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Angeles University Foundation

Angeles City

College of Nursing

“Cerebrovascular Accident Infarct


Right hemisphere”
In Partial Fulfillment of the Requirements in NCM RLE 102

OB- Pedia Ward, Balitucan District Hospital

Submitted by:

Ano Carl Elexer C.

Balilo, Noel Leonicio

Dizon, Requelito

Estrada, Florence Ancel

BSN III-1 Group 1

Submitted To:

Fe Pagado R.N., M.N.

February 21, 2009

I. Introduction
Many studies were conducted regarding cerebrovascular accidents tackling
different aspects of cerebrovascular accident such as; the cause, precipitating factors,
predisposing factor, and its prevalence throughout the world as one of the top ten
leading causes of morbidity.

Cerebrovascular accident (CVA) is the medical term for what is commonly


termed a stroke. It refers to the injury to the brain that occurs when flow of blood to
brain tissue is interrupted by a clogged or ruptured artery, causing brain tissue to die
because of lack of nutrients and oxygen.

The severity associated with cerebrovascular accident can best be demonstrated


by the following facts: CVA is the leading cause of adult disability in the world. Two –
thirds of strokes appear among 65 year old and above. Stroke affects more men than
women and most of the cases are among African American. (Accessed on:
http://www.wikidoc.org/index.php/Cerebrovascular_accident)

A. Current Trends about the Disease Condition

Blunt cerebrovascular injuries can be diagnosed using whole body 16 multi-


detector CT (MDCT); there's no need for an additional neck MDCT angiography
examination according to a recent study conducted by researchers at the University of
Maryland Medical Center and R. Adams Cowley Shock Trauma Center, both in
Baltimore, MD. The study showed that whole body MDCT is just as accurate as neck
MDCTA. Blunt cerebrovascular injuries are uncommon but potentially devastating
injuries that can lead to stroke and death. These include dissections,
pseudoaneurysms, and arteriovenous fistulae.

For the study, the researchers identified 108 blunt trauma patients that were
examined with either whole-body MDCT or neck MDCTA followed by angiography over
a 23-month period. From this group, 77 whole body MDCT and 48 neck MDCTA
examinations were compared with the results that were pulled from the reports of
correlative angiography.

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According to the study, angiography confirmed blunt cerebrovascular injuries in
83 patients with 25 of those showing injury to more than one of the four major arteries
(carotid or vertebral). In the neck, where injuries were most common, each technique
showed low sensitivity for blunt carotid (69% for whole-body MDCT and 64% for
MDCTA) and blunt vertebral artery injuries (74% for whole-body MDCT and 68% for
MDCTA), but specificities were high for both carotid (82% for whole-body MDCT and
94% for MDCTA) and vertebral artery injuries (91% for whole-body MDCT and 100% for
MDCTA). The two techniques diagnosed blunt cerebrovascular injuries with statistically
comparable accuracy. Routine use of whole-body MDCT would facilitate diagnosis and
treatment of asymptomatic blunt cerebrovascular injuries in patients without typical risk
factors for injuries. (Accessed on: http://www.eurekalert.org/pub_releases/2008-03/arrs-
wbm032808.php)

B. Reasons for choosing such case for presentation

Initially the researchers have difficulty of an appropriate case for presentation


since most of the cases present on the institution are common illness such as Acute
Gastroenteritis and Bronchopneumonia where in there is a lot of information available
regarding these diseases.

With that problem in hand, the group decided to ask permission to their clinical
instructor to utilize a medical case, and with the approval of their clinical instructor, the
group came up into a medical case of a 58 years old widowed female with a diagnosis
of Cerebrovascular infarct right hemisphere with accompanying past illnesses of active
renal disease, hypertension and Diabetes mellitus.

Objectives

After the completion of the study, the researchers shall be able to:

 Identify and differentiate risks for cerebrovascular accident


 Be updated with the latest trends in the treatment of cerebrovascular accident
 Perform a comprehensive assessment of Cerebrovascular accident
 Enumerate the different signs and symptoms of Cerebrovascular accident

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 List down the different diagnostic procedures that would help in the diagnosis of
Cerebrovascular accident.
 Identify and understand different types of medical treatment necessary for the
treatment of Cerebrovascular accident.
 Formulate nursing care plans utilizing the nursing process
 Formulate conclusions based on the findings and enumerated a
recommendations concerning Cerebrovascular accident.

Nurse Centered Objectives:

At the end of the study, the researchers:

• Shall have critical thinking skills necessary for providing safe and effective
nursing care.

• Shall have a comprehensive assessment and implement care base on our


knowledge and skills of the condition

• Shall have familiarized us with effective inter-personal skills to emphasized


health promotion and illness prevention.

• Shall have imparted the learning experience from direct patient care.

Patient/Family Centered Objectives:

At the end of this study, the patient/family will be able to:

1. Identify measures that could minimize the risk of occurrence of the disease.
2. Identify possible risk factors that may have contributed to the development of
Cerebrovascular accident.
3. Increase awareness on the risk factors of Cerebrovascular accident.
4. Develop the family’s support system and distinguish their respective roles in
improving patient’s health status.
5. Involve them in promoting the health care of the patient.

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II. Nursing Assessment

A. Personal Data

1. Demographic data

Mrs. Kitty Sanrio is a 58 year old widow, Filipino who was born on
September 18, 1951 in Magalang, Pampanga.

She is the second child among the 3 siblings of Disney family and all
of them are married. She, together with her youngest daughter Po, currently
resides at San Francisco, Magalang, Pampanga. She is religiously affiliated
as a Roman Catholic. She is presently unemployed but used to be an eatery
vendor. When she was 35 years old she smokes 1 pack of cigarette per day,
yielding a pack year history of 23, she was forced to quit smoking due to her
present illness. She was admitted at Balitucan District Hospital in Magalang
with an admitting diagnosis of cerebrovascular infarct right hemisphere with
chief complaints of left sided weakness.

2. Socio-economic and Cultural Factors

Mrs. Kitty Sanrio was able to finish her high school education but she
was able to pursue a vocational course on dressmaking. She is religiously
affiliated to Roman Catholic. As mentioned the family believed on the
common practices of the Catholics which her daughter termed as “apis –apis”
they also believe in manghihilot. With regards to their sanitary condition of
their home it was reported that Mrs. Sanrio always does the housekeeping.

In the year 2007, Mrs. Sanrio used to work as an eatery vendor that
was specifically year ago before she was been diagnosed of renal disease
last 2008, at present her daughters support her daily expenses including
household bills.

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B. Pertinent Family Health History

Disney Family

Father Mother

Legend:

Renal

Heart Sister Sister

HPN

CVA, HPN,
Mrs. Mr. Sanrio
DM, Renal
Disease

Epilepsy

Liver

Daughte Daughte Daughte Daughte


Normal
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Upon interview it was reported that Mrs. Sanrio’s father died of renal failure at the
age of 82, her mother died of heart attack at the age of 89. Mrs. Sanrio has two sisters,
both of them also has hypertension. Mrs. Sanrio’s husband died 8 years ago at the age
of 52 due to liver cancer. 3 years after, specifically 2005, Mrs. Sanrio was diagnosed
Diabetes Mellitus type 2. At the year 2008, she was diagnosed of renal disease and
hypertension by accident. Her four daughters do not have any major illness except for
her youngest daughter which has epilepsy which was diagnosed at the age of 15.

C. History of Past Illness

Upon interview, her daughter told the student nurses that Mrs. Sanrio was
diagnosed of Diabetes Mellitus Type II in the year 2004, and she is taking Diamicron as
her medication, according to her mother is also fond of eating foods which are rich in fat
and cholesterol. She has also mentioned that Kitty cannot eat without putting extra salt
on her food. Information relayed by Tinky Winky states that Kitty undergone an incision
and drainage surgery due to thumbtacks pricks which became infected and developed a
large pus filled lesion in the year 2008. Together with that during her stay on the
hospital, it was found out that Kitty has a renal disease; Tinky Winky was not able to
specify the exact diagnosis given by the physician, it has also found out that she has a
hypertension. In line with this, Kitty managed her renal disease with Bactrim and Eprex.
She is also taking Capoten and Neobloc for her Hypertension. Mrs. Sanrio wears a
prescribed eyeglass for 3 years now with a grade of 200 as mentioned by Tinky winky.

D. History of Present Ilness

As narrated by Tinky winky at the district hospital 2-3 days prior to Kitty’s
admission she is already complaining of headache, and they regarded it as the usual
headache associated with high blood pressure. They have just managed it with her
medicines for hypertension. The symptoms persisted for another day and managed it
the same way.

January 27, 2009 1:30 am, Kitty woke them up with complains of numbness on
her body and blurry vision “dudurut ya kanu lawe”, she doesn’t want anybody to touch
her as she can feel that her conditions aggravates every time someone will touch her.
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According also to Tinky winky upon seeing her mother, she have noticed that there is an
obvious asymmetry on her mother’s face “balamu mekubit ya lupa, balamu babalag ya
lupa” and slurring of speech, she then had an idea that it may be a stroke.

They planned to bring Kitty to a private hospital, but Mrs. Sanrio disagreed
insisting that she wants to be admitted at the district hospital. So after a few hours of
debate, they have decided to bring her to the District Hospital. Upon consult, she was
advised to stay at the hospital on January 27, 2009 with admitting diagnosis of CVA
infarct right Hemisphere, with accompanying illnesses of renal disease, hypertension
and diabetes mellitus.

A. Physical Examination

January 27, 2009 (lifted from chart)

Patient has chief complaints of left sided body weakness, conscious, alert, (+)
facial asymmetry, normal rate and regular rhythm, clear breath sounds,
normoactive bowel sounds, GCS= 15, BP= 200/100 mmHg, PR= 85, RR= 16

R L

5/5 1/5

1/5
5/5

General Appearance - Initial [(January 29, 2009)]

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Patient is wearing a black with floral design clothing, with unkempt hair,
appears weak; patient has halitosis, conscious and coherent. She is lying on bed
with an ongoing IVF of #2 D5 0.3 NaCl 500 cc x 20 - 21 µgtts/ min infusing well
on the right metacarpal vein currently at 50 cc level, patient has an indwelling
Foley catheter attached to urine bag with current urine out put of 2000 ml.

Patient has the following vital signs:

R L
T= 35.8 ° C 5/5 0/5

P= 79 bpm

R= 20 cpm
5/5 4/5
BP= 190/90 mmHg

Upon the assessment of her head, the researchers noted a normal finding,
characterized by symmetrical skull, no presence of nodules and lesions, and with
hair properly distributed.

Upon the assessment of the client’s face, most of the findings are of
normal findings characterized by pupils which are equally round in shape,
reactive to light and accommodation, with her right eyebrows evenly distributed
and symmetrically aligned. With eyelashes of normal growth, there are no
purulent or any discharges seen on the client’s eyes. No periorbital edema noted,
cornea is transparent and shiny. Ears are of normal findings. Nose is also of
normal findings.

Further more upon the assessment of the throat and the mouth, the
researchers have noted the following manifestations: lips that are dark and dry,

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difficulty of swallowing, tongue which deviates towards the right side. Gums are
pale. There are no abnormal findings found upon the assessment of the neck.

The patient does not have any reports of chest pain upon assessment;
there were no presence of murmurs heard upon auscultation of the heart rate.
With the gastrointestinal assessment, abdomen is soft and not tender, there were
5 bowel sounds/ min/ quadrant upon auscultation, there were no presence of
organomegaly upon palpation.

The client was observed with no ROM and sensation on the upper left
extremity, there were no presence of edema and with a capillary refill of less than
3 sec, it was also noted that her both lower extremities has scars specifically on
the dorsal right lower extremity. It was also noted that the client has weakness on
the left lower extremity.

January 31, 2009

General Appearance

Patient is wearing a dark blue with floral design clothing, with unkempt hair,
appears weak, conscious, lethargic. She is lying on bed with an ongoing IVF of
#5 D5 0.3 NaCl 500 cc x 20 - 21 µgtts/ min infusing well on the right metacarpal
vein currently at 150 cc level, patient has an indwelling Foley catheter attached to
urine bag with current urine out put of 100 ml and currently undergoing bladder
training.

Patient has the following vital signs:


R L
T= 36° C
5/5 1/5
P= 63 bpm

R= 18 cpm
5/5
4/5
BP= 170/60 mmHg

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Upon the assessment of her head, the researchers noted a normal finding,
characterized by symmetrical skull, no presence of nodules and lesions, and with
hair properly distributed.

Upon the assessment of the client’s face, most of the findings are of
normal findings characterized by pupils which are equally round in shape,
reactive to light and accommodation, with her right eyebrows evenly distributed
and symmetrically aligned. Patient has eyelashes of normal growth, with dried
exudates, with a prescribed eyeglasses “200 ya gradu ing salamin na”. No
periorbital edema noted, cornea is transparent and shiny. Ears are of normal
findings. Nose is also of normal findings.

Further more upon the assessment of the throat and the mouth, the
researchers have noted the following manifestations: lips that are dark and dry,
with visible cracking of the lips, difficulty of swallowing, tongue which deviates
towards the right side. Gums are pale. There are no abnormal findings found
upon the assessment of the neck.

The patient does not have any reports of chest pain upon assessment;
there were no presence of murmurs heard upon auscultation of the heart rate.
With the gastrointestinal assessment, abdomen is soft and not tender, there were
5 bowel sounds/ min/ quadrant upon auscultation, there were no presence of
organomegaly upon palpation.

The client was observed with no ROM and sensation on the upper left
extremity, there were no presence of edema and with a capillary refill of less than
3 sec, it was also noted that her both lower extremities has scars specifically on
the dorsal right lower extremity. It was also noted that the client has weakness on
the left lower extremity.

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F. Diagnostic and Laboratory Procedures

DATE
DIAGNOSTIC OR
ORDERED INDICATIONS OR NORMAL ANALYSIS AND
LABORATORY RESULTS
AND DATE PURPOSES VALUES INTERPRETATION
PROCEDURES
RESULTS IN
CLINICAL CHEMISTRY
A fasting blood
A fasting
sugar level
blood sugar
117mg/ dL
test measures
the amount of which is
sugar in your obviously above
Date the normal
blood after
Ordered: limits.
you fast for at
1/27/09 least eight This justifies
hours or 70- 105 the patients
117mg/dL
FBS Date overnight. It is mg/dL current health
Results a test that is condition of
In: routinely done Type II
in all clients Diabetes
1/28/09
with possible Mellitus as
cardiovascula reflected on
r disorders to the
determine pathophysiolo
blood glucose gy.
levels.
FBS, Blood:
 Pre-test:
1. Inform the patient that the test is used to assist in the evaluation of fasting
hypoglycemia
2. Obtain a history of the patient’s complaints, including a list of known allergens such
as allergy to latex.
3. Obtain a history of the patient’s endocrine system and results of previously
performed laboratory tests, surgical procedures, and other diagnostic procedures.

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4. Note any procedures that can interfere with the test results.
5. Obtain a list of medications patient is taking, including herbs, and nutritional
supplements.

 Intra-test;
1. Ensure that the patient has complied with dietary or medication restrictions and other
pretesting preparations.
2. Instruct the patient to cooperate fully and to follow directions. Direct patient to
breathe normally and to avoid unnecessary movement.
3. If the patient has a history of severe allergic reaction to latex, care should be taken
and to avoid the use of equipment containing latex.
4. Observe Standard precautions.
5. After obtaining the specimen, promptly transport to the laboratory for processing and
analysis.

 Post-test:
1. Observe venipuncture site for bleeding or hematoma formation.
2. Instruct the patient to report signs and symptoms of hypoglycemia or hyperglycemia.
3. Emphasize that good glycemic control delays the onset of and slows the progression
of diabetic retinopathy, nephropathy, and neuropathy.
4. Reinforce information regarding the test results and address concerns voiced by the
family or the patient.
It is checked in
Date order to assess
requested a known and
The potassium
: suspected
3.6 3.5 – 5.3 electrolyte level
disorder
1/27/09 mmoL/L mmoL/L is within normal
Potassium associated with
range.
renal disease,
Date glucose
results in: metabolism,
1/28/09 trauma or
burns.
Potassium, blood,
 Before

1. Check the doctor’s order


2. Explain the procedure
3. Explain the purpose and what to expect
4. No food or fluid restrictions
 During

1. Do not take the blood sample from hand or arm with receiving IVF
2. The tourniquet should be less on a minute
3. Do not squeeze the punctured site rightly
4. Wipe away the first drop of blood
5. Collect 2ml venous blood in a lavender top tube

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 After

1. Observed and record vital signs.


2. Check injection sites for bleeding, infection, tenderness or thrombosis.
3. Report untoward reaction to the physician.
4. Apply warm compress to ease discomfort, as ordered.
5. Encourage relaxation by allowing client to discuss experiences and verbalize
feelings.
6. Interpret results and provide counsel appropriately. Provide health teachings
regarding proper lifestyle changes and symptoms that may warrant immediate
medical attention.
The creatinine
level is
Date The creatinine
significantly
requested test is used to above the
: diagnose
normal limits
1/27/09 impaired kidney
Creatinine 41mg/dL 0.6 – 1.2 which is a
function and to
mg/dL result of renal
determine renal
Date (kidney)
impairment
results in: related to the
damage.
1/28/09 client’s active
renal disease.

The blood uric


acid test
measures the
amount of uric
acid in a blood The uric acid
sample. level is
Date significantly
Increased level
requested above the
of uric acid in
: normal limits
the blood is 8.5 mg/
1/27/09 2.0 – 6.0 this also gives
BUA brought by too dL mg/dL justification to
Date much uric acid the
results in: is being deteriorating
1/28/09 produced or if function of the
the kidneys are renal system.
not able to
remove it from
the blood
normally.

Date Blood urea The BUN level


requested nitrogen (BUN) is significantly
: measures the 64 mg/dL 7-18 mg/ above the
BUN dL normal limits
1/27/09 amount of urea
nitrogen, a which denotes
Date waste product an impairment
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of protein
metabolism, in
the blood. Urea
is formed by
the liver and
carried by the
blood to the
kidneys for
excretion.
Because urea
is cleared from
the
bloodstream by
the kidneys, a
test measuring
how much urea
nitrogen
results in: in renal
remains in the
function
1/28/09 blood can be
used as a test
of renal
function.
However, there
are many
factors besides
renal disease
that can cause
BUN
alterations,
including
protein
breakdown,
hydration
status, and liver
failure.

Creatinine, BUN, BUA, Blood,

 Prior:

1. Select vein for venipuncture (usually antecubital space).


2. Apply tourniquet several inches above intended venipuncture site
3. Clean venipuncture site (with povidone iodine or alcohol, allow area to dry).
 During:

1. Perform venipuncture by entering the skin with needle at approximately a 15-degree


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angle to the skin, needle bevel up.
2. If using a Vacutainer, ease tube forward in holder once in the vein. If using a syringe,
pull back on the barrel with slow, even tension as blood fills the syringe.
3. Release tourniquet when the blood begins to flow.
 After:

1. After the blood is drawn, place cotton ball over site; withdraw the needle and exert
pressure. Apply bandage if needed.
2. Properly dispose contaminated materials.
3. Record the date and time of blood collection. Attach a label to each blood tube.
4. Relay results to the doctor.
LIPID PROFILE
This is a blood
test that
measures a
kind of fat
Date (lipid) in the
requested blood. The HDL
: test helps The LDL level is
1/27/09 check your risk within the
HDL for heart 87mg/dL
30mg/dL > normal range
disease or
Date atherosclerosis,
results in: which is a
1/28/09 hardening,
narrowing, or
blockage of the
arteries.

Used to
estimate risk of
developing a
disease The client has
specifically an increased
Date heart disease. cholesterol
requested Because high level which is
: blood 351 140-
one of the
CHOLESTEROL 1/27/09 cholesterol has mg/dL 250mg/dL
been precipitating
Date associated with factor of the
results in: hardening of client’s
1/28/09 the arteries, Hypertension.
heart disease
and a raised
risk of death
from heart
attacks.
The LDL test 219 <178 This is also
Date
measures how mg/dL mg/dL one of the
LDL requested much low- factors that
: density aggravates or
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lipoprotein
1/27/09 (LDL) you have triggers the
in your blood. client’s
Date Too much LDL hypertensive
results in: in the blood episodes.
1/28/09 can clog
arteries.
This is also
A test to one of the
determine the factors that
cholesterol 209 10- aggravates or
Triglycerides mg/dL 190mg/dL triggers the
level circulating
in the client’s
bloodstream hypertensive
episodes.

Total Cholesterol Test: (NSG. Implications)


 Pretest:
1. Inform the patient that the test is used to assess and monitor risk for coronary artery
disease.
2. Obtain history of the patient’s past health history and previously performed laboratory
tests, surgical procedures, and other diagnostic procedures.
3. Instruct the patient to withhold drugs and alcohol known to alter cholesterol levels for
12 to 24 hours before specimen collection.
4. Fasting 6 to 12 hours before specimen collection is required if triglyceride
measurements are included; it is recommended if cholesterol levels alone are
measured for screening.

 Intratest:
1. Ensure that the patient has complied with the dietary restrictions and pre testing
precautions.
2. If the patient has a history of severe allergic reaction to latex, care should be taken to
avoid the use of equipment containing latex.
3. Instruct the client to cooperate fully and to follow directions.
4. Observe Standard Precautions.
5. Remove the needle and apply pressure dressing over the puncture site.
6. Immediately transport the specimen to the laboratory for processing and analysis.
 Post-test:
1. Observe venipuncture site for bleeding or hematoma formation.
2. Instruct the patient to reduce intake of foods high in saturated fats and cholesterol
and triglyceride levels. (E.g. red meats, eggs, and dairy products are major sources
of saturated fats and cholesterol.
3. Consider social and cultural beliefs and practices of the client.
4. Recognize anxiety related to test results. Discuss the implications of abnormal test
results on the patient’s lifestyle.
5. Provide teaching and information regarding the clinical indications of the test results.
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BLOOD HEMATOLOGY
The patient
Date - to monitor having a
requested Hgb value in decreased
: the RBC hemoglobin
12-16
- to suggest the 8.0mg% level with
Hemoglobin 1/27/09 mg%
presence of accompanying
(Hgb) body fluid signs of pallor
Date deficit due to indicates that
results in: elevated Hgb the client has
1/28/09 level anemia.

To aid
diagnosis of
abnormal The hematocrit
states of level is below
Date the normal
hydration,
requested polycythemia range, which
: and anemia. 37-47 denotes a
1/27/09 27.0 vol%
Hematocrit vol% decreased
- It measures
(Hct) the concentration
Date concentration of RBC in the
results in: of RBC within blood or
1/28/09 the blood hemodilution.
volume and is
expressed as a
percentage.

The test is
performed to The WBC
find out how
count is below
many white
Date blood cells you the normal
requested have. Your limits a
: body produces 4900/ cu. decrease or
5-10 x
1/27/09 more white mm increase in the
WBC 103mm
blood cells WBC count
Date when you have denotes
results in: an infection or
infection or
1/28/09 allergic
reaction, even inflammation.
when you are
under general
stress
Neutrophils/ Date To detect 76% 50-70% The
Segmenters requested presence of Neutrophils is
: infection in the above the
1/27/09 body normal limits
indicating
infection.
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Date
results in:
1/28/09
Date The number of
requested lymphocytes is
: To detect slightly
presence of 24% 25-40%
1/27/09 decreased
Lymphocytes infection within
the body. which
Date indicates
results in: infection
1/28/09

Date
requested To detect The eosinophils
: presence of count is within
Eosinophils 1/27/09 infection within 1% 1-4%
the normal
the body. range

Date
results in:
1/28/09
Nursing Implications for Blood Hematology Test:
 Pretest:
1. Inform the patient that the test is used to evaluate numerous conditions inflammation,
infection, and response to chemotherapy.
2. Obtain a history of the patient’s complaints (such as allergies and sensitivity to latex.
3. Obtain a history of the patient’s gastrointestinal, hematopoietic, immune, and
respiratory systems, as well as results of previously performed laboratory tests,
surgical procedures, and other diagnostic procedures.
4. Obtain a list of medications the patient is taking, including herbs, nutritional
supplements, and nutraceuticals.
5. Review the procedure with the patient. Explain the duration of the procedure and
inform the client that there may be some discomforts during the procedure.
6. Consider the patient’s cultural beliefs and practices and it is important to provide
psychological support before, during, and after the procedure.

 Intratest:
1. Avoid using equipment containing latex if the patient has allergy to it.
2. Instruct the patient to cooperate fully and to follow directions. Direct the patient to
breathe normally and to avoid unnecessary movement.
3. Observe Standard precautions.
4. Remove the needle, and apply a pressure dressing over the puncture site.
5. Promptly transport the specimen to the laboratory for processing and analysis.

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 Post-test:
1. Observe venipuncture site for bleeding or hematoma formation. Apply paper tape or
other adhesive to hold pressure bandage in place.
2. Instruct the patient to limit salt intake, alcohol intake and cut down smoking.
3. Reinforce information regarding the test results and address any concerns voiced by
the patient or family.

IMAGING
Chest
Roentgen
ogram
X-rays - a reveals
diagnostic test minimal
which uses hazy
invisible infiltrates
electromagneti on both
c energy lower
beams to lung
produce fields.
images of Heat and
internal tissues, great
bones, and vessels Normal
Date The chest x-
organs onto are of anatomical
requested ray denotes
film. Chest normal feature of
: abnormal
radiographs size and the lungs.
features of the
1/27/09 may depict configurat Without
CXR APL patient lungs, it
segmental or ion. signs of
shows that her
Date lobar infiltrate effusion,
both lung
results in: but they more Hemidiag and other
parenchyma
1/30/09 commonly phragms, abnormal
are inflamed.
reveal a sulci, and findings.
diffuse, fine, other
reticulogranular visualized
pattern, much including
like what is chest
observed in structures
RDS. Pleural are
effusions may unremark
also be able.
observed.
Remarks:
Pneumon
itis ,
bilateral
Nursing Implication

 BEFORE:
1. Explain the purpose of the CXR to the mother.
2. Inform the mother whether they will be transported to the radiology department or

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have the x-ray done at bedside (portable CXR).
3. Tell the mother that the test will take only a few minutes and is painless

 DURING:
1. Provide a lead apron for any person who must hold the patient during the procedure.
2. Provide extra blankets for patient chilled from exposure during CXR.

 AFTER:
No aftercare is generally required following a chest x - ray. Immediately following the exam,
the technologist will continue to watch the patient for patient’s respiratory pattern.
FECALYSIS
Color:
Brown

Consistency:
Soft

This was done Trichiuris:


Date to the patient Color: none Fecalysis
requested as a screening Brown
shows that
: for Amoeba: the patient
abnormalities Consiste None
1/27/09 has a positive
FECALYIS within the ncy:
parasitic
gastrointestinal Soft Hookworm:
Date infestation
tract including None
results in: specifically
bleeding and Trichiuris:
1/30/09 trichiuris
parasitic 0-1/hpf Pus Cells:
infection. None

RBC:
None

Bacteria:
None
Nursing Implication

 Prior:
1. Explain the procedure to the client in order to gain her
2. Inform the client that there is no need for NPO.
3. Educate the patient on the proper way of collecting fecal matter
4. Prepare the container for the stool.

 During:
1. Provide privacy.
2. Assist the patient if unable to get her stool sample on her own.
3. Instruct the patient to prevent contamination of the stool and not to add water to the
stool specimen, to prevent alteration of results.

 After:
21
1. Continue taking the medications that were stopped prior to the procedure.
URINALYSIS
Urinalysis
Color: shows that
Yellow Color: patient is
Yellow manifesting
Appearance:
Clear pyuria
This was done Appearance:
Clear indicating
to the patient
infection
Date as a screening Ph: Acidic
Ph: Acidic within the
requested for
Pus urinary tract.
: abnormalities
Cells: Pus Cells: She also
within the
1/27/09 4-6/HPF none manifests red
URINALYSIS urinary system
blood cells on
as well as for
Date Red Red Cells: her urine
system
results in: Cells: none indicating a
problems that
1/29/09 6-8/HPF problem on
may manifest
Albumin: the kidney
through the
Albumin: negative filtration; this
urinary tract.
4 is supported
Glucose: by
Glucose: negative albuminuria
rare and
glucosuria.
Nursing Implication

 Prior:
5. Explain the procedure to the client in order to gain her
6. Inform the client that there is no need for NPO.
7. Educate the patient on the proper way of collecting urine (clean catch midstream
specimen).
8. Prepare the container for the urine.

 During:
4. Provide privacy.
5. Assist the patient if unable to get her urine sample on her own.
6. Instruct the patient to prevent contamination of the urine and not to add water to the
urine specimen, to prevent alteration of results.

 After:
1. Refrigerate the specimen.
2. Continue taking the medications that were stopped prior to the procedure.

22
III. ANATOMY AND PHYSIOLOGY

The Cardiovascular System

The heart and circulatory system make up


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

The one-way circulatory system carries


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

23
that brings oxygen-rich blood back to the heart. (Rod R. Seeley et. al, Essentials of
Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

Twenty major arteries make a path through the tissues, where they branch into
smaller vessels called arterioles. Arterioles further branch into capillaries, the true
deliverers of oxygen and nutrients to the cells. Most capillaries are thinner than a hair. In
fact, many are so tiny, only one blood cell can move through them at a time. Once the
capillaries deliver oxygen and nutrients and pick up carbon dioxide and other waste,
they move the blood back through wider vessels called venules. Venules eventually join
to form veins, which deliver the blood back to the heart to pick up oxygen.
Vasoconstriction or the spasm of smooth muscles around the blood vessels causes and
decrease in blood flow but an increase in pressure. In vasodilation, the lumen of the
blood vessel increase in diameter thereby allowing increase in blood flow. There is no
tension on the walls of the vessels therefore, there is lower pressure. (Rod R. Seeley et.
al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

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

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

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

Red blood cells (also called erythrocytes) are shaped like slightly indented,
flattened disks. Red blood cells contain an iron-rich protein called hemoglobin. Blood
gets its bright red color when hemoglobin in red blood cells picks up oxygen in the
lungs. As the blood travels through the body, the hemoglobin releases oxygen to the
tissues. The body contains more red blood cells than any other type of cell, and each
24
red blood cell has a life span of about 4 months. Each day, the body produces new red
blood cells to replace those that die or are lost from the body.

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

Several different parts of blood are involved in fighting infection. White blood cells
called granulocytes and lymphocytes travel along the walls of blood vessels. They fight
bacteria and viruses and may also attempt to destroy cells that have become infected or
have changed into cancer cells. (Rod R. Seeley et. al, Essentials of Anatomy and
Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

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

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

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

25
Platelets and clotting factors work together to form solid lumps to seal leaks,
wounds, cuts, and scratches and to prevent bleeding inside and on the surfaces of our
bodies. The process of clotting is like a puzzle with interlocking parts. When the last part
is in place, the clot is formed.

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

In addition to the cells and clotting factors, blood contains other important
substances, such as nutrients from the food that has been processed by the digestive
system. Blood also carries hormones released by the endocrine glands and carries
them to the body parts that need them. (Rod R. Seeley et. al, Essentials of Anatomy
and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

Blood is essential for good health because the body depends on a steady supply
of fuel and oxygen to reach its billions of cells. Even the heart couldn't survive without
blood flowing through the vessels that bring nourishment to its muscular walls. Blood
also carries carbon dioxide and other waste materials to the lungs, kidneys, and
digestive system, from where they are removed from the body. (Rod R. Seeley et. al,
Essentials of Anatomy and Physiology 5th
edition, McGraw-Hill Int. NY 10020 2005)

The Endocrine System

The endocrine system is made up of


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

26
body. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-
Hill Int. NY 10020 2005)

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

Hormones are chemical messengers created by the body. They transfer


information from one set of cells to another to coordinate the functions of different parts
of the body. Hormones can act on some specific cells because they themselves do not
actually cause an effect. It is only through binding with a receptor (part of the cell
specifically designed to recognize the hormone) like a key into a lock - that causes a
chain reaction to occur, changing the activity of the cells. If a cell does not have a
receptor for a hormone then there will be no effect. Also, there can be different receptors
for the same hormone, and so the same hormone can have different effects on different
cells. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-
Hill Int. NY 10020 2005)

The major glands of the endocrine system are the pituitary, thyroid, parathyroids,
adrenals, pineal body, thymus, and the reproductive organs (ovaries and testes). The
pancreas is also a part of this system; it has a role in hormone production as well as in
digestion. A gland is a group of cells that produces and secretes chemicals. A gland
selects and removes materials from the blood, processes them, and secretes the
finished chemical product for use somewhere in the body. The endocrine gland cells
release a hormone into the blood stream for distribution throughout the entire body.
These hormones act as chemical messengers and can alter the activity of many organs
at once. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition,
McGraw-Hill Int. NY 10020 2005)

The hypothalamus controls all the processes undergone by the anterior and
posterior pituitary glands. It initiates the production of hormones by the APG. The APG
is controlled by releasing hormones which are chemical signals produced by the nerve

27
cells of the hypothalamus, causing either stimulation or inhibition of hormone
production. Secretion of hormones by the PPG is controlled by nervous system
stimulation of nerve cells in the hypothalamus. Parathyroid glands secrete parathyroid
hormone which is essential for the regulation of blood calcium levels. Adrenal glands
produce epinephrine and norepinephrine which are fight-or-flight hormones that prepare
the body for vigorous physical activity. Testes and ovaries produce hormones that are
responsible for secondary sex characteristics, spermatogenesis, and oogenesis. The
thymus gland secretes thymosin which aids in the synthesis of WBC for fighting
infection. This gland decreases in size in some older adults. The pineal body releases
melatonin that is thought to decrease the secretion of LSH & FSH by decreasing the
release of hypothalamic-releasing hormones. The thyroid gland, located on either side
of the trachea, is controlled by the thyroid stimulating hormone releases by the anterior
pituitary gland, which was initially stimulated by the TSH releasing hormone from the
hypothalamus. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition,
McGraw-Hill Int. NY 10020 2005)

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

In humans, the pancreas is a 15-25 cm (6-10 inch) elongated organ in the


abdomen adjacent to the small intestine and lies toward the back. It has three regions: a
head (abuts a part of the duodenum), body (at the level of L2 of the spine) and tail

28
(extends toward the spleen). (Rod R. Seeley et. al, Essentials of Anatomy and
Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

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

The pancreas is supplied arterially by the Pancreaticoduodenal arteries and the


splenic artery: the splenic artery supplies the neck, body, and tail of the pancreas; the
superior mesenteric artery provides the inferior pancreaticoduodenal artery; and the
gastroduodenal artery provides the superior pancreaticoduodenal artery.

Venous drainage is via the pancreaticoduodenal veins which end up in the portal
vein. The splenic vein passes posterior to the pancreas but is said to not drain the
pancreas itself. The portal vein is formed by the union of the superior mesenteric vein
and splenic vein posterior to the neck of the pancreas. In some people (some books say
40% of people); the inferior mesenteric vein also joins with the splenic vein behind the
pancreas (in others it simply joins with the superior mesenteric vein instead). (Rod R.
Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY
10020 2005)

The pancreas is a compound gland in the sense that it is composed of both


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

There are four main types of cells in the islets of Langerhans. They are relatively
difficult to distinguish using standard staining techniques, but they can be classified by
29
their secretion: Beta cells secretes Insulin and Amylin lower blood sugar, Alpha Cells
secretes Glucagon raise blood sugar, Delta Cells secretes Somastotatin inhibit
endocrine pancreas, PP Cells secretes pancreatic polypeptide which inhibits exocrine
pancreas

The islets are a compact collection of endocrine cells arranged in clusters and
cords and are crisscrossed by a dense network of capillaries. The capillaries of the
islets are lined by layers of endocrine cells in direct contact with vessels, and most
endocrine cells are in direct contact with blood vessels, by either cytoplasmic processes
or by direct apposition. There are two main types of exocrine pancreatic cells,
responsible for two main classes of secretions: Centroacinar cells secretes bicarbonate
ions, Basophilic cells secretes digestive enzymes such as pancreatic amylase,
pancreatic lipase. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5 th
edition, McGraw-Hill Int. NY 10020 2005)

The Nervous System

The nervous system is a network of


specialized cells that communicate information
about an animals surroundings and its self, it
processes this information and causes reactions
in other parts of the body. It is composed of
neurons and other specialized cells called glia,
that aid in the function of the neurons.

The nervous system is divided broadly


into two categories; the peripheral nervous
system and the central nervous system. Neurons
generate and conduct impulses between and
within the two systems. The peripheral nervous
system is composed of sensory neurons and the
neurons that connect them to the nerve cord,
spinal cord and brain, which make up the central nervous system. In response to

30
stimuli, sensory neurons generate and propagate signals to the central nervous system
which then process and conduct back signals to the muscles and glands. (Rod R.
Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY
10020 2005)

The neurons of the nervous systems of animals are interconnected in complex


arrangements and use electrochemical signals and neurotransmitters to transmit
impulses from one neuron to the next. The interaction of the different neurons form
neural circuits that regulate an organism’s perception of the world and what is going on
with its body, thus regulating its behavior. Nervous systems are found in many
multicellular animals but differ greatly in complexity between species

The central nervous system (CNS) is the largest part of the nervous system, and
includes the brain and spinal cord. The spinal cavity holds and protects the spinal cord,
while the head contains and protects the brain. The CNS is covered by the meninges, a
three layered protective coat. The brain is also protected by the skull, and the spinal
cord is also protected by the vertebrae. (Rod R. Seeley et. al, Essentials of Anatomy
and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

Brain is a part of the Central Nervous System, it plays a central role in the
control of most bodily functions, including awareness, movements, sensations,
thoughts, speech, and memory. Some reflex movements can occur via spinal cord
pathways without the participation of brain structures. (Rod R. Seeley et. al, Essentials
of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

The cerebrum is the largest part of the brain and controls voluntary actions,
speech, senses, thought, and memory.

The surface of the cerebral cortex has grooves or infoldings (called sulci), the largest of
which are termed fissures. Some fissures separate lobes.

The convolutions of the cortex give it a wormy appearance. Each convolution is


delimited by two sulci and is also called a gyrus (gyri in plural). The cerebrum is divided
into two halves, known as the right and left hemispheres. A mass of fibers called the

31
corpus callosum links the hemispheres. The right hemisphere controls voluntary limb
movements on the left side of the body, and the left hemisphere controls voluntary limb
movements on the right side of the body. Almost every person has one dominant
hemisphere. Each hemisphere is divided into four lobes, or areas, which are
interconnected.

• The frontal lobes are located in the front of the brain and are responsible for
voluntary movement and, via their connections with other lobes, participate in the
execution of sequential tasks; speech output; organizational skills; and certain
aspects of behavior, mood, and memory.

• The parietal lobes are located behind the frontal lobes and in front of the occipital
lobes. They process sensory information such as temperature, pain, taste, and
touch. In addition, the processing includes information about numbers,
attentiveness to the position of one’s body parts, the space around one’s body,
and one's relationship to this space.

• The temporal lobes are located on each side of the brain. They process memory
and auditory (hearing) information and speech and language functions.

• The occipital lobes are located at the back of the brain. They receive and process
visual information (Rod R. Seeley et. al, Essentials of
Anatomy and Physiology 5th edition, McGraw-Hill Int.
NY 10020 2005)

The urinary system is system of organs that


produces and excretes urine from the body. Urine is a
transparent yellow fluid containing unwanted wastes, mostly
excess water, salts, and nitrogen compounds. The major
organs of the urinary system are the kidneys, a pair of
bean-shaped organs that continuously filter substances

32
from the blood and produce urine. Urine flows from the kidneys through two long, thin
tubes called ureters. With the aid of gravity and wavelike contractions, the ureters
transport the urine to the bladder, a muscular vessel. The normal adult bladder can
store up to about 0.5 liter (1 pt) of urine, which it excretes through the tubelike urethra.

An average adult produces about 1.5 liters of urine each day, and the body
needs, at a minimum, to excrete about 0.5 liter of urine daily to get rid of its waste
products. Excessive or inadequate production of urine may indicate illness and doctors
often use urinalysis (examination of a patient’s urine) as part of diagnosing disease. For
instance, the presence of glucose, or blood sugar, in the urine is a sign of diabetes
mellitus; bacteria in the urine signal an infection of the urinary system; and red blood
cells in the urine may indicate cancer of the urinary tract. (Rod R. Seeley et. al,
Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

Kidney
s are
paired or gans w
hose fun ctions
include

removing waste products from the blood and regulating the amount of fluid in the body.
The basic units of the kidneys are microscopically thin structures called nephrons, which
filter the blood and cause wastes to be removed in the form of urine. Together with the
bladder, two ureters, and the single urethra, the kidneys make up the body’s urinary

33
system. Human beings, as well as members of all other vertebrate species, typically
have two kidneys. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th
edition, McGraw-Hill Int. NY 10020 2005)

Like kidney beans, the body’s kidneys are dark red in color and have a shape in
which one side is convex, or rounded, and the other is concave, or indented. The
kidneys of adult humans are about 10 to 13 cm (4 to 5 in) long and about 5 to 7.5 cm (2
to 3 in) wide—about the size of a computer mouse.

The kidneys lie against the rear wall of the abdomen, on either side of the spine.
They are situated below the middle of the back, beneath the liver on the right and the
spleen on the left. Each kidney is encased in a transparent, fibrous membrane called a
renal capsule, which helps protect it against trauma and infection. The concave part of
the kidney attaches to two of the body’s crucial blood vessels—the renal artery and the
renal vein—and the ureter, a tubelike structure that carries urine to the bladder. (Rod R.
Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY
10020 2005)

A primary function of kidneys is the removal of poisonous wastes from the blood.
Chief among these wastes are the nitrogen-containing compounds urea and uric acid,
which result from the breakdown of proteins and nucleic acids. Life-threatening illnesses
occur when too many of these waste products accumulate in the bloodstream.
Fortunately, a healthy kidney can easily rid the body of these substances.

In addition to cleaning the blood, the kidneys perform several other essential
functions. One such activity is regulation of the amount of water contained in the blood.
This process is influenced by antidiuretic hormone (ADH), also called vasopressin,
which is produced in the hypothalamus (a part of the brain that regulates many internal
functions) and stored in the nearby pituitary gland. Receptors in the brain monitor the
blood’s water concentration. When the amount of salt and other substances in the blood
becomes too high, the pituitary gland releases ADH into the bloodstream. When it

34
enters the kidney, ADH makes the walls of the renal tubules and collecting ducts more
permeable to water, so that more water is reabsorbed into the bloodstream. (Rod R.
Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY
10020 2005)
The hormone aldosterone, produced by the adrenal glands, interacts with the
kidneys to regulate the blood’s sodium and potassium content. High amounts of
aldosterone cause the nephrons to reabsorb more sodium ions, more water, and fewer
potassium ions; low levels of aldosterone have the reverse effect. The kidney’s
responses to aldosterone help keep the blood’s salt levels within the narrow range that
is best for crucial physiological activities. (Rod R. Seeley et. al, Essentials of Anatomy
and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
Aldosterone also helps regulate blood pressure. When blood pressure starts to
fall, the kidney releases an enzyme (a specialized protein) called renin, which converts
a blood protein into the hormone angiotensin. This hormone causes blood vessels to
constrict, resulting in a rise in blood pressure. Angiotensin then induces the adrenal
glands to release aldosterone, which promotes sodium and water to be reabsorbed,
further increasing blood volume and blood pressure.

The kidney also adjusts the body's acid-base balance to prevent such blood
disorders as acidosis and alkalosis, both of which impair the functioning of the central
nervous system. If the blood is too acidic, meaning that there is an excess of hydrogen
ions, the kidney moves these ions to the urine through the process of tubular secretion.
An additional function of the kidney is the processing of vitamin D; the kidney converts
this vitamin to an active form that stimulates bone development. (Rod R. Seeley et. al,
Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)
Several hormones are produced in the kidney. One of these, erythropoietin,
influences the production of red blood cells in the bone marrow. When the kidney
detects that the number of red blood cells in the body is declining, it secretes
erythropoietin. This hormone travels in the bloodstream to the bone marrow, stimulating
the production and release of more red cells. (Rod R. Seeley et. al, Essentials of
Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

35
The respiratory system generally includes tubes, such as the bronchi, used to carry air
to the lungs, where gas exchange takes place. A diaphragm pulls air in and pushes it
out. Respiratory systems of various types are found in a wide variety of organisms.
Even trees have respiratory systems.

In humans, the respiratory system


consists of the airways, the lungs, and the
respiratory muscles that mediate the
movement of air into and out of the body.
Within the alveolar system of the lungs,
molecules of oxygen and carbon dioxide
are passively exchanged, by diffusion,
between the gaseous environment and
the blood. Thus, the respiratory system
facilitates oxygenation of the blood with a
concomitant removal of carbon dioxide
and other gaseous metabolic wastes from
the circulation. The system also helps to maintain the acid-base balance of the body
through the efficient removal of carbon dioxide from the blood. (Rod R. Seeley et. al,
Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

1. The SINUSES (frontal, maxillary, and sphenoidal) are hollow spaces in the bones
of the head. Small openings connect them to the nose. The functions they serve include
helping to regulate the temperature and humidity of air breathed in, as well as to lighten
the bone structure of the head and to give resonance to the voice.
36
2. The NOSE (nasal cavity) is the preferred entrance for outside air into the respiratory
system. The hairs that line the wall are part of the air-cleaning system.

3. Air also enter through the MOUTH (oral cavity), especially in people who have a
mouth-breathing habit or whose nasal passages may be temporarily obstructed, as by a
cold or during heavy exercise.

4. The ADENOIDS are lymph tissue at the top of the throat. When they enlarge and
interfere with breathing, they may be removed. The lymph system, consisting of nodes
(knots of cells) and connecting vessels, carries fluid throughout the body. This system
helps to resist body infection by filtering out foreign matter, including germs, and
producing cells (lymphocytes) to fight them.

5. The TONSILS are lymph nodes in the wall of the throat (pharynx) that often become
infected. They are part of the germ-fighting system of the body.

6. The THROAT (pharynx) collects incoming air from the nose and mouth and passes it
downward to the windpipe (trachea).

7. The EPIGLOTTIS is a flap of tissue that guards the entrance to the windpipe
(trachea), closing when anything is swallowed that should go into the esophagus and
stomach.

8. The VOICE BOX (larynx) contains the vocal chords. It is the place where moving air
being breathed in and out creates voice sounds.

9. The ESOPHAGUS is the passage leading from the mouth and throat to the stomach.

10. The WINDPIPE (trachea) is the passage leading from the throat (pharynx) to the
lungs.

11. The LYMPH NODES of the lungs are found against the walls of the bronchial tubes
and windpipe.

12. The RIBS are bones supporting and protecting the chest cavity. They move to a
limited degree, helping the lungs to expand and contract.

37
13. The windpipe divides into the two main BRONCHIAL TUBES, one for each lung,
which subdivide into each lobe of the lungs. These, in turn, subdivide further.

14. The right lung is divided into three LOBES, or sections. Each lobe is like a balloon
filled with sponge-like tissue. Air moves in and out through one opening -- a branch of
the bronchial tube.

15. The left lung is divided into two LOBES.

16. The PLEURA are the two membranes, actually one continuous one folded on itself,
that surround each lobe of the lungs and separate the lungs from the chest wall.

17. The bronchial tubes are lines with CILIA (like very small hairs) that have a wave-like
motion. This motion carried MUCUS (sticky phlegm or liquid) upward and out into the
throat, where it is either coughed up or swallowed. The mucus catches and holds much
of the dust, germs, and other unwanted matte that has invaded the lungs. You get rid of
this matter when you cough, sneeze, clear your throat or swallow.

18. The DIAPHRAGM is the strong wall of muscle that separates the chest cavity from
the abdominal cavity. By moving downward, it creates suction in the chest to draw in air
and expand the lungs.

19. The smallest subdivisions of the bronchial tubes are called BRONCHIOLES, at the
end of which are the air sacs or alveoli (plural of alveolus).

20. The ALVEOLI are the very small air sacs that are the destination of air breathed in.
The CAPILLARIES are blood vessels that are imbedded in the walls of the alveoli.
Blood passes through the capillaries, brought to them by the PULMONARY ARTERY
and taken away by the PULMONARY VEIN. While in the capillaries the blood gives off
carbon dioxide through the capillary wall into the alveoli and takes up oxygen from the
air in the alveoli. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5 th
edition, McGraw-Hill Int. NY 10020 2005)

38
Mechanics of Breathing

To take a breath in, the external intercostal muscles contract, moving the ribcage up and
out. The diaphragm moves down at the same time, creating negative pressure within
the thorax. The lungs are held to the thoracic wall by the pleural membranes, and so
expand outwards as well. This creates negative pressure within the lungs, and so air
rushes in through the upper and lower airways.

Expiration is mainly due to the natural elasticity of the lungs, which tend to collapse if
they are not held against the thoracic wall. This is the mechanism behind lung collapse
if there is air in the pleural space (pneumothorax). (Rod R. Seeley et. al, Essentials of
Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

Physiology of Gas Exchange

Each branch of the bronchial tree eventually sub-divides to form


very narrow terminal bronchioles, which terminate in the alveoli.
There are many millions of alveloi in each lung, and these are
the areas responsible for gaseous exchange, presenting a
massive surface area for exchange to occur over.

Each alveolus is very closely associated with a network of


capillaries containing deoxygenated blood from the pulmonary
artery. The capillary and alveolar walls are very thin, allowing
rapid exchange of gases by passive diffusion along concentration gradients.
CO2 moves into the alveolus as the concentration is much lower in the alveolus than in
the blood, and O2 moves out of the alveolus as the continuous flow of blood through the
capillaries prevents saturation of the blood with O2 and allows maximal transfer across
the membrane. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition,
McGraw-Hill Int. NY 10020 2005)

39
IV. THE PATIENT AND HIS ILLNESS

A. PATHOPHYSIOLOGY (BOOK BASED)

Modifiable Factors Non Modifiable Factors

Smoking, Obesity, Hypertension, High Cholesterol Age, Family History of CVA,


Level, Excessive Alcohol Consumption, Drug Family History of DM, Sex
Addiction, High Dose of estrogen OC, Diabetes (Men), Race
Mellitus, Atrial Fibrillation, Type A personality,
Sedentary Life Style

Weight
Loss

Destruction of alpha and


beta cells of the pancreas

Polydipsia Polyuria Polyphagia

Failure to produce insulin


Production of
excess glucagon Inc. Ketones

Production of Acidosis
Inc. osmolarity Inc. serum glucose level glucose from protein
due to glucose and fat stores
Acetone breath

Wasting of lean
Glycoprotein cell body mass Fatigue
wall deposits
Weight loss
40
Impaired immune
function
(decrease level of Small vessel
morphonuclear disease
leukocytes)

Diabetic
Nephropathy
Accelerated
Neuropath atherosclerosis
y

Infection Delayed wound Diabetic


healing Retinopathy Renal
Disease

Symmetri Hypertension
cal loss of
protective
Loss of vision
sensation
Blindness

Increase LDL levels

Numbness Autonomic
and tingling neuropathy
in the
extremities

Dry cracked skin

Wasting of Gastro paresis


intrinsic
muscle CEREBROVASCULAR
Thrombus
ACCIDENT
Impotence
Emboli
Charcot Hemiparesis
changes in Decreased Tissue
joints perfusion (brain)
Neurogenic Loss of speech
bladder
Hemisensory loss
Cerebral Hypoxia
Syncope/ Vertigo
Source: Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005
Cerebral ischemia

Short term Long term


Eschemia Eschemia
(<10- (>10-
15mins) 15mins)

Temporary Permanent
Deficit Deficit

No Irreversible
permanent damage
damage
41

MID CEREBRAL ANTERIOR POSTERIOR VERTEBROBASILAR


ARTERY CEREBRAL A. CEREBRAL A. ARTERY
Hemiparesis/ Hemiplegia Visual Changes
Dysphagia Dysarthia Horner’s
Syndrome

Aphasia Apraxia

Agnosia Hemisensory loss

Ataxia Unilarteral Neglect

42
Incontinence

Source: Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005

B. PATHOPHYSIOLOGY (CLIENT BASED)

Modifiable Factors Non Modifiable Factors

Hypertension (BP-200/100 -01/27/09), High Age (58 yrs. Old), Family History
Cholesterol Level (Total Chol: 351), Diabetes of Cardiovascular diseases
Smoking (23 pack Mellitus (Diagnosed with since 2004) (Mother of the patient died from
years) heart attack), Family History of
DM,

Pneumonitis- radiology
report (01-30-09) Destruction of alpha and
beta cells of the pancreas

Failure to produce insulin Production of


excess glucagon
43
Inc. osmolarity Inc. serum glucose level
Polyuria due to glucose
Production of
FBS: 117 mg/dl (01/28/09) glucose from protein
and fat stores
01/29/09 -01/31/09
Glycoprotein cell
wall deposits

01/29/09 -01/31/09

Wasting of lean
Impaired immune
body mass Fatigue
function
(decrease level of Small vessel
morphonuclear disease
leukocytes)

Diabetic
Nephropathy Accelerated
atherosclerosis

Infection Delayed Diabetic BP- 200/100


wound healing Retinopathy (01/27/09)
Lab results:
WBC: 4,900 Normal:
(5-10x103)
(01/28/09) Hypertension

Blurred Vision
Renal 01/27/09 -01/31/09
Affectation
Pus Cell Increase LDL levels

Urinalysis Lab results:


Albumin: high Total Chol: 351
Sugar: rare HDL: 87
Pus cells: 46 /hpf LDL: 219
Glucosuria Decreased
RBC: 68 /hpf Triglycerides: 209
Production of
(01/29/09) (1/28/09)
Erythropoeitin

Proteinuria

Decreased RBC
production in the
bone marrow

Lab results:
Hemoglobin: 8 (F: 12-16)
Hematocrit: 27 (F: 37-
47)
(01/28/09)
Anemia

44
Thrombus
CEREBROVASCULAR
ACCIDENT
Emboli

01/27/09
Hemiparesis

Decreased Tissue
perfusion (brain) 01/27/09

Slurred speech

01/27/09
Hemisensory loss

Cerebral Hypoxia

Vertigo
01/27/09

Cerebral ischemia

Short term
Eschemia
(<10-
15mins)

Temporary
Deficit

No
permanent
damage

MID CEREBRAL ANTERIOR POSTERIOR VERTEBROBASILAR


ARTERY CEREBRAL A. CEREBRAL A. ARTERY

45
01/29/09 -01/31/09

Dysphagia Dysarthia

Apraxia 01/29/09 -01/31/09


01/29/09 -01/31/09
01/29/09 -01/31/09

Ataxia Hemisensory loss Left


upper extremities

Hemiparesis (left upper 01/29/09 -01/31/09


extremities) Hemiplegia (left
lower extremities)

01/29/09 -01/31/09

B. SYNTHESIS OF THE DISEASE

B.1. DEFINITION OF DISEASE

Stroke is a term used to describe neurologic changes caused by an interruption


in the blood supply to part of the brain. Two major types of stroke are ischemic and
hemorrhagic. Ischemic stroke is caused by thrombotic or embolic blockage of blood flow
to the brain. Bleeding into the brain tissue or the subarachnoid space causes a
hemorrhagic stroke. Ischemic strokes account for about 83% of all strokes. The
remaining 17% of strokes are hemorrhagic.

46
Cerebrovascular disorders are the third leading cause of death in United States
and account for about 164, 000 mortalities annually. An estimated 550,000 strokes
people experience a stroke each year. When second strokes are considered in the
estimates, the incidence increases to 700, 000 per year in the united States alone.
Stroke is a leading cause of adult disability and leading primary diagnosis for long term
care. More than four million stroke survivors are living with varying degrees of disability
in the United States. Along with a high mortality rate, strokes produce significant
morbidity in people who survive them. (Joyce M.
Black et al Medical Surgical Nursing 7th edition
Elsevier Suanders 2005)

Vascular Disease which includes C.V.A. is


the second leading cause of death in the
Philippines with a total of 51,680 according to
DOH 2004. Along with this are 37,092 who
survived with it. (http://www.doh.gov.ph/kp/statistics/morbidity)

New therapies can now prevent or limit the extent can now prevent or limit the
extent of damage to brain tissue caused by acute ischemic stroke. Thrombolytic therapy
must be administered as soon as possible after onset of the stroke; a treatment window
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
manifestation, and early treatment of brain attack. (Joyce M. Black et al Medical
Surgical Nursing 7th edition Elsevier Suanders 2005)

Diabetes Mellitus is a chronic systemic disease characterized by either a


deficiency of insulin or a decreased ability of the body to use insulin Diabetes mellitus is
sometimes referred to as “high sugars” by both clients and health care providers. The
notion of associating sugar with diabetes is appropriate because the passage of large
amounts of sugar-laden urine is characteristic of poorly controlled diabetes. However
high levels of blood glucose are only one component of the pathologic process and
clinical manifestation associated with DM. DM can be associated serious complications,
47
but people with diabetes can take preventive measures to reduce the likelihood of such
occurrences. (Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier
Suanders 2005)

B.2. Modifiable and Non Modifiable Factors (Book Based)

1. Modifiable

a. Smoking –nicotine content of cigarettes causes vasoconstriction there by resulting


hypertension which may lead to CVA.

b. Hypertension –this is due to plaque deposits on the wall of the arteries which causes
narrowing of the blood vessel thereby causing hypertension which may lead to
hemorrhagic stroke.

c. Obesity –This is due to increase cholesterol in the body which may contribute plaque
formation that will narrow the blood vessel or may cause thrombus formation.

d. Hyperlipidemia –too much lipid in the blood may cause increase plaque formation
which may cause thrombus formation.

e. Drug addiction –This may cause vasopasm, hypertension, hypercoagulability and


cerebral eschemia which may cause CVA.

48
f. Excessive alcohol consumption –heavy alcohol consumption increases one’s risk of a
stroke, light or moderate alcohol may protect against ischemic stroke.

(Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005)

g. High dose Estrogen Oral Contraceptives –increases the risk of stroke in women.

h. Diabetes Mellitus –The mechanism is related to macrovascular changes in people


with diabetes mellitus. There is an increase viscousity of blood which may cause
formation of thrombus formation.

i. Atrial fibrillation –pulling of blood from poorly emptying atrial which leads to formation
of tiny clots in Left atrium which can move on the cerebral circulation.

j. Type A personality –stress causes hypertension thereby increasing chance of having


hemorrhagic stroke.

k. Sedentary lifestyle –increase of having DM and Obesity which one of the factors of
having CVA

(Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005)

2. Non-Modifiable

a. Age –Intracranial hemorrhage is most often secondary to hypertension and is most


common after age 50 years.

49
b. Family history of CVA – Family history of stroke increase one’s risk

c. Family history of DM –Family which has history of DM especially type 2 is high risk of
having stroke due to accelerated atherosclerosis.

d. Sex (Male) –Incidence of stroke in men is slightly higher than that of women.

e. Race – (more prevalent among African Americans than whites or Hispanics)

(Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005)

SIGNS AND SYMPTOMS (Book Based)

DIABETES MELLITUS

HYPERGLYCEMIA (INCREASED BLOOD SUGAR LEVEL)

Diabetes Mellitus type II may be due to lack of physiologically active insulin that
stimulates glucose uptake in the muscles and tissues. Therefore, it leads to an
accumulation of glucose in the intravascular space. The glucose is not utilized by the
body and it remains in the blood stream.

50
POLYURIA

Polyuria is an increased frequency of urination. This may be due to the osmotic diuretic
effect of the glucose, wherein it attracts water during urination.

When you have diabetes, excess sugar (glucose) builds up in your blood. Your kidneys
are forced to work overtime to filter and absorb the excess sugar. If your kidneys can't
keep up, the excess sugar is excreted into your urine along with fluids drawn from your
tissues. This triggers more frequent urination, which may leave you dehydrated.

POLYDIPSIA

Polydipsia is an increased thirst and fluid intake. This may be due to the activation of
the thirst center in the hypothalamus resulting from the intracellular dehydration or
volume depletion caused by excessive urine production.

POLYPHAGIA

Increased hunger and food intake. Because glucose cannot enter cells of the satiety
center of the brain without insulin, the satiety center in the hypothalamus is stimulated
resulting in a “hunger sensation” as if there were very little blood glucose, resulting in an
exaggerated appetite.

BODY MALAISE

This is due to the decreased glucose uptake by the tissues leading to decreased energy
production.

(Joyce M. Black et al Medical Surgical Nursing 7th edition Elsevier Suanders 2005)

51
GLYCOSURIA

The kidney filters the blood, making it to its normal state. Glucose was filtered out and
excreted in the urine. Due to the excess glucose ad compared to the kidney threshold,
which results to the excretion of glucose in the urine.

BLURRED VISION

Diabetes can affect the lens, vitreous, and retina, causing visual symptoms. Visual
blurring may develop acutely as the lens changes shape with marked changes in blood
glucose concentrations. This effect, which is caused by osmotic fluxes of water into and
out of the lens, usually occurs as hyperglycemia increases.

WEIGHT LOSS

Despite eating more than usual to relieve constant hunger by the stimulation of satiety
center, weight loss may still exist. Without the glucose supplies, muscle tissues and fat
stores may deplete.

SLOW-HEALING SORE AND FREQUENT INFECTION

High levels of blood sugar impair your body's natural healing process and your ability to
fight infections. For women, bladder and vaginal infections are especially common.

TINGLING SENSATION/ NUMBNESS IN THE HAND AND FEET

Excess sugar in your blood can lead to nerve damage. You may notice tingling and loss
of sensation in your hands and feet, as well as burning pain in your arms, hands, legs
and feet.

52
PROTEINURIA

Testing the urine for microalbuminuria shows early nephropathy, long before it would be
on routine urinalysis,

ANEMIA

If there are renal affectations, this might bring to decrease production of erythropoietin
which brings to decrease production of RBC from the bone marrow that may result to
anemia.

CEREBROVASCULAR ACCIDENT

Clinical Manifestations

1. headache and vomiting – due to an increase ICP which causes cerebral

edema, and compressing the medulla oblongata

2. seizures – due to hyper-excitability of neurons because of irritation.

3. changes in mental status – affectation in the RAS

4. fever – affectation in the hypothalamus

5. ECG changes – problem with the medulla oblongata

Warning Signs

1. transient hemiparesis

53
2. loss of speech

3. hemisensory loss

4. vertigo/syncope

Specific Deficits

1. Hemiparesis/Hemiplegia – the former means weakness of one side of the body while
the latter means paralysis of one side of the body.

2. Aphasia – defects on using and interpreting symbols of language

3. Apraxia - a condition in which a client can move the affected part but cannot use it for
purposeful actions.

4. Homonymous Hemianopsia – a defective vision or vision loss in the same half of the
visual field.

5. Agnosia – a problem in interpreting visual, tactile or other sensory information.

6. Dysarthia – imperfect articulation condition.

7. Kinesthesia – alteration in sensation.

8. Incontinence – due to inattention, memory lapses, emotional factors, and inability to


communicate.

9. Shoulder pain – severe pain in the affected shoulder after CVA

10. Horner’s syndrome – paralysis of sympathetic nerves to the eye causing sinking of
the eyeball, ptosis of the upper eyelid, constriction of pupil, and lack of tearing in the
eye.

11. Unilateral neglect – inability to respond to stimulus on the contralateral side.

54
12. Dysphagia (01/29/09 -01/31/09) – difficulty of swallowing

13. Ataxia (01/29/09 -01/31/09) –Problem with motor coordination

B.2. Modifiable and Non Modifiable Factors (Client Based)

1. Modifiable

a. Smoking – (23 pack years) nicotine content of cigarettes causes vasoconstriction


there by resulting hypertension which may lead to CVA.

b. Hypertension – (BP-200/100 -01/27/09) this is due to plaque deposits on the wall of


the arteries which causes narrowing of the blood vessel thereby causing hypertension
which may lead to hemorrhagic stroke.

d. Hyperlipidemia – Total Cholesterol: 351 (01/28/09) too much lipid in the blood may
cause increase plaque formation which may cause thrombus formation.

e. Diabetes Mellitus – (She was diagnosed with DM since 2004) The mechanism is
related to macrovascular changes in people with diabetes mellitus. There is an increase
viscousity of blood which may cause formation of thrombus formation.

2. Non-Modifiable

55
a. Age –Intracranial hemorrhage is most often secondary to hypertension and is most
common after age 50 years. (Kitty Sanrio is 58 yrs. Old)

b. Family history of Cardiovascular Diseases – Family history of stroke increases one’s


risk. Kitty Sanrio’s mother died from cardiovascular disease specifically heart attack.

c. Family history of DM –Family which has history of DM especially type 2 is high risk of
having stroke due to accelerated atherosclerosis.

SIGNS AND SYMPTOMS (Client Based)

DIABETES MELLITUS

HYPERGLYCEMIA (INCREASED BLOOD SUGAR LEVEL) (01/28/09)

Diabetes Mellitus type II may be due to lack of physiologically active insulin that
stimulates glucose uptake in the muscles and tissues. Therefore, it leads to an
accumulation of glucose in the intravascular space. The glucose is not utilized by the
body and it remains in the blood stream.

POLYURIA (01/29/09 -01/31/09)

Polyuria is an increased frequency of urination. This may be due to the osmotic diuretic
effect of the glucose, wherein it attracts water during urination.

When you have diabetes, excess sugar (glucose) builds up in your blood. Your kidneys
are forced to work overtime to filter and absorb the excess sugar. If your kidneys can't

56
keep up, the excess sugar is excreted into your urine along with fluids drawn from your
tissues. This triggers more frequent urination, which may leave you dehydrated.

BODY MALAISE (01/29/09 -01/31/09)

This is due to the decreased glucose uptake by the tissues leading to decreased energy
production.

GLYCOSURIA (01/29/09)

The kidney filters the blood, making it to its normal state. Glucose was filtered out and
excreted in the urine. Due to the excess glucose ad compared to the kidney threshold,
which results to the excretion of glucose in the urine.

BLURRED VISION (01/29/09 -01/31/09)

Diabetes can affect the lens, vitreous, and retina, causing visual symptoms. Visual
blurring may develop acutely as the lens changes shape with marked changes in blood
glucose concentrations. This effect, which is caused by osmotic fluxes of water into and
out of the lens, usually occurs as hyperglycemia increases.

ANEMIA [Hemoglobin: 8 (F: 12-16) (01/28/09)]

If there are renal affectations, this might bring to decrease production of erythropoietin
which brings to decrease production of RBC from the bone marrow that may result to
anemia.

57
FREQUENT INFECTION (01/29/09 -01/30/09)

High levels of blood sugar impair your body's natural healing process and your ability to
fight infections. This is due to low morphonuclear leukocytes which decreases her
resistance from infection. For women, bladder and vaginal infections are especially
common.

PROTEINURIA (01/29/09)

Testing the urine for microalbuminuria shows early nephropathy, long before it would be
on routine urinalysis,

PNEUMONITIS – Radiology report (01-30-09). Many factors can cause pneumonitis,


including breathing in animal dander, inhaling small food particles "down the wrong
pipe" and receiving radiation therapy to your chest and smoking.

CEREBROVASCULAR ACCIDENT

Clinical Manifestations

1. headache and vomiting – due to an increase ICP which causes cerebral

edema, and compressing the medulla oblongata

2. seizures – due to hyper-excitability of neurons because of irritation.

3. changes in mental status – affectation in the RAS

4. fever – affectation in the hypothalamus

5. ECG changes – problem with the medulla oblongata

58
Warning Signs

1. transient hemiparesis (01/27/09)

2. slurred speech (01/27/09)

3. hemisensory loss(01/27/09)

4. vertigo/syncope (01/27/09)

Specific Deficits

1. Hemiparesis/Hemiplegia (01/29/09 -01/31/09) – the former means weakness of one


side of the body whiles the latter means paralysis of one side of the body.

2. Apraxia (01/29/09 -01/31/09) –a condition in which a client can move the affected
part but cannot use it for purposeful actions.

3. Dysarthia (01/29/09 -01/31/09) – imperfect articulation condition.

4. Dysphagia (01/29/09 -01/31/09) – difficulty of swallowing

5. Ataxia (01/29/09 -01/31/09) –Problem with motor coordination

59
V. The Patient and His Care

A. Medical Management

a. IVF’s, BT, NGT Feedings, Nebulization, TPN, Oxygen Therapy.etc.

Medical Date ordered/


General Indication or Client’s
Management/ Date
Description purpose Response
Treatment Performed

D5 LRS (5% 01-27-09 Hypertonic Since the patient The patient was
Dextrose solution that has was on NPO able to maintain
Lactated Ringer’s higher osmolarity upon admission,
normal hydration
Solution) 1L than the serum. It she was given D5
pulls fluid and LRS as her IVF status and
electrolytes from administered electrolyte
the intracellular intravenously to
balance AEB
and interstitial serve as a source
compartments of water, patient had
into the electrolytes, and moist skin and
intravascular calories. It also
good skin turgor.
compartment. It is serves as a route
a sterile, for medication
nonpyrogenic administration.
solution for fluid
and electrolyte
replenishment
and caloric
supply
administered
intravenously.

D5 0.3 NaCl Jan. 27-31, ‘09 To maintain


Hypotonic Patient
(5% Dextrose 0.3 rehydration and to
solution that has responded well
Sodium Chloride) replace fluid loss,
greater as she did not
500cc patient was given
concentration of manifest any
this IVF. Also, for
free water signs and
medication
molecules that symptoms of
administration.
are found inside dehydration
the cell. such as dry skin
60
and mucous
membranes.

Nursing Implication:

 Before:
1. Check the physician’s order for IV solution and explain to the client the procedure.
2. Check the potency of IV line and needle
3. Check the type of infusion, condition of the vein and medical condition of the patient

 During:
1. Maintenance of Aseptic Technique
2. Proper procedure and steps in infusing IV solution
3. Count drops per minute in drip chamber.

 After:
1. Monitor IV infusion at least every 2 hour
2. Adjust IV clamp as needed and recount drop per minute.
3. Monitor client for fluid overflow
4. More frequent check maybe prn if a medication(s) are being infused.
5. Inspect site for pain, swelling, coolness or pallor at the site of insertion, which may
indicate infiltration of IV
6. Inspect site for redness, swelling, heat and pain which may indicate phlebitis

61
b. Drugs

Date Dosage,
Ordered/ Route,
Name of Date Frequenc General Indication or Client’s Nursing
Drugs Perform y of Action Purpose Response Responsibilities
ed/ Date Administr
Given ation

Piracetam 01-27-09 800mg 1 Piracetam Since the patient The client Prior to:
tab PO q6 improves the is diagnosed of improved her Wash hands
hrs then function of the CVA, she is given mentation as she
thoroughly.
BID on neurotransmit this drug to is able to feel deep
01-28-09 ter improve her brain touch and could
Ask the patients
acetylcholine function raise his right arm
via muscarinic and leg as well as name
cholinergic comprehend with
(ACh) what the SO is Always observe
receptors saying. There are aseptic technique
which are no side/adverse
implicated in effects noted During:
memory
Explain the
processes. It
improves procedure to the
brain function patient/SO.
and
stimulates the Explain what is the
central
general action of the
nervous
system drug to the body.

62
without any After:
toxicity or Record the drug after
addictive
its administration
properties
(charting).

Observe the patients


for possible untoward
reaction.

Instruct to take the


medication exactly as
directed.

Captopril Jan. 27- 25mg SL Captopril Indicated for the Patient did not Prior to:
31, ‘09 TID lower blood patient since the improve condition Wash hands
pressure by drug is said to since she still had
thoroughly.
inhibiting the treat hypertension. elevated blood
formation of pressure of
Ask the patients
angiotensin II, 180/100
thus relaxing name
the arteries.
Relaxing the Always observe
arteries not aseptic technique
only lowers
blood During:
pressure, but
Explain the
also improves
the pumping procedure to the
efficiency of a
63
failing heart patient/SO.
and improves
cardiac output Instruct the patient to
in patients put the medicine
with heart
under her tongue or
failure.
sublingually.

After:
Record the drug after
its administration
(charting).

Observe the patients


for possible untoward
reaction.

Instruct to take the


medication exactly as
directed.

Monitor blood
pressure

Ranitidine 01-27-09 50mg IV It is a This is indicated The patient Prior to:


q8 then competitive, for the patient as improved condition Wash hands
d/c on reversible she manifested as she did not
thoroughly.
Jan. inhibitor of the abdominal pain manifest
30,’09 action of Ask the patients
64
histamine at abdominal pain. name.
the histamine
H2 receptors, Recheck the order of
including the doctor
receptors on
the gastric Always observe
cells
aseptic technique

Check the patency of


the IV site

During:
Explain the
procedure to the
patient/SO.
Observe patient
closely for at least 30
minutes following
administration.

After:
Record the drug after
its administration
(charting).
Observe the patients
for possible untoward
65
reaction.

Simvastatin 01-28-09 40mg 1tab Simvastatin is Since the patient Patient did not Prior to:
OD a had high levels of improve condition Wash hands
hypolipidemic cholesterol with since she still has
thoroughly.
drug 351 mg/dl, she elevated
belonging to was given this cholesterol..
Ask the patients
the class of drug.
pharmaceutic name
als called
"statins". It is Always observe
used to aseptic technique
control
hypercholeste During:
rolemia
Explain the
(elevated
cholesterol procedure to the
levels) and to patient/SO.
prevent
cardiovascula After:
r disease.
Record the drug after
its administration
(charting).

Observe the patients


for possible untoward
reaction.

66
Instruct to take the
medication exactly as
directed.

Metoprolol 01-28-09 50mg 1tab Metoprolol It is also indicated The client did not Prior to:
BID then reduces heart for the patient improve condition Wash hands
increased rate and because the since she still had
thoroughly.
frequency cardiac output patient has elevated blood
of 100mg at rest and elevated blood pressure
Ask the patients
on Jan. upon pressure.
30,’09 exercise, name
reduces
systolic blood Always observe
pressure aseptic technique
upon
exercise, During:
inhibits
Explain the
isoproterenol-
induced procedure to the
tachycardia, patient/SO.
and reduces
reflex After:
orthostatic
Record the drug after
tachycardia.
its administration
(charting).

Observe the patients


for possible untoward
reaction.

67
Instruct to take the
medication exactly as
directed.

Monitor BP

Ketosteril 01-30-09 2 tabs TID Ketosteril Protein-energy Patient improved Prior to:
normalizes malnutrition, condition as she Wash hands
metabolic prevention and did not manifest
thoroughly.
processes, treatment of body weakness
Improves conditions caused because of the
Ask the patients
nitrogen by modified or energy
exchange, insufficient protein supplemented. name
reduce ion metabolism.
concentration Always observe
s of aseptic technique
potassium,
magnesium During:
and
Explain the
phosphate.
procedure to the
patient/SO.

After:
Record the drug after
its administration
(charting).

68
Observe the patients
for possible untoward
reaction.

Instruct to take the


medication exactly as
directed.

Ferrous 01-30-09 1 cap OD Ferrous Indicated for the Patient did not Prior to:
Sulfate Sulfate is an patient as a improve condition Wash hands
essential supplement for as she still has low
thoroughly.
body mineral. iron hemoglobin count.
Ferrous
Ask the patients
sulfate is
used to treat name
iron
deficiency Always observe
anemia aseptic technique

During:
Explain the
procedure to the
patient/SO.

After:
Record the drug after
its administration
(charting).

69
Observe the patients
for possible untoward
reaction.

Instruct to take the


medication exactly as
directed.

Hydralazine 01-29-09 5mg IV Hydralazine is Indicated for the The patient did not Prior to:
q6hrs a direct-acting patient as she has improve her Wash hands
PRN for smooth elevated blood condition as she
muscle thoroughly.
BP 130/90 pressure still had elevated
relaxant used
blood pressure of Ask the patients
to treat
hypertension 180/100 name.
by acting as a
vasodilator Recheck the order of
primarily in
arteries and the doctor
arterioles. By
relaxing Always observe
vascular
aseptic technique
smooth
muscle,
vasodilators Check the patency of
act to the IV site
decrease
peripheral
resistance, During:
thereby Explain the
lowering
blood procedure to the
pressure. patient/SO.

70
Observe patient
closely for at least 30
minutes following
administration.

After:
Record the drug after
its administration
(charting).
Observe the patients
for possible untoward
reaction.
Monitor BP

71
c. Diet

Date
Type ordered Specific
General Client’s
Of Date given Indication Foods
description response
diet Date Taken
changed
Nothing per 01-27-09 A type of Diet It is for the None The patient
Orem (NPO) where the purpose of participated
patient observation with the
cannot eat or precaution Doctor’s
drink anything order

Soft Diet 01-28-09 Very similar This was Boiled Eggs, The client
to regular diet ordered to Sopas, enjoyed
except that provide a Lugaw eating her
the textures transitional food and
of foods have diet between manifested
been liquids and feeling of
modified. regular food fullness after
for patients the meal. She
who have did not
difficult in manifest
swallowing or dysphagia.
who
undergone
surgery.

Nursing Responsibilities for NPO

● Check the doctor’s order.


● Educate the patient and significant others why NPO is indicated.
● Discuss to the patient the importance of the diet.
● Assess patient’s level of hydration.

Nursing Responsibilities for soft diet

● Check the doctor’s order.


● Educate the patient and significant others on the right foods to be taken.
● Discuss to the patient the importance of nutrition.
● Provide a variety of choices of foods.
● Assess patient’s appetite.

72
d. Activity/ Exercise

Date ordered
Type
Date given General Client’s
Of Indication
Date description response
exercise
changed
High Back 01-27-09 A type of To reduce Patient
Rest activity or oxygen shows
exercise demand and gradual
wherein the prevent increase in
patient is kept fatigue. Rest strength.
on bed with decreases
the head of body
bed held at at metabolic
least 45° with rate. Since
limitations to the patient is
other old, she is
activities. prone to have
pressure
ulcers and
she is more
likely to
manifest
fatigue.

Nursing Responsibilities
● Assist patient if with such privilege in going to the bathroom.
● Change client’s position from time to time, to promote circulation and prevent
bed sores.

73
B. Nursing Management

NURSING CARE PLAN

Problem No:1 Acute Pain

NURSING SCIENTIFIC EXPECTED


ASSESSMENT PLANNING INTERVENTIONS RATIONALE
DIAGNOSIS EXPLANATION OUTCOME
Acute Pain Lots of medicine has the Short Term Establish rapport To gain pt’s Short Term
S=” Masakit ku side effect of gastric Objective: therapeutic Objective:
atsan” upset causing relationship After the nsg int the
After 2 hr of
abdominal pain to pt shall verbalized a
nursing
patient after intake of Monitor v/s To obtain baseline relief of pain.
intervention the pt
The patient medication specially PO data
will verbalized
manifested the drugs. It has a side
rlieve of pain from
following: effect of causing Assess pt’s To note for the
8/10 to 4/10
abdominal cramps, and general condition etiology or
pain. precipitating
O= with facial factors that can Long Term
grimace, with lead to fever. Objective:
guarding Long Term After the nsg int the
behaviors, pain Objective: Encourage rest To overcome pain pt shall
scale of 8/10, at opportunities at rest demonstratetechniq
After 3 days of NI,
abdominal area, ue to alleviate pain
pt will
with quality of dull Ecourage to divert the pt’s
demonstrate
pain, after intake diversional attention

74
of meds, left side technique to activities such as
paralysis alleviate pain talking to S.O.

Encourage deep Helps to lessen


The patient may breathing the feeling of
also manifest he exercises pain.
following:
Provide comfort To let pt feel safe
measures and and comfortable
>discomfort safety

>anxiety
Provide Health To lessen the pt’s

>irritable information feeling of anxiety


regarding the
>Fatigue
occurring problem

>headache
Provide To promote rest
conducive and pt’s wellness
environment for
resting

75
Problem No: 2 impaired cerebral tissue perfusion r/t vascular occlusion secondary to disease condition

NURSING SCIENTIFIC EXPECTED


ASSESSMENT PLANNING INTERVENTIONS RATIONALE
DIAGNOSIS EXPLANATION OUTCOME
S= 0 Impaired cerebral In cerebral tissue Short term Establish Rapport > To gain pt’s Short term
tissue perfusion perfusion, there is a objective: therapeutic objective:
The patient r/t vascular decrease in oxygen After 5hrs. of relationship After 5hrs. of
manifested the occlusion supply which results in Nursing Nursing
ff: secondary to the failure to nourish the intervention, the Monitor Vital > To identify any intervention, the pt.
disease condition tissues at the capillary pt. will signs other deviations shall be able to
O= without signs level. Blood vessels demonstrate from normal. demonstrate
of IV infiltration, w/ which function is to increased increased perfusion
contralateral supply blood to the perfusion as Assist pt. in >To aid with as individually
hemiparesis, different parts of the individually assuming proper perfusion appropriate
sensory loss, brain are impaired. appropriate semifowler’s or flow of blood
muscle weakness, Thus, the O2 supply position w/ head (circulation or Long Term
slurred speech, going to the brain is also Long Term midline. venous drainage). Objective:
with GCS=15 impaired. Proper Objective: After 2-3 days of
perfusion is needed in After 2-3 days of Administer >To probably Nursing
order to give adequate Nursing medications as decrease cardiac Intervention, the pt.
The patient may nourishment to he Intervention, the ordered such as workload and in shall be able to
also manifest the different parts of the pt. will be able o antihypertensive maximizing tissue demonstrate
ff: brain in order for it to demonstrate or diuretics. perfusion behaviors which
function well. behaviors which may improve proper
>Change in may improve >Encourage quiet circulation such as

76
pupillary reactions proper circulation and restful >To conserve compliance to
>Change in such as atmosphere. energy which health management
Mental Status compliance to could aid in & therapies
>Behavioral health lowering the O2 provided.
Changes management & >Exercise caution tissue demand.
>Capillary refill therapies in using hot or >The t issues
longer than 3 provided. cold pads. may have
secs. decreased
>Encourage use sensitivity due to
of relaxation ischemia.
techniques or
exercises. >To decrease the
tension level

>Discuss the
importance of
preventing >To retain heat or
exposure to cold warmth efficiently
or extreme cold
temp

>Discuss to the
patient’s SO the
importance of >To promote

77
care of dependent wellness
limbs, body
hygiene, and foot
care when
circulation is
impaired.

Problem No: 3 Impaired Physical Mobility Neuromuscular and Musculoskeletal Impairment

NURSING SCIENTIFIC EXPECTED


ASSESSMENT PLANNING INTERVENTIONS RATIONALE
DIAGNOSIS EXPLANATION OUTCOME
S= 0 Impaired physical The nervous system is Short Term >Establish > To gain pt’s Short Term
mobility made up of nerve cells Objective: Rapport therapeutic Objective:
The patient neuromuscular called neurons that After 4 hrs. Of relationship After 4 hrs. Of
manifested the and serve as the Nursing Nursing
following: musculoskeletal communication system Intervention, the >Monitor Vital > To identify any Intervention, the pt.
impairment as of the body. They carry pt. will be able to signs other deviations shall be able to
O= w/ pale evidence by messages in the form of maintain from normal. maintain increased
palpebral limited motor electrical impulses. The increased >Assess patient >To determine strength and
conjunctiva, w/ skills. messages move from strength and condition any other function of affected
pale nail beds, w/ one neuron to another function of underlying cause or compensatory
capillary refill to keep the body affected or of manifestations part.
time, <3sec. pt. is functioning. Because compensatory >Provide > To prevent
able to feel deep neurons have, limited part. adequate rest further stress &
touch, raise his ability to repair periods as well as fatigue Long Term
78
right arm and leg, themselves unlike other comfort & safety Objective:
w/ slurred speech, body tissues that is why Long Term measures After 2-3 days of
w/ left sided nerve cells cannot be Objective: nursing
weakness, with repaired if damaged After 2-3 days of >Turn pt. slowly > To provide intervention, the pt.
limited ROM on due to injury or disease. nursing from side to side proper circulation shall be able to
upper and lower intervention, the of blood flow on demonstrate
extremities, pt. will be able to both sides behaviors that
afebrile, (-) DOB, demonstrate enable resumption
(-) chest pain. behaviors that >Determine pt. >To assess of activities.
enable level of mobility functional ability
resumption of
The patient may activities. >Assist pt. in his >To promote
also manifest he activities optimal level of
following: function

>Slowed >Encourage >Promotes well-


movement, adequate intake being and
>Postural of fluids & maximizes
instability during Nutritious foods energy
performance of production.
ADLs
>Movement >Involve client’s >To assist in
induced shortness SO in care learning ways of
of breath. managing

79
problems of
immobility.

Problem: 4 Activity Intolerance r/t immobility

Nursing Scientific Nursing Expected


Assessment Objective Rationale
Diagnosis Explanation Intervention Outcome
S>O Activity Infarction on the Short Term: >Establish Rapport >To gain Short Term:
Intolerance r/t right hemisphere After 3 hrs of patient’s Trust After the
immobility has a contra nursing nursing
lateral intervention the >Assess V.S. >To gain intervention the
O>The Patient manifestation of patient will use baseline data patient shall use
Manifests: either left side identified identified
paralysis and/or techniques to >Assess General >To note for techniques to
weakness due to enhance activity Condition signs and enhance activity
>with Paralysis left hemisphere tolerance. symptoms tolerance.
of the Left Body affectation
Side causing the >Adjust Activity >To prevent
>with Left side immobility overexertion
weakness because of
>with Blurred stiffness of Long Term: >Provide positive >to minimize Long term:
Vision muscle and After 3 days atmosphere frustration After the
>with infraction unability to of nursing nursing

80
on right mobilize due to intervention the >Promote comfort >to enhance intervention the
hemisphere the patient will measure and ability to patient shall
>requires manifestation of demonstrate provide for relief of participate in demonstrate
assistance and the disease increase in pain activities increase in
guidance from condition. activity activity
S.O. tolerance. >Provide ROM >to promote tolerance.
circulation

>Give client >to sustain


The Patient may information that motivation
Manifest: provides
evidence/difference
>headache
>pain >Assist client in >to prevent
>irritable learning and injuries
>discomfort demonstrating
>cold clammy appropriate safety
skin measures
>dehydration

Problem No: 5 impaired verbal and/or written communication r/t impaired cerebral circulation
81
NURSING SCIENTIFIC EXPECTED
ASSESSMENT PLANNING INTERVENTIONS RATIONALE
DIAGNOSIS EXPLANATION OUTCOME
impaired verbal There is an affectation Short Term Establish rapport To gain pt’s Short Term
S= 0 and/or written of the certain brain Objective: therapeutic Objective:
communication lobes that caused by After 3 hrs of nsg relationship After the nrsing
The patient r/t impaired impaired cerebral int. the pt will be intervention the pt
manifested the cerebral circulation that affects able to verbalize Monitor v/s To obtain shall verbalize ir
following: circulation its proper functions that or indicate baseline data indicate
leads to decreased, understanding of understanding of
O= w/ pale delayed or absent the Assess pt’s To note for the communication
palpebral ability to receive, communication general condition etiology or difficulty and plans
conjunctiva, w/ process, transmit and difficulty and precipitating for ways of
pale nail beds, w/ use a system o plans for ways of factors that can handling
capillary refill symbols in handling. lead to fever.
time, <3sec., pt. communicating
is able to feel resulting in impaired Note results of To assess
deep touch, raise verbal communication. Long Term neurological causative/contrib Long Term
his right arm and Objective: testing such as uting factors Objective:
leg, w/ slurred After 3 days of EEG/CTscan and After the nursing
speech, w/ left nursing the likes intervention the pt
sided weakness, intervention the shall be albe to
with limited ROM pt will establish Assess To assess establish methods
on upper and method of environment causative/contrib of communication
lower extremities, communication in factors that may uting factors in which can be
which needs can affect ability to expressed.
82
The patient may be expressed. communicate
also manifest he
following: Establish To assist client to
relationship with establish a
>weakness the client , means of
>headache listening carefully communication to
>dyspnea and attending to express needs,
>unable to speak clients wants, ideas and
>discomfort verbal/nonverbal questions
>irritability expressions
>low self esteem
>Difficulty in Maintain a calm, Individuals may
expressing needs unhurried talk more easily
manner, provide when they are
sufficient time for rested and
the client to relaxed
responds
Anticipate needs
until effective To attend pt’s
communication is needs
reestablished immediately

Administer due For pt’s recovery


meds and to treat

83
underlying
conditions

Problem No: 6 Risk for Aspiration

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EXPECTED


DIAGNOSIS EXPLANATION OUTCOME
S= 0 Risk for Aspiration When there is a Short term >Established >To gain the trust Short term
blockage of objective: Rapport & compliance of objective:
The patient vertebrobasilar artery After 5hrs. of the patient & SO The patient shall
manifested the there will be Cranial Nursing have demonstrated
ff: nerves affectations. CN intervention, the >Monitored Vital > To identify any techniques to
V, VII, IX, XII blockage pt. demonstrate signs other deviations prevent aspiration.
O= Dysphagia, may result to dysphagia techniques to from normal.
impaired or difficulty of prevent Long Term
swallowing swallowing which aspiration. >Note level of >To assess if Objective:
thereby having high risk consciousness of there is gag reflex The patient shall
The patient may for aspiration. Long Term surroundings, and or difficulty of have experienced
also manifest the Objective: cognitive swallowing. no aspiration aeb
ff: After 1-2 days of impairment. noiseless
Nursing respirations, and
>Depressed gag Intervention, the >Suction as >To clear clear breath sounds.
reflex. pt. will experience needed secretions
>Reduced level of no aspiration aeb
consciousness noiseless >Auscultate lung >to determine
respirations, and sounds presence of
clear breath secretions
sounds.
>Give semisolid >To prevent
84
foods; avoid aspiration and to
pureed that may aide swallowing
increase risk of effort.
aspiration.

>Provide very >This activates


warm or cold temperature
liquids receptors in the
mouth that help to
stimulate
swallowing.

>Refer to speech >To strengthen


therapist muscles and
techniques to
enhance
swallowing.

Problem no: 7 Risk for impaired skin integrity

85
NURSING
ASSESSMENT SCIENTIFIC EXPLANATION PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME
DIAGNOSIS
Risk for Impaired The skin is the baseline Short Term Establish To gain pt’ and The pt shall have
S= 0 skin integrity defense of the body Objective: therapeutic SO’s trust and took actions
against infection. Any relationship cooperation
After 4 hr of regarding
break in the skin may
harbor microorganisms nursing Monitor v/s To obtain baseline minimizing the risk
The patient intervention the pt
that may invade the data
manifested the will take actions
normal processing of
following: regarding
the body, which may Assess pt’s To note for the
inflict or aggravate the minimizing the general condition etiology or The pt shall have
pt’s disease condition. risk precipitating been free from risk.
O= with factors that can
dysphagia, with aggravate the
reports of body risk.
malaise, Monitor I&O To have a
increased urine Long Term baseline data
output indwelling Objective: regarding input
Foley catheter, and output
pallor, cold skin, After 3 days of NI,
physical pt will be free of
Encourage To maintain
immobility. the risk.
increase OFI to al hydration status
least 2-3 liters per .
day

Arrange bed To prevent


linens increase pressure

Encourage and To maintain blood


assist client to flow
active and
passive ROM
86
exercises

Encourage rest To promote


opportunities optimum level of
functioning

Provided comfort To let pt feel safe


measures and and comfortable
safety

Carefully wash To maintain skin


and pat dry skin, moisture
including skinfold
area. Use
hydration and
moisturization on
all at-risk
surfaces.

Assist client in To prevent


changing pressure ulcer
positions every
two hours

Provided Health To lessen the pt’s


information feeling of anxiety
regarding the
occurring problem

Provided To promote rest


conducive and pt’s wellness
87
environment for
resting

Encourage client To promote


to have balanced adequate
diet especially nourishment.
with increased
intake of vitamin
C and Protein.

Monitor and
For proper
Regulate IVF as
replacement of
per doctor’s order
fluid losses.

Problem: 8 Risk for deficient fluid volume


88
Nursing Expected Outcome
Assessment Scientific Explanation Objectives Interventions Rationale
Diagnosis
S> Risk for Deficient Since the patient had Short Term >Evaluate > Assess Short Term:
Fluid Volume AEB polyuria, she After 4 hours of nutritional status, causative factors
O>the patient polyuria experienced frequent nursing noting current leading to deficit Patient shall have
manifested: urination and with that, interventions, intake, weight demonstrated
 Fatigue she might have lost patient/SO changes, and behaviors and
 Weakness fluids that could lead to demonstrate problems with oral techniques to correct
 Polyuria deficient fluid volume. behaviors and intake. Measure deficit
 Pale to pink She, then is at risk of techniques to subcutaneous fat
palpebral fluid volume deficit. correct deficit and muscle mass
conjunctiva
Long Term: >Assess vital >Evaluate degree Long Term:
 Change in
After 2-3 days of signs; note of deficit
mental status
nursing strength of Patient shall have
interventions, peripheral pulses. demonstrated
patient will Measure blood management to
 The patient
demonstrate pressure. Note prevent fluid volume
may manifests:
management to presence of deficit.
 Hemoconcentr
prevent fluid physical signs.
ation
volume deficit Monitor I/O, color
 Pale skin measure amount
 Poor skin and specific
turgor gravity of the
 Capillary refill urine.
time of less
than 3 secs. >Establish 24-hour > Prevent peaks
replacement and valleys in
needs and routes fluid level
to be used.
>Note client >Encourage the
preference client to increase
89
concerning fluids intake of foods
and foods with high in fluid
high fluid content content

>Provide nutritious >Correct/Replace


diet via fluid losses to
appropriate route reverse
pathophysiologic
mechanism

>Weigh daily >Assess progress


or status of efforts

>Bathe less >Maintain skin


frequently using integrity and
mild cleanser/soap prevent excessive
and provide dryness
optimal skin care

>Provide frequent >Prevent injury


oral and eye care from dryness

>Change position >Promote comfort


frequently and safety

>Discuss factors >Promote


related to wellness
occurrence of the
deficit as
individually
appropriate.
Instruct client how
90
to measure and
record I/O

Problem: 9 Risk for imbalanced nutrition: less than body requirements

Nursing Scientific Nursing


Assessment Objectives Rationale Expected Outcome
Diagnosis Explanation Interventions
S> Risk for A paralysis and muscle SHORT TERM: >Establish >To obtain trust SHORT TERM:
imbalanced weakness could lead After 4 hours of therapeutic and cooperation The patient shall have
O> The patient nutrition: less to impaired mobility, NI, the patient relationship of the pt. verbalized
manifested: than body lack of adequate will verbalize understanding of
-muscle weakness requirements strength to do activities understanding of >Assess and >To obtain causative factors
- with contralateral AEB inability to of daily living such as causative factors monitor vital signs baseline date when known and
hemiparesis ingest adequate eating. As the patient when known and necessary
- pale to pink nutrition does not ingest necessary >Identify clients at >To assess interventions.
palpebral adequate food first interventions. risk for malnutrition causative
conjunctiva because she was factors LONG TERM:
- sensory loss ordered to be on NPO, LONG TERM: The patient shall have
second because she After 4 days of >Determine ability to >Factors that demonstrated
> The patient may could not ingest the NI, the patient chew, swallow and can affect behaviors to regain or
manifest: food adequately as will demonstrate taste ingestion or maintain appropriate
- loss of weight she has paralysis, she behaviors to digestion of weight.
- capillary fragility could be at risk of regain or nutrients
- decreased in imbalanced nutrition: maintain
subcutaneous fats less than body appropriate >Discuss eating >To appeal to
and muscle mass requirements. weight. habits, including clients
food preferences, likes/desires
intolerances,
aversions

>Assess weight, >Provides


age, body build, comparative
strength, activity/rest baseline
level

91
>Note total daily >To reveal
intake changes that
should be made
in client’s
dietary intake

>Provide diet >To establish a


modifications nutritional plan
indicated for the that meets
client’s condition or individual needs
health status

>Increase oral fluid >To prevent


intake dehydration and
liquefy
respiratory
secretions

>Encourage client to >To stimulate


choose foods that are appetite
appealing

>Limit fiber/bulk if >May result to


indicated early satiety

>Promote pleasant, >To enhance


relaxing environment intake

>Provide oral care >To keep mouth


before/after meals clean

>Emphasize >To promote


importance of well- wellness
balanced, nutritious

92
intake

>Give supplemental >To humidify


humidification as airways and
needed (oxygen supplement
supply) need for oxygen

Problem no: 10 Risk for Infection

NURSING
ASSESSMENT SCIENTIFIC EXPLANATION PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME
DIAGNOSIS
Risk for Infection An infection is the Short Term Establish To gain pt’ and The patient shall
S= 0 detrimental colonization Objective: therapeutic SO’s trust and have demonstrated
of a host organism by a relationship cooperation
After 4 hr of appropriate hygienic
foreign species. In an
infection, the infecting nursing Monitor VS To obtain baseline measures such as
The patient intervention the pt
organism seeks to data hand washing, oral
manifested the will demonstrate
utilize the host's
following: appropriate care, and perineal
resources to multiply. Assess pt. To note for the
The infecting organism, hygienic general condition etiology or care
or pathogen, interferes measures such as precipitating
O= with with the normal hand washing, factors that can
dysphagia, with functioning of the host oral care, and aggravate the
reports of body and can lead to chronic perineal care risk.
malaise, wounds, gangrene, loss
increased urine of an infected limb, and Observe and To have a The pt shall have
output indwelling even death. report signs of baseline data
Foley catheter, infection such as regarding client’s maintained white
pallor, cold skin, Long Term redness, warmth, risk blood cell (WBC)
cracked and cry Objective: discharge, and count and
lips. increased body
After 3 days of NI, differential within
temperature.
pt will maintain
93
white blood cell normal limits.
(WBC) count and Assess skin for To note for degree
differential within color, moisture, of deficiency
normal limits. texture, and
turgor (elasticity).
Keep accurate,
ongoing
documentation of
changes.
To promote
Preventive skin optimum level of
assessment functioning
protocol, including
documentation,
assists in the
prevention of skin
breakdown.
To prevent skin
Carefully wash impariment
and pat dry skin,
including skinfold
areas. Use
hydration and
moisturization on
all at-risk
surfaces.
To promote pt’s
Encourage a wellness
balanced diet,
emphasizing
proteins, fatty
acids, and
94
vitamins listed
below.
To maintain
Encourage fluid hydration status
intake.
To prevent
Use appropriate nosocomial
"hand hygiene" infection
(i.e., hand
washing or use of
alcohol-based
hand rubs).
To avoid cross
Use careful contamination
technique when
changing and
emptying urinary
catheter bags.
To prevent good
Ensure the source of
client's bacterial
appropriate multiplication
hygienic care with
hand washing;
bathing; and hair,
nail, and perineal
care performed by
either the nurse or
the client.
To
Administer pharmacologically
antibiotics; use manage the
95
antibiotics problem.
sparingly as per
doctor’s order

Problem No: 11 Risk for Injury

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EXPECTED


DIAGNOSIS EXPLANATION OUTCOME
Risk for Injury Because of limited Short Term >Establish rapport >To gain pt’ and Short Term
S= 0 range of motion and Objective: SO’s trust and Objective:
slightly paralyze body After 2 hr of cooperation The patient shall
The patient the patient is unable to nursing have demonstrated
manifested the mobilize properly which intervention the pt >Monitor v/s >To obtain behaviors, lifestyle
following: maybe a risk for injury. will demonstrate baseline data changes to reduce
behaviors, risk factors and
O= with limited lifestyle changes >Assess pt’s >To note for the protect self from
range of motion. to reduce risk general condition etiology or injury
contralateral factors and precipitating
hemiparesis, protect self from factors that can
sensory loss, injury lead to fever.
muscle weakness,
Blurred vision >Assess mood, >that may result Long Term
Long Term coping abilities, in carelessness Objective:
The patient may Objective: personality styles and increased risk The patient shall
also manifest he After 2 days of NI, taking without have been free of
following: pt will be free of considerations of injury.
injury consequences
>Fatigue
>headache >Identify >To promote safe
96
>Dizziness interventions and physical
safety devices environment and
individual safety

>Encourage >To enhance self


participation in esteem. sense of
self-help worth
programs, such
as assertiveness
training, positive
self image

>raise the side >To promote safe


rails of the bed physical
environment and
individual safety

>Frequent skin > To assess if


inspection there is presence
of pressure
ulcers.

>Use effective >To promote


lighting safety and easy
scanning of the
environment.

>Remind client to >To prevent injury


walk slowly due to slipping,
and to promote
safety.

97
>Keep things into >To prevent injury
right premises and promote
and clear the way safety.
going to the
restroom

Problem No: 12 Self Care Deficit: Bathing/Hygiene

NURSING SCIENTIFIC INTERVENTION EXPECTED


ASSESSMENT PLANNING RATIONALE
DIAGNOSIS EXPLANATION S OUTCOME
S= 0 Self Care deficit Body movements are Short Term >Established > To gain trust of Short Term
r/t possible because of the Objective: Rapport the patient and Objective:
The patient neuromuscular, movement of impulses After 4 hrs. Of SO in order to After 4 hrs. Of
manifested the musculoskeletal elicited by such stimuli Nursing acquire Nursing
following: impairment which then passes Intervention, the compliance with Intervention, the
through our nerves pt. will be able to appropriate pt. shall be able to
O= w/ pale going to our neurons identify personal treatments or identify personal
palpebral which are then resources which teachings resources which
conjunctiva, w/ interpreted by our brain. can help in can help in
pale nail beds, w/ Nerves and Neurons providing >Monitored Vital > To identify any providing
capillary refill serve as messengers. If assistance. signs other deviations assistance.
time, 1-3sec., pt. these are impaired, the from normal.
is able to feel affectation to the brain
deep touch, raise function would be Long Term >Assessed >To determine Long Term
his right arm and decreased function Objective: patient condition any other Objective:
leg, w/ slurred which may later on After 2-3 days of underlying cause After 2-3 days of
98
speech, w/ left cause impairment also nursing of manifestations nursing
sided weakness, to other structures of intervention, the >Provided > To prevent intervention, the
with limited ROM the body and this could pt. will be able to adequate rest further stress & pt. shall be able to
on upper and affect the performance demonstrate periods as well as fatigue demonstrate
lower extremities, of ADLs. An example of techniques or comfort & safety techniques or
afebrile, (-) DOB, that is Impaired ability changes to meet measures changes to meet
(-) chest pain. to perform self care needs. self care needs.
bathing/hygiene, >Turned pt. > To provide
The patient may dressing or grooming. slowly from side proper circulation
also manifest he to side of blood flow on
following: both sides of he
body
>Inability to get
bath supplies >Determined pt. >To assess
>Inability to wash strengths and degree of
body parts skills disability
>Inability to pick
appropriate >Assisted pt. in >To promote
clothing his activities optimal level of
>Inabiliy to function
replace articles or
clothing on own >Encouraged >Promotes well-
>Inability to adequate intake being and
maintain of fluids & maximizes

99
appearance at a Nutritious foods energy
satisfactory level production.
>Provided time >To assist with
for listening to the patient’s
patient and SO, current disability
and provided or condition.
privacy during
personal care
activities.
>Involved client’s >To assist in
SO in care learning ways of
managing
problems of
immobility and for
providing
appropriate
nursing care.
> Provided health >To provide
teachings and clarification
support o the SO Reinforcement
for care options and and periodic
Review by
client/caregivers.

100
B. Actual Soapies

01-30-09

S =”masakit ku atsan”

O =received with patient lying on bed awake and coherent, afebrile with Ivf # 2 of D50.3 NaCl
regulated at 20 gtts/min at level of 400cc infusing well on right hand with indwelling folley
catheter connected to urine bag draining a dark yellow urine at level of 1000cc, with facial
grimace, with guarding behaviors, with dull abdominal pain, with pain scale of 8/10, with pale to
pink palpebral conjunctiva, with capillary refill time of 1-3 seconds, with left side paralysis, with
VS are as follows: Temp: 36.7c, PR: 71 bpm, RR: 21 bpm, BP: 130/70 mmHG

A =Acute Pain

P =After 2 hrs of nursing intervention the pt will verbalize relief of pain from 8/10 to 4/10

I = Established rapport

= Assessed and Recorded VS

= Maintained and Regulated IVF

= Assessed General Condition

= Encouraged diversional activities such as talking to S.O.

= Encouraged rest to overcome pain

= Assisted the pt to turn to side q 2hr

= Encouraged deep breathing and coughing exercises

= Provided comfort and safety measures

= Provided back rubbing to alleviate pain

= Secured and Documented Lab Result

= Seen on round by Dr lumboy with orders made and carried out:

-hold hydralazine IV PRN – meds updated

101
-for fecalysis – requested

-D/C ranitidine – meds updated

-Monitor BD q 4hr

-Bladder training q2

= Due meds Given as ordered and indicated by doctors

E = Goal met as pt verbalized a relief of pain

01-31-09

S=O

O = received with patient on bed conscious and coherent, afebrile with an IVF #2 d5 0.3 NaCl
500cc regulated at 20 gtts/min at level of 50cc infusing well on right hand with indwelling folley
catheter connected to a urine bag draining a dark yellow urine, with weak appearance, with
moist skin, with good skin turgor, (+) pallor, GCS of 15, with dec. Hgb 8mg, with dec. Hct 27 Vol.
right ext. 5/5 and 5/5 and left extremity of 0/5 and 4/5, with left side body paralysis.

A = Ineffective tissue perfusion r/t decreased Hgb concentration in the blood

P = after 4 hrs of nsg. Int. the pt will demonstrate understanding of health teachings

I = Established Rapport

= Assessed and Recorded VS

= Assessed General Condition

= Maintained and Monitored IVF

= Instructed pt to increase OFI

= Instructed pt to Iron rich foods

= Provided assistance in turning pt to side q 2 hr

= Provided ROM exercises to promote blood circulation

102
= Instructed pt on strict compliance to medication

= Changed IVF with D5o.3 NaCl 500cc regulated at 20 gtts/min

= Provided Adequate rest periods

= Assessed range of movement

= Prescribed all unavailable meds

= Provided health teaching regarding problems

E = Goal met As evidenced by pt and S.O. adheres with the health teachings

VI. CLIENT’S DAILY PROGRESS IN THE HOSPITAL

1. Client’s Daily Progress Chart (From admission to discharge)


Days 01-27-09 01-28-09 01-29-09 01-30-09 01-31-09
(Admission)

Nursing Problems:

1.) Acute Pain * *


2.) Impaired
* * * * *
cerebral tissue
perfusion
3.) Impaired
* * * * *
physical
mobility
4.) Activity
* * * * *
Intolerance
5.) Impaired verbal * * * * *
and/or written
communication
6.) Risk for * * * * *
Aspiration
7.) Risk for * * * * *

impaired skin
integrity

103
8.) Risk for * * * * *
deficient fluid
volume
9.) Risk for * * * * *
imbalanced
nutrition: less
than body
requirements
* * * * *
10.)Risk for
Infection * * * * *
11.)Risk for Injury
* * * * *
12.)Self care
Deficit

Vital Signs:

Temperature 36.2c 36.5c 37c 36c 36c

Pulse Rate 84 bpm 88 bpm 76 bpm 71 bpm 69 bpm

Respiratory rate 18 bpm 22 mmHg 19 bpm 17 bpm 18 pbm

Blood Pressure 170/100 140/50 180/90 180/90 170/90


mmHg mmHg mmHg mmHg mmHG

Diagnostics
Procedures:
*
1.) CXR APL
*
2.) Fecalysis
3.) Urinalysis * *
4.) Potassium K
*
5.) CBC

104
*

Drugs:

1. Piracetam * * * * *
2. Captopril
* * * D/C
3. Ranitidine
4. Simvastatin * * * *
5. Metoprolol
* * * *
6. Ketosteril
7. FeSo4 *
8. Hydralazine
*

* Hold

Medical
managements:

1. D5 LRS 1L
*
2. D5 0.3 NaCl
500cc * * * *

Diet:

1. NPO *
2. Soft Diet
* * * *

Activity/Exercises:

1. High Back Rest * * * * *

VII. Conclusion

Stroke is a term used to describe the neurologic changes caused by an


interruption in the blood supply to a part of the brain. The incidence of stroke and stroke

105
mortalities has gradually declined in many industrialized countries in recent years as a
result of increased recognition and treatment of risk factors, which may include
modifiable risk factors such as hypertension

Public education is focused on prevention, recognition of manifestations and


early treatment of brain attack. As they say prevention is better than cure. Therefore it is
important for each and every one of us to avoid these modifiable risk factors and
change sedentary lifestyles to healthy lifestyles. Cholesterol levels should be brought to
a normal level, diabetes should be controlled and reducing heavy alcohol consumption.
The best intervention is to stop smoking cigarettes.

As nursing students, this study showed us the importance of early detection of


diseases such as stroke since it may lead to more serious conditions if it is not properly
managed or treated. Knowledge of the risk factors and preventive measures can help in
reducing the incidence of stroke. Prompt recognition, which allows for early treatment of
stroke is recommended to lessen residual deficits and decreased disability. Through this
study, may we be able to help others to understand and know more about stroke and
ways to prevent and treat its signs and symptoms.

The group was able to assess one patient having a case of Cerebral vascular
accident and through the study of case the group was able to identify of the causative
factors that predisposes the patient in acquiring such disease condition. Furthermore
the group was able to identify how was it occurred and how it would be worse if left
untreated, with several condition such as this case a lot of problems has occurred that
would might permanently affect the lifestyle of the patient.

In this study the group was able to be familiarized to medical managements and
its benefits and s side effect to patient during therapy

106
VIII. Bibliography

Joyce M. Black et al (2005) Medical Surgical Nursing 7th edition Elsevier Suanders

Smeltzer, S. et. al. (2008). Brunner and Suddarth’s Textbook of Medical-Surgical


Nursing 11th edition. Philadelphia: Lippincott-Williams & Wilkins

Spratto, G. and Woods, A. (2008). 2008 Edition PDR® Nurse’s Drug Handbook. New
York: Thomson Delmar Learning.

Berman, A. et. al. (2008). Kozier & Erb’s Fundamentals of Nursing: Concepts, Process
and Practice 8th edition Jurong, Singapore: Pearson Education South Asia

Seely, R., Stephens, T., Tate, P. (2007). Essentials of Human Anatomy & Physiology 6th
edition. New York: McGraw-Hill.

Van Leeuwen, A., Kranpitz, T., Smith, L., (2006) Davis’s Comprehensive Handbook of
Laboratory and Diagnostic Test with Nursing Implication 2nd edition, U.S.A, F.A
Davis Company

Nurse’s Quick Check - Signs and Symptoms (2006) Philadelphia, Lippincott Williams &
Wilkins

Nurse’s 5- minute Clinical Consult – Diseases, (2007) Philadelphia, Lippincott Williams


& Wilkins

Hansel, D., Dintzis, R. (2006) Lippincott’s Pocket Pathology, Philadelphia, Lippincott


Williams & Wilkins

Stewart, Joseph (1989) Clinical Anatomy and Pathophysiology for the Health
Professional, Miami, MedMasters Inc.

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