabilitation team is necessary to assist and
support clients and their families during this time. The recommended plan of
care includes using interdisciplinary services to :

document the client’s condition and course fully, including deficits, status
of other disease, complications, changes in status, and functional status
before stroke.

Begin physical activity as soon as the client’s medical condition is stable;
use caution with early mobilization in clients with progressing neurologic
deficit, subarachnoid or intracerebral hemorrhage, severe orthostatic
hypotension, acute myocardial infarction, or acute deep vein thrombosis

Assist n managing general health functions throughout all stages of
treatment such as managing dysphagia, nutrition, hydration, bladder and
bowel function, sleep and rest, co-morbid conditions, and acute illnesses.

Prevent complications, including deep vein thrombosis and pulmonary
embolism, aspiration, skin breakdown, urinary tract infections, falls,
spasticity and contractures, shoulder injury and seizures.

Prevent recurrent strokes through control of modifiable risk factors, oral
anticoagulation, antiplatelet therapy, or surgical intervention.

Assess throughout acute and rehabilitation stages

Use reliable standardized instruments for evaluation

Evaluate for formal rehabilitation during acute stage
24

Choose individual or interdisciplinary program based on the client’s and
family’s needs; success of the program requires full support and active
participation of the client and family; families must be involved at the
outset

Choose the local rehabilitation program that best meets the client’s and
family’s needs
INTERDISCIPLINARY
MANAGEMENT.
Physical
therapy,
occupational therapy, speech therapy.
PHARMACOLOGIC MANAGEMENT. Steroids and osmotic diuretics
may be used to reduce ICP.
Hypertension is commonly controlled with
antihypertensives and diuretics.
Anticoagulants are commonly used initially through intravenous routes
and then orally.
Monitoring of clotting times is important for preventing
overanticoagulation, which increases the risk of bleeding.
Headache and neck stiffness can usually be treated with mild analgesics,
such as codeine and acetaminophen. Stronger narcotics are usually avoided; these
agents sedate the client and can make neurologic assessment inaccurate.
If the client develops seizures, phenytoin (Dilantin) or Phenobarbital may
be used.
Barbiturates and other sedative agents are avoided.
If the client
develops fever, antipyretics may be prescribed.
DIETARY MANAGEMENT. Because of the high risk for aspiration;
choking, excessive coughing, and vomiting, oral food and fluids are generally
withheld for 24 to 48 hours. If the client cannot eat or drink after 48 hours,
alternative feeding routes are used, such as tube feedings or hyperalimentation.
When the swallowing mechanism has returned, the client can be fed orally.
SURGICAL MANAGEMENT. Several criteria are used to determine
candidates for rapid evacuation of hematoma in clients with hemorrhagic stroke
or bleeding on the dominant side.
Another guide commonly used in the
determination of the need for surgery is ICP. Pressures below 20 mm HG are
usually managed without surgery; pressures above 30 mm Hg often require
surgery. Clients who have large areas of blood removed have been shown to
recover a substantial portion of speech. Clients with relatively large areas of
25
superficial cerebral bleeding or shifts may also require surgery. Likewise, clients
who suddenly deteriorate to from lethargy to unconsciousness may benefit from
surgery. Surgery is usually not performed on clients with bleeding in the basal
ganglia or thalamus.
Surgery is also performed on some intracranial aneurysms and on the
carotid arteries (carotid endarterectomy) to reduce the risk of CVA.
NURSING MANAGEMENT. The initial assessment of the client with
CVA is very important.
The assessment must be complete and accurate to
provide a baseline for ongoing assessments. The client who is awake and alert
should be taught about the pathologic process and instructed to inform the nurse
about any changes in sensation, movement, or function regardless of how minor
they may seem. Increasing neurologic deficits may indicate either progression of
the infarct or ischemia of the area from cerebral edema or bleeding. Changes in
neurologic assessments must be reported promptly to the physician.
A complete history of the presenting problem as well as past medical and
social history will provide data about the problem source of the CVA.
Ongoing assessments of the neurologic status and vital signs are
imperative. These assessments may be required as often as hourly for unstable
clients. Assessment of hemiplegia includes the repeated assessment of motor
function, sensation, and reflex activity.
26
2. Actual Patient Care
2.1 Nursing Assessment
Name of Patient: Mr. George Ang Lee
Impression/Diagnosis: Cerebrovascular accident
Attending Physician: Dr. M. Lim, Dr. W. Briones, Dr. G. Lim, Dr. E. Hernandez
ACTIVITY/REST
Difficulty with activity due to generalized weakness, loss of sensation, or
paralysis (hemiplegia) tires easily; difficulty resting. Altered muscle tone and level
of consciousness. Incoherent.
CIRCULATORY
Electrocardiogram (ECG) changes. Elevated BP 160/100. strong
peripheral pulses.
EGO INTEGRITY
Feelings of helplessness and hopelessness, emotional liability an
inappropriate response to anger, sadness and happiness, difficulty expressing self.
ELIMINATION
Constipated.
FOOD/ FLUID
Mastication problems. Loss of sensation in tongue, cheek.
NEUROSENSORY
Weakness on the right side of the body, drowsy, sensory loss on
contralateral side (right side of body) in extremities and some part of the left face.
Disturbances in senses of taste and smell. Aphasia: defect or loss of language
function may be global.
PAIN/ DISCOMFORT
Guarding behavior on the GUT (scrutom).
RESPIRATION
On tracheostomy.
27
SAFETY
Swallowing difficulty, inability to meet own nutritional needs. Diminish
response to heat and cold.
SOCIAL INTERACTION
Speech problems, inability to communicate.
TEACHING/LEARNING
Family history of hypertension, strokes. Requires medication regimen/
therapeutic treatments.
2.2 Nursing Care Plan
Name of Patient: Mr. George Ang Lee
Age: 5 4
Room/Ward: 221
Sex: Male
Chief Complaints: Right sided weakness and slurred speech
Needs/
Problems/
Cues
NCP 1
Subjective:
no
subjective
cues
Objective:
-on semiFowler’s
position
-with NGT
in place
-with
D5NSS 1L
@ 20
gtts/min
-with O2
@ 2LPM
-with
Nursing
Scientific
Objectives
Nursing
Diagnosis
Basis
of Care
Intervention
After eight
hours of
nursing
interventions,
the patient
will be able
to maintain
usual/
improved
level of
consciousnes
s, cognition,
and motor
sensory
function.
Specifically,
he shall be
able to:
1.demonstrat
e stable vital
signs and
absence of
Independent
1. Determine factors
related to individual
situation/ cause for
decreased cerebral
perfusion, and
potential for
increased ICP.
Cerebral
infarction
cerebral
is
deprivation
tissue
of blood
perfusion
supply to a
localized
related to
area of the
interruption brain. The
extent of
of blood
infarction
flow
depends on
factors
(occlusive
such as the
disorder /
location
and the size
hemorrhag
of an
e)
occluded
vessel and
the
adequacy
of
Altered
2. Monitor/
document neurologic
status frequently and
compare with
baseline.
Rationale
1. Influences choice of
interventions.
Deterioration in
neurologic signs and
symptoms or failure to
improve after initial
insult may require
surgical intervention
and/or that the patient
be transferred to critical
care area for monitoring
of ICP.
(Doenges,p293)
2. Assesses trends in
LOC and potential for
increased ICP and is
useful in determining
location, extent, and
progression/ resolution
of CNS damage. May
28
FBC-UB
-lethargy
noted
-slurring
of speech
noted
-with the
ff. V/S:
BP –
170/100
mm Hg
PR – 90
bpm
RR – 24
cpm
T – 37.5*C
collateral
circulation
to the area
supplied by
the
occluded
vessel.
If cerebral
circulation
is
interrupted
extensively
, cerebral
anoxia
develops,
that is, lack
of oxygen
to the
brain.
(Black:199
any signs of
increased
ICP.
2.displays no
further
deterioration/
recurrence of
deficits.
also reveal presence of
TIA, which may warn
of impending
thrombotic CVA.
(Doenges p293)
3. Monitor vital
signs, note:
- Hypertension /
hypotension, compare
BP readings in both
arm.
3,p707)
- Heart rate and
rhythm, auscultate for
murmurs.
- Respirations,
noting patterns and
rhythm, e.g., periods
of apnea after
hyperventilation.
4. Document
changes in vision.
3. Variations may
occur because of
cerebral pressure /
injury in vasomotor
area of the brain.
Hypoertension or
postural hypotension
may have been a
precipitating factor.
Hypotension may occur
because of shock
(circulatory collapse).
Increased ICP may
occur (tissue edema,
clot formation).
Subclavian artery
blockage may be
revealed by difference
in pressure readings
between arms.
- Changes in rate
especially bradycardia
can occur because of
the brain damage.
Dysrhythmias and
murmurs may reflect
cardiac disease, which
may have precipitated
CVA.
- Irregularities can
suggest location of
cerebral insult/
increasing ICP and need
for further intervention,
including possible
respiratory support.
(Doenges,p293)
4. Specific visual
alterations reflect are of
brain involved, indicate
safety concerns, and
influence choice of
interventions.
(Doenges,p293)
29
5. Assess higher
functions, including
speech, if patient is
alert.
5. Changes in cognition
and speech content are
indicator of location/
degree of cerebral
involvement and may
indicate deterioration /
increased ICP.
(Doenges,p293)
6. Position with head
slightly elevated and
in neural position.
6. Reduces arterial
pressure by promoting
venous drainage and
may improve cerebral
circulation/ perfusion.
(Doenges,p293)
7. Maintain bed rest;
provide quiet
environment.
Provide rest periods
in between care
activities, limit
duration of
procedures.
7. Continual
stimulation/ activity can
increase ICP. Absolute
rest and quiet may be
needed to prevent
rebleeding in the case
of hemorrhage.
8. Prevent straining
at stool, holding
breath.
8. Valsalva maneuver
increases ICP and
potentiates risk of
rebleeding.
(Doenges,p293)
9. Assess for nuchal
rigidity, twitching,
increased
restlessness,
irritability, onset of
seizure activity.
9. Indicative of
meningeal irritation,
especially in
hemorrhagic disorders.
Seizures may reflect
increased ICP/ cerebral
injury, requiring further
evaluation and
intervention.
(Doenges,p293)
Collaborative
1. Administer
supplemental oxygen
as indicated.
2. Administer
1. Reduces hypoxemia,
which can cause
cerebral vasodilation
and increase pressure/
edema formation.
(Doenges,p293)
2. Preexisting / chronic
30
medications
(Antihypertensive) as
indicated.
hypertension requires
cautious treatment,
because aggressive
management increases
the risk of extension of
tissue damage.
(Doenges,p293)
3. Monitor lab
studies as indicated,
e.g., PT/PTT time.
3. Provides information
about drug
effectiveness/
therapeutic level.
(Doenges,p293)
NCP2
Subjective:
-no
subjective
cues
Objective:
-on semiFowler’s
position
-with NGT
in place
-with
D5NSS 1L
@ 20
gtts/min
-with O2
@ 2LPM
-with
FBC-UB
-lethargy
noted
-slurring
of speech
noted
-inability
to
purposely
move
noted
Impaired
physical
mobility
related to
paralysis
Hemiplegia
results
from
damage to
the motor
area of the
cortex or
pyramidal
tract fibers.
Hemorrhag
e or clot in
the brain’s
left side
causes
right-sided
hemiplegia,
and viceversa. This
is because
the nerve
fibers cross
over in the
pyramidal
tract as
they pass
from the
brain to the
spinal cord.
(Black:199
3,p709)
After eight
hours of
nursing
interventions,
the patient
will be able
to maintain
optimal
position of
function.
Specifically,
he shall be
able to:
1.demonstrat
e absence of
contractures,
footdrop.
2.maintain/
increase
strength and
function of
affected or
compensator
y body part
3. maintain
in integrity.
Independent
1. Assess functional
ability/ extent of
impairment initially
and on a regular
basis.
1. Identifies strengths/
deficiencies and may
provide information
regarding recovery.
Assist in choice of
interventions, because
different techniques are
used for flaccid or
spastic paralysis.
(Doenges,p296)
2. Change position at
least every two hours
and possibly more
often when place on
affected side.
2. Reduces risk of
tissue ischemia/ injury.
Affected side has
poorer circulation and
reduced sensation and is
more predisposed to
skin breakdown /
decubitus.
(Doenges,p296)
3. Begin
active/passive ROM
to all extremities on
admission.
Encourage exercises
such as squeezing
rubber ball, extension
of fingers and legs/
feet.
3. Minimizes muscle
atrophy, promotes
circulation, helps
prevent contractures.
Reduces risk of
hypercalciuria and
osteoporosis if
underlying problem is
hemorrhage.
(Doenges,p296)
-impaired
31
coordinati
on noted
4. Elevate arm and
hand.
4. Promotes venous
return and helps prevent
edema formation.
(Doenges,p296)
5. Place knee and hip
in extended position.
5 Maintains functional
position.
(Doenges,p296)
-limited
ROM
noted
-decreased
muscle
strength
and
control
observed
Collaborative
1. Provide egg crate
1. Promotes even
mattress, as indicated. weight distribution
decreasing pressure on
bony points and helping
prevent skin
breakdown/ decubitus
formation.
(Doenges,p296)
-with the
ff. V/S:
BP –
170/100
mm Hg
PR – 90
bpm
RR – 24
cpm
T – 37.5*C
2. Consult with
physical therapist
regarding active,
resistive exercises,
and patient
ambulation
2. Individualized
program can be
developed to meet
particular needs/ deal
with deficits in balance,
coordination and
strength.
(Doenges,p296)
NCP3
Subjective:
-no
subjective
cues
Self-care
deficit
(inability to
Objective:
-on semiFowler’s
position
perform
-with NGT
in place
paralysis.
-with
D5NSS 1L
@ 20
gtts/min
-with O2
@ 2LPM
-with
ADLs)
related to
Hemiplegia
results
from
damage to
the motor
area of the
cortex or
pyramidal
tract fibers.
Hemorrhag
e or clot in
the brain’s
left side
causes
right-sided
hemiplegia,
and viceversa. This
is because
the nerve
fibers cross
After eight
hours of
nursing
interventions,
the patient
will be able
to perform
self-care
activities
within level
of own
ability.
Specifically,
he shall be
able to:
1.demonstrat
e techniques/
lifestyle
changes to
meet selfcare needs.
Independent
1. Assess abilities
and level of deficit
for performing
ADLs.
1. Aids in anticipating
for meeting individual
needs.
(Doenges,p302)
2. Avoid doing
things for the patient
that the patient can
do.
2. These patients may
become fearful and
dependent, and
although assistance is
helpful in preventing
frustration, it is
important for the patient
to do as much as
possible for self to
maintain self esteem
and promote recovery.
(Doenges,p302)
3. Be aware of
impulsive behaviors/
3. May indicate need
for additional
32
FBC-UB
-lethargy
noted
-slurring
of speech
noted
-inability
to
purposely
move
noted
-impaired
coordinati
on noted
-limited
ROM
noted
-decreased
muscle
strength
and
control
observed
-inability
to perform
ADLs
observed
over in the
pyramidal
tract as
they pass
from the
brain to the
spinal cord.
When
voluntary
muscle
control is
destroyed,
strong
flexor
muscles
overbalanc
e the
extensors.
This can
cause
serious
deformities
.
(Black:199
2. identify
personal/
community
resources that
can provide
assistance as
needed
actions suggestive of
impaired judgment.
interventions and
supervision to promote
patient safety.
(Doenges,p302)
4. Maintain a
supportive, firm
attitude. Allow
patient sufficient time
to accomplish tasks.
4. Patients will need
empathy but need to
know caregivers will be
consistent in their
assistance.
(Doenges,p302)
5. Provide positive
feedback for efforts/
accomplishments.
5 Enhances sense of
self-worth, promotes
independence, and
encourages patient to
continue endeavors.
(Doenges,p302)
Collaborative
1. Administer
suppositories and
stool softeners.
3,p709)
2. Consult with
physical /
occupational
therapist.
1. May be necessary at
first to aid in
establishing regular
bowel function.
(Doenges,p302)
2. Provides expert
assistance for
developing a therapy
plan and identifying
special equipment
needs. (Doenges,p302)
-inability
to perform
oral care
noted
-with the
ff. V/S:
BP –
170/100
mm Hg
PR – 90
bpm
RR – 24
cpm
T – 37.5*C
33
2.3 Drug Therapy Record
Hospital No.:782349
Service: Medical
Physician: Dr. M. Lim, Dr. W. Briones,
Impression:Cerebrovascular
Dr. G. Lim, Dr. E. Hernandez
Drug/
Route/
Frequency/
Route
Ranitidine
(Zantac)
150 mg
1 tab BID
Classification/
Mechanism of Contraindications/
Action
Histamine2
Antagonist
Competitively
inhibits the
action of
histamine at the
histamine2 (H2)
receptors of the
parietal cells of
the stomach,
inhibiting basal
gastric acid
secretion and
gastric acid
secretion that is
stimulated by
food, insulin,
histamine,
cholinergic
agonists,
gastrin, and
pentagastrin.
(Karch,p1039)
Ciprofloxacin
(ciprobay)
500 mg 1 tab
q 12H
Indications/
Inhibits
bacterial DNA
synthesis,
mainly by
Side Effects
Indicated for
duodenal ulcer
(short-term
treatment),
pathologic
hepersecretory
conditions,
maintenance therapy
for duodenal or
gastric ulcer, erosive
esophagitis,
heartburn and
gastroesophageal
reflux dse.
Contraindicated for
patients
hypersensitive to
drugs.
CNS: vertigo,
malaise, headache
EENT: blurred vision
Hepatic: jaundice.
Indicated for mild to
moderate urinary
tract infections,
severe or
Accident
Principles
of Care
Have regular
medical
follow-up to
evaluate your
response.
Use
cautiously in
patient with
hepatic
dysfunction.
Drug may
cause falsepositive
results in
urine protein
test using
Multistix.
May be added
to total
parenteral
nutrition
solutions.
Use
cautiously
with patients
Treatment
Evaluation
Take drug
with meals
and at
bedtime.
Therapy may
continue for
4–6 wk or
longer.
Continually
given to
prevent
further
complication
If you also are
on an antacid,
take it exactly
as prescribed,
being careful
of the times of
administration.
Adjust dosage
in patients
with impaired
renal function
Assess patient
for abdominal
pain. Note
presence of
blood in
emesis, stool
or gastric
aspirate
Obtain
specimen for
culture and
sensitivity test
before giving
Continually
given to
prevent
further
complication
34
blocking DNA
gyrase;
bactericidal
complicated UTI’s,
mild to moderate
bone infections,
chronic bacterial
prostatitis,
Contraindicated in
patients sensitive to
fluoroquinolones.
CV: edema, chest
pain
CNS: headache,
restlessness and
tremor
GI: abdominal pain
or discomfort,
constipation,
flatulence
Musculoskeletal:
arthralgia, joint
inflammation, joint
or back pain
Indicated to control
for tonic-clonic and
complex partial
seizures, for patient
requiring a loading
dose, status
epilecticus.
Phenytoin
(dilantin) 100
mg I tab TID
Unknown. A
hydantoin
dereivative that
probably
stabilizes
neuronal
membranes and
limits seizure
activity by
either increasing
efflux or
decreasing
influx of
sodium ions
across cell
membranes in
the motor cortex
during
generation of
nerve impulse.
Contraindicated for
hypersensitivity and
in those with sinus
bradychardia, SA
block, second or third
degree AV block,
and Adam-Strokes
syndrome.
CNS: ataxia, slurred
speech and dizziness
CV: periarteritis
nodosa
EENT: nystagmus,
diplopia, blurred
vision
GI: nausea, vomiting
and constipation
Hapatic: toxic
hepatitis
with CNS
disorders
the first dose.
Food doesn’t
delay
absorption but
may delay
peak serum
levels
Monitor
patient’s
intake and
output and
observe for
signs of
crystalluria.
Tendon
rupture has
been reported
in patients
receiving
quinolones.
Give oral
forms 2 hours
after a meal or
2 hours before
or after taking
antacids.
Lon g-term
therapy may
result in
overgrowth of
organism
resistant to
ciprofloxacin.
Discontinue in
pain,
inflammation,
or tendon
rupture occurs.
Use
cautiously in
patients with
hepatic
dysfunction,
hypotension
Divided doses
given with or
after meals
may decrease
adverse GI
reactions.
Elderly
patient tends
to metabolize
phenytoin
slowly and
may need
reduced
dosages.
Stop drug if
rash appears.
Use only clear
solution for
injection.
Continually
given to
prevent
further
complication
Don’t
withdraw drug
suddenly
because
seizures may
worsen
35
2.4 Health Teaching Plan
Patient’s Name: Mr. George Ang Lee
Impression: Cerebrovascular Accident
Complaints: Right sided weakness and slurred speech
Physician: Dr. M. Lim, Dr. W. Briones, Dr. G. Lim, Dr. E. Hernandez
Objectives
Content
Methodology
Evaluation
After the period of nursing
The family
care, the patient and family
were able
shall be able to acquire basic
to
knowledge, positive attitude,
assimilate
and beginning skills in
the
rendering wholistic care to the
information
patient post hospitalization.
given.
Specifically, the patient and
family shall be able to:
1. be reminded of medication
Medication should be
Interaction
schedule.
administered as ordered.
(discussion)
15-20 mins
2. establish exercise
routine.
3. adhere to dietary
management.
4. provide psychological
support to patient.
Provide basic ROM exercises
Demonstration
to prevent contractures.
Low salt, low fat diet should
be facilitated
It is always important to
maintain an open
communication with the
patient to relieve patient’s
anxiety.
5. visit the attending
Usually when CVA patient is
physician post
discharged, constant medical
hospitalization to
consultation should be
36
provide continuity of
maintained.
care.
V. Evaluation and Recommendation
After rendering holistic care, the patient and the nurse were able to
achieve the specific objectives.
The degree of outcome attainment should be evaluated on an ongoing
basis. After CVA, some outcomes are achieved early (e.g., cerebral perfusion);
others may require rehabilitation (e.g., self-care deficit).
It is important to
monitor progress toward outcomes, working with both the client and the family.
Continuing medications even after symptoms abate is recommended.
Continue encouraging the client to verbalizes and express his feelings, this
would always be effective and therapeutic to the client. Emotional support must
be provided to both the client and family members.
If the client is to be
discharged home, the family needs clear understanding of the residual deficits.
The family and client need to have realistic expectations about the client’s
abilities; yet encourage independence when the client is able.
VI. Evaluation and Implication of This Case Study To:
Nursing Practice
This case study would make a contribution to the practice of medical
nursing as it would serve as a documentation that would then contribute to the
appropriate plan of care in patients with cerebrovascular accident (CVA). This
would also provide information about cerebrovascular accident (CVA) and
nursing interventions and therapeutic techniques used with patients who have this
37
disorder. It also provides information about the plan of care for patients who have
this condition for efficient nursing care.
Nursing Education
To nursing education, this case study would help by providing information
about the disease condition, cerebrovascular accident (CVA). The student nurses,
as well as the clinical instructors could gain additional information about this
disorder that ranks 2nd in the ten leading causes of death in the Philippines, so that
it could better equip them for efficient nursing care in the future. This study
would explain the future nurses’ adequate background knowledge regarding
medical nursing before one is to be exposed to the clinical setting. This would
help expand knowledge regarding the disease and would correct misconceptions
toward this case. It would then promote awareness.
Nursing Research
Research is now an integral part of nursing. Through research, betterment
or improvement of nursing education to be practiced competitively in the clinical
setting will be achieved. In Nursing Research, this case study may broaden the
scope or extent of research done previously for cerebrovascular accident (CVA).
This may lead to another breakthrough study in the details of the condition. This
can also contribute in upgrading and updating the interventions made for this
condition.
VII.
The Referral and Follow-up
Rehabilitation from stroke requires specialized help from neurologists,
physiotherapists,
physical
therapist,
occupational
therapist
and
speech
therapists—especially during the first six months, when most progress is made.
Passive stretching exercises and thermal applications are used to regain motor
38
control of limbs, which become rigidly flexed after a stroke has occurred. A
patient may recover enough to do pulley and bicycle exercises for the arms and
legs and, through speech therapy, may regain the language abilities often lost
following a stroke; the degree of recovery varies greatly from patient to patient.
VIII. Bibliography
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Nursing Clinical Management for Positive Outcomes. 6th Edition. Philadelphia,
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Doenges, Marilynn, Moorhouse, Mary Frances and Geissler-Murr, Alice. Nursing Care
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Davis Company. 2002
Deglin, Judith and Vallerand, April. Davis’s Drug Guide for Nurses. 5th Edition.
Philadelphia, Pennsylvania: 1997
Kozier, Barbara, ET. Al. Fundamentals of Nursing: Concept, Process and Practice. 5th
Edition. USA: Addison-Wesley Longman, Inc., 1998.
Potter, Patricia and Perry, Anne Griffin. Fundamentals of Nursing.5th Edition. St. Louis,
Missouri: Mosby, Inc., 2001
Smeltzer, Suzanne and Bare, Brenda. Textbook of Medical Surgical Nursing. 10th
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Nettina, Sandra M. Manual of Nursing Practice. 7th Edition. Philadelphia: Lippincott,
1996
Bates, Barbara, MD. A Guide to Physical Examination. 2nd Edition. Philadelphia:
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Positive Outcomes. Vol. 2, 6th Edition. Philadelphia: W. B. Saunders Company, 2001.
Doenges, Marilyn E. et al. Nurses Pocket Guide. 8th Edition F. A. Davis Company, 2002
Porth, Carol Matson. Pathophysiology, Concepts of Altered Health States. 6th Edition.
Lippincott Williams and Wilkins, 2002
MIMS, Philippines Index of Medical Specialties Established Since 1968, 100th Ed., 2004.
Oxford Reference. Dictionary of Nursing, Published by Oxford Melbourne, Oxford
University Press, Market House Books Ltd. 1990.
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