PAMANTASAN NG LUNGSOD NG MAYNILA (University of the City of Manila) Intramuros Manila

College of Nursing

A Case Study of Transient Ischemic Attack

In partial fulfillment for the requirement in Medical-Surgical Nursing I

Submitted By: ESTEVES, Christian C. BSN III-1

Submitted To: Professor Enrico P. de Jesus, RN, RM

August 25, 2011

I. CASE INTRODUCTION Transient Ischemic Attack is the temporary episode of neurologic dysfunction that may last a few seconds or minutes but not longer than 24 hours. It occurs when the blood supply to part of the brain is briefly interrupted. It occurs when an area in the brain loses blood supply. As a compensatory mechanism, brain tries to restore blood flow. If blood supply is restored, affected brain cells function may return, permitting the return of function to the affected body part. It is also called as mini-stroke, hemorrhagic stroke, or ischemic stroke. Generally, Transient Ischemic Attack happens when blood clot is present in the arteries, making blood flow to a part of the brain be reduced or blocked. Within 24 hours, blood flows again. Below is a presentation of case on Transient Ischemic Attack.

CASE REPORT This is a case of a 33 year-old, married, female, Filipino, who is currently residing at Quiapo,Manila, and admitted at Ospital ng Maynila on March 6, 2010 diagnosed with Transient Ischemic Attack, with chief complaint of Syncope. Upon admission, patient had positive signs and symptoms of sudden onset of dyspnea followed by vomiting and syncope. The sequence of the appearance of signs and symptoms are as follows: During dinner, Mrs. PIE suddenly experienced difficulty of breathing. Shortly after her dyspneic episode, the patient vomited, and experienced leftsided weakness followed by loss of consciousness. On examination, the patient exhibited Anicteric sclera, pink palbebral conjunctiva, with clear breath sounds, no rales present, no murmur present upon auscultation, abdomen is flabby with presence of striae.

II. SCHEMATIC DIAGRAM OF PATHOPHYSIOLOGY

III. DIAGNOSTIC PROCEDURES AND LABORATORY ANALYSIS NURSING HEALTH HISTORY Past Health History Upon interview, the patient confirmed that she was confined to Ospital ng Tondo three years ago (2007) with a medical diagnosis of Gastroenteritis, and was also discharged after four (4) days. Other than that, there were no known past illness related to TIA. Present Health History The Chief Complaint of the patient is Syncope. Prior to Admission, Mrs. PIE experienced difficulty of breathing, vomiting and leftsided weakness followed by loss of consciousness. Family Health - Illness History Patient PIEs mother had a cerebrovascular accident in 2003 and bedridden for 3 years. Also, one of her first degree relatives, her uncle (fathers brother) and auntie(mothers sister) was diagnosed of Hypertension in the year 2002. On 1999, Her father and auntie also had Transient Ischemic Attack. Other than these, there were no other reported illness-related case within her family and relatives. PHYSICAL ASSESSMENT On arrival at the emergency department, 2 hours after the onsent of symptoms, she reports vomiting, with no headache. She is a current smoker with a history of 1 pack-year. Her blood pressure is 140/80 mm Hg, and her pulse is 97 beats per minute, and is regular. The patient has a capillary refill of 5 seconds on blunch test, the patients skin is cold, and clammy to touch, and has pale skin color on elevation. The patient has positive Homans sign. Neurologic examination shows dysarthria, left homonymous hemianopia, sever left sided-weakness, and a failure to register light touch on the left side of the body when both sides are touched simultaneously, and has a cognitive orientation of 3 (moderately compromised).

DIAGNOSTIC AND LABORATORY PROCEDURES Diagnostic/ Laboratory Procedure Potassium Indications or Purposes To determine the amount of Potassium present in the blood. Potassium is an important electrolyte that helps regulate the flow of fluids in and out of the cells The creatinine blood test is usually ordered along with a BUN (blood urea nitrogen) test to assess kidney function The amount of Sodium present in the blood. Sodium is an important electrolyte that helps regulate the flow of fluids in and out of the cells. Results 3.3 Normal Values (Units used in the hospital) 3.6-5.0 mmo/L Analysis and Interpretation of Results Decreased levels of potassium indicate hypokalemia.

Creatinine

0.64

0.5-1.69 mg/dl

Normal

Sodium

141

137-145 mEq/L

Glucose: FBS

Glucose, 83.8 formed by digestion of carbohydrates and the conversion of glycogen by the liver, is the primary source

76-111 mg/ dl

Normal -low level of blood sodium means you have hyponatremia, which is usually due to too much sodium loss, too much water intake or retention, or to fluid accumulation in the body (edema). -high blood sodium level means you have hypernatremia, almost always due to excessive loss of water (dehydration) without enough water intake. Normal

BUN

Uric Acid

of energy for most cells. The BUN test is primarily used, along with the creatinine test, to evaluate kidney function under a wide range of circumstances and to monitor patients with acute or chronic kidney dysfunction or failure The uric acid test is used to learn whether the body might be breaking down cells too quickly or not getting rid of uric acid quickly enough. The test also is used to monitor levels of uric acid when a patient has had chemotherapy or radiation treatments.

7.0

7-21 mg/dl

Normal -Increased BUN levels suggest impaired kidney function. This may be due to acute or chronic kidney disease, damage, or failure. -Low BUN levels are not common and are not usually a cause for concern. They may be seen in severe liver disease, malnutrition, and sometimes when a patient is overhydrated (too much fluid volume), but the BUN test is not usually used to diagnose or monitor these conditions. Normal - Higher than normal uric acid levels mean that the body is not handling the breakdown of purines well. The doctor will have to learn whether the cause is the over-production of uric acid, or if the body is unable to clear away the uric acid. - Low levels of uric acid in the blood are seen much less commonly than high levels and are seldom considered cause for concern. Although low values can be associated with some kinds of liver or kidney diseases, exposure to toxic compounds, and rarely as the result of an inherited metabolic defect, these conditions are typically identified by other tests and symptoms and not by an isolated low uric acid result. Normal

5.07

2.5-7 mg/dl

Cholesterol

To determine your nutritional status or to screen for certain liver and kidney disorders as well as other

187.9

up to 200 mg/dl

Triglycerides

SGOT/AST

diseases Blood tests for triglycerides are usually part of a lipid profile used to identify the risk of developing heart disease. As part of a lipid profile, it may be used to monitor those who have risk factors for heart disease, those who have had a heart attack, or those who are being treated for high lipid and/or triglyceride levels. Used to detect liver damage.

115.0

35-135 mg/dl

A normal level for fasting triglycerides is less than 150 mg/dL . It is unusual to have high triglycerides without also having high cholesterol. Most treatments for heart disease risk will be aimed at lowering LDL cholesterol. However, the type of treatment used to lower LDL cholesterol may differ depending on whether triglycerides are high or normal.

13

5-35 u/L

SGPT/ ALT

To detects liver injury.

7-56 u/L

Potassium

To determine the amount of Potassium present in the blood. Potassium is

3.7

3.6-5.0 mEq/L

Normal Very high levels of AST (more than 10 times the highest normal level) are usually due to acute hepatitis, often due to a virus infection. Normal Very high levels of ALT (more than 10 times the highest normal level) are usually due to acute hepatitis, often due to a virus infection. In acute hepatitis, ALT levels usually stay high for about 12 months, but can take as long as 36 months to come back to normal. Normal -Increased potassium levels indicate hyperkalemia. Decreased levels of potassium indicate hypokalemia -Decreased levels of potassium

an important electrolyte that helps regulate the flow of fluids in and out of the cells

indicate hypokalemia.

Diagnostic/ Laboratory Procedure HCT

Indications or Purposes Hematocrit test measures the amount of space (volume) RBC take up in the blood. Blood gas measurements are used to evaluate your oxygenation and acid/base status.

Results

Normal Values

Analysis and interpretation

36.9

37-47

Decreased hematocrit indicates anemia, such as that caused by iron deficiency or other deficiencies

pH

343

140-440

Normal -Abnormal results of any of the blood gas components may mean that your body is not getting enough oxygen, is not getting rid of enough carbon dioxide, or that there is a problem with kidney function. If left untreated, these conditions create an imbalance that could eventually be life threatening. Normal -An elevated number of white blood cells is called leukocytosis. This can result from bacterial infections, inflammation,

WBC

Determines the 7.6 number of circulating WBCs per cubic ml of whole blood. It

4.3-10.0

is an indicator of immune function and helps to determine infection or inflammation

leukemia, trauma, intense exercise, or stress. A decreased WBC count is called leukopenia. It can result from many different situations, such as chemotherapy, radiation therapy, or diseases of the immune system.

Granulocytes

Determines the 62 level of granulocytes in the blood. An elevated level means that there is hgh bacterial infection

44.2-80.2

The result is within normal range

(x10/1) Lympho/ monocytes

Small agranulocytic leukocytes originating from fetal stem cells. It is especially helpful in the evaluation of the patient with infection.

4.7 38

2.0-8.8 28-48

The result is within normal range

Below-normal hemoglobin levels

HGB

Measures the amount of hemoglobin in blood and is a good measure of the bloods ability to carry oxygen throughout the body.

11.2

12-16 may lead to anemia that can be the result of iron deficiency

Diagnostic/ Laboratory Procedure Urinalysis

Indications or Purpose To obtain clinical information, to detect renal and metabolic disease, diagnosis of disease or disorder on kidneys or urinary tract.

Results Macroscopic: Color: yellow Specific Gravity:1.015 Sugar: negative Appearance: slightly turbid Reaction: pH 6.0 Albumin: negative Microscopic: Pus cells: 1-2 Red Cells: 0-1 Epithelial cells: few Mucus threads: rare Results

Analysis and Interpretation of Results The greater the concentration of the abnormal substance (such as greatly increased amounts of glucose, protein, or red blood cells), the more likely it will be that there is a problem that needs to be addressed.

Diagnostic/ Laboratory Procedure Brain Scan

Indications or Purpose To identify structural lesions whether vascular or tumors.

Analysis and Interpretation of Results

Lacunar Infarct, sub Plain multiple axial views of the head cortical portion, left reveals a small, hyper lucent focus on parietal lobe the sub cortical portion of the left parietal lobe. The ventricles and cistern are not dilated. The midline structures are not displaced. The sella turtica, posterior fossae and basal skull structures are intact.

IV. MEDICAL-SURGICAL MANAGEMENT

Intravenous Fluid Medical Management IVF D5NM General description It is a sterile, nonpyrogenic, hypertonic solution of balanced maintenance electrolytes and 5% dextrose injection in water for injection. The solution is administered by intravenous infusion for parenteral maintenance of routine daily fluid and electrolyte requirements with minimal carbohydrate calories. Indications/ purpose It is indicated for parenteral maintenance of routine daily fluid and electrolyte requirements with minimal carbohydrate calories from dextrose. Magnesium in the formula may help to prevent iatrogenic magnesium deficiency in patients receiving prolonged parenteral therapy.

Drugs Drugs Generic Name: Potassium Chloride Brand Name: Kalium Durule Action -Replaces potassium and maintains potassium level Indication To prevent hypokalemia

Generic Name: Citicoline Brand Name: Somazine

-increases the neurotransmission levels because it favors the synthesis and production speed of dopamine in the striatum, acting then as dopominergic agonist through the inhibition of tyrosine hydroxilase.

To increase brain metabolism

Generic Name: Mannitol Brand Name: Osmitrol

-Increases osmotic pressure of glomerular filtrate, inhibiting tubular reabsorption of water and electrolytes; drug elevates plasma osmolality; increasing water flow into extracellular fluid. inhibits secretion of gastric acid by irreversibly blocking the enzyme system of hydrogen/potassium adenosine triphosphate (H+/K+ ATPase), the proton pump of the gastric parietal cell. - Inhibits the binding of adenosine diphosphate (ADP) to its platelet receptor, impeding ADPmediated activation and subsequent platelet aggregation, and irreversibly modifies the platelet ADP receptor.

To prevent oliguria or acute renal failure

Generic Name: omeprazole Brand Name: Risek

To prevent gastroesophageal reflux and peptic ulcer.

Generic Name: Clopidogrel bisulfate Brand Name: Plavix

- to reduce thrombotic events in patients with atherosclerosis documented by recent stroke, MI, or peripheral arterial disease

Generic Name: Citicoline Na Brand Name: Cholinerv

-increases the neurotransmission levels because it favors the synthesis and production speed of dopamine in the striatum, acting then as dopominergic agonist through the inhibition of tyrosine hydroxilase.

to increase brain metabolism

Diet

Type of Diet

General description

Indications /purpose To prevent the problems that result from the need to withhold food.

Low salt and low fat

Acrivity Type of Exercise

General description

Indications /purpose To prevent venous stasis, thrombophlebitis, pressure ulcer formation and respiratory complication. To increase muscle strength.

Turning exercise

Turning the client side to side on bed every 2 hours

Flexionextension exercise

Flexion and extension the unaffected extremities.

V. NURSING MANAGEMENT Encourage early ambulation when possible to enhance venous return Elevate the Head of Bed at night to increase gravitational blood flow Provide information on smoking cessation, low fat and low cholesterol diet, birth control alternatives, exercise and stress out the importance of need to lifestyle modification to decrease the prevalence of cerebrovascular disease and to prevent stroke Encourage energy-conserving techniques to prevent fatigue and overexertion. Change lying position every 2 hours to prevent the stasis of blood and to reduce the risk of pressure ulcers. Increase fluid intake and reinforce nutrition-rich foods to aid in supplementing normal body functions. Reinforce low salt, low fat diet to assure compliance with daily diet regimen and to provide a continuous recovery state.

NURSING CARE PLAN PATIENT: MRS. PIE ASSESSMENT Subjective Cues: Sumasakit yung paa ko pag naglalakad, pero nawawala yung sakit pag napapahinga,as verbalized by the patient. Objective Cues: HR: 97 bpm BP: 140/80 mmHg > Capillary Refill of 5 seconds > Cold, Clammy skin > Pale skin color on elevation (+) Altered Sensation (+) Homans Sign (+) Claudication AGE: 33 years old INFERENCE History of Hypertension and Stroke in the family (Predisposing Factor) and Precipitating Factors (Stress, Smoking) Formation of Lacunar Infarction Decreased Blood Supply in the Brain Decreased Oxygen to the brain Hypoxia Ischemia Temporary Neurologic GENDER: Female PLANNING Within 2 days of nursing intervention, the patient will demonstrate increased perfusion, as manifested by: - Capillary Refill of less than or equal to 3 seconds > Warm skin (-) Homans Sign (-) Claudication (-) Altered Sensation Diagnosis: Transient Ischemic Attack RATIONALE >To obtain baseline data >To decrese Oxygen demand >To maximize tissue perfusion >To enhance venous return >To increase gravitational blood flow > To prevent venous stasis EVALUATION GOAL MET. Within 2 days of nursing intervention, the patient will demonstrate increased perfusion, as manifested by: - Capillary Refill of less than or equal to 3 seconds > Warm skin (-) Homans Sign (-) Claudication (-) Altered Sensation

NURSING DIAGNOSIS Ineffective Peripheral Tissue Perfusion related to impaired transport of oxygen, as manifested by: > Capillary Refill of 5 seconds > Cold, clammy Skin > Pale skin color on elevation (+) Altered Sensation (+) Homans Sign (+) Claudication

INTERVENTION >Monitor vital signs q4 >Encourage quiet and restful environment >Caution patient to avoid activities that increases cardiac workload >Encourage early ambulation, if possible >Elevate Head of Bed at night >Apply antithromboembolic hose bandages to lower extremities before arising from bed

Deficit Altered cerebral metabolism Decreased Cerebral Perfusion S/Sx Capillary Refill of 5 seconds (+) Homans Sign

>Encourage smoking cessation

>Because smoking causes vasoconstrictio n and may further compromise perfusion >To decrease tension level

>Demonstrate use of relaxation activities, exercises or techniques

PATIENT: MRS. PIE ASSESSMENT Subjective Cues: Hindi mahimbing yung tulog ko, lagi akong nagigisinggising, as verbalized by the patient Objective Cues: BP: 140/80 mm Hg HR: 97 bpm (+) restlessness (+) fluctuation in sleep-wake cycle (+) fluctuation in level of consciousness > Cognitive Orientation of 3 [moderately compromised]

AGE: 33 years old INFERENCE History of Hypertension and Stroke in the family (Predisposing Factor) and Precipitating Factors (Stress, Smoking) Formation of Lacunar Infarction Decreased Blood Supply in the Brain Decreased Oxygen to the brain Hypoxia Ischemia Temporary Neurologic Deficit

GENDER: Female OBJECTIVES Within 2 days of nursing intervention, the patient will demonstrate restoration of cognitive status to baseline, as manifested by: (-) restlessness > Normal sleep-wake cycle > Cognitive Orientation of 5 [not compromised]

Diagnosis: Transient Ischemic Attack RATIONALE > To obtain baseline data >To identify possible deficiencies of essential nutrients that could affect mental status > For client not to feel endanger with his safety EVALUATION GOAL MET. Within 2 days of nursing intervention, the patient will demonstrate restoration of cognitive status to baseline, as manifested by: (-) restlessness > Normal sleepwake cycle > Cognitive Orientation of 5 [not compromised

NURSING DIAGNOSIS Acute Confusion related to decreased blood supply in the brain, as manifested by: (+) restlessness (+) fluctuation in sleep-wake cycle (+) fluctuation in L.O.C. > Cognitive Orientation of 3

INTERVENTION > Monitor vital signs q4 > Assess diet or nutritional status

> Orient client to surroundings, staff, and necessary activities, as needed. > Maintain calm environment and eliminate extraneous noise/ stimuli

> To prevent overstimulation > To diagnose presence/seve rity of lungs disease. >To meet identified needs

> Discuss situation with family and involve in planning

Altered cerebral metabolism Confusion

>Discuss need for ongoing medical review of patients medications

>To limit possibility of misuse or potential dangerous side effects

PATIENT: MRS. PIE ASSESSMENT Subjective data: Nahihirapan akong igalaw tong left arm ko, parang nanghihina, as verbalized by the patient. Objective data: BP: 140/80 mm Hg HR: 97 bpm (+)left extremity weakness (+) fatigue

AGE: 33 years old

GENDER: Female

Diagnosis: Transient Ischemic Attack RATIONALE >To enhance sense of wellbeing > To develop individually appropriate therapeutic regimens. EVALUATION GOAL MET. Within 8 hours of nursing intervention, the patient will participate willingly in necessary/ desired activities, as manifested by: (-) left extremity weakness (-) fatigue

NURSING INFERENCE DIAGNOSIS Activity History of Intolerance Hypertension related to and Stroke in neuromuscular the family impairment as (Predisposing manifested by: Factor) and (+) left Precipitating extremity Factors weakness (Stress, (+) fatigue Smoking) Formation of Lacunar Infarction Decreased Blood Supply in the Brain Decreased Oxygen to the brain Hypoxia Ischemia Temporary Neurologic Deficit Hypoxia at the

OBJECTIVES Within 8 hours of nursing intervention, the patient will participate willingly in necessary/ desired activities, as manifested by: (-) left extremity weakness (-) fatigue

INTERVENTION >Encourage client to maintain positive attitude >Provide referral to other disciplines, such as exercise physiologist, psychological counseling/therapy, etc. > Provide positive atmosphere, while acknowledging difficulty of the situation of the patient >Plan care to carefully balance rest periods >Assist with activities and monitor patients use of assistive devices >Plan care with rest periods between activities

> To help minimize frustration and rechannel energy. >To reduce fatigue

>To protect client from injury >To reduce fatigue

brain Left-sided weakness

>Promote comfort measures and provide relief of pain

>To enhance ability to participate in the activities