SAN ISIDRO COLLEGE CITY OF MALAYBALAY COLLEGE OF NURSING

A CASE STUDY OF A 60 YEAR OLD FEMALE DIAGNOSED WITH CEREBROVASCULAR ACCID ENT, HEMORRHAGIC
In partial Fulfillment of the Requirements in RLE 104

SUBMITTED TO: MS. IRENE R. MINA, RN MAN MS. MARIZ ROCHELLE B. CANONIGO, RN MR. IAN CID C. DESCALLAR RN MS. KATHLEEN OBICE, RN MS. ELAINE GAY TUMADA, RN MR. MARLON ARANO, RN

SUBMITTED BY: MAY ANTHONY MAHINAY MICHAEL ANTHONY SOLON ELEANOR EGAR FRICHEE MAE PIO DAISY JANE SOLIVA MAY ANN MADELO LADY DIANE VELASCO ALYSON MADJUS LEVEL 3, GROUP B NURSING STUDENTS 10

NOVEMBER 2011
San Isidro College College of Nursing NURSING HISTORY AND ASSESMENT RECORD Name of Patient: C Date of Birth: 5/3/1951 Religion: Roman Catholic Age:60 y/old Sex :F Status: ( ) S ( )M ( /)W ()Ch ( ) Sep Birth Place: Manolo Fort. Bukidnon Nationality: Filipino

Date Admitted: October 31, 2011 Admitted By:

Time: 12:00

( ) AM ( /) PM

Attending Physician: Dr. Marie Alexis De Castro Informant: ( ) Patient ( /)Others(specify)Significant others BP Height Weight 180/100 50 56 kg

( ) Ambulatory ( /) Stretcher ( ) Wheelchair Temperature 38.2C Pulse 115 bpm Respiration 26cpm

( ) Oriented to Unit ( /) Not Oriented

Reason: ( ) Confused ( ) Comatose ( ) Critical ( /) Language Barrier

Chief Complaint/Reason of Hospitalization: High blood pressure and right sided body weakness

HISTORY OF PRESENT ILLNESS Two months prior to admission, patient C experienced high blood pressure of 170/90 mmHg as she had her check up at the RHU, she was advised by the RHU doctor to maintain some medication but did not comply with it. One day prior to admission patient complaints of severe headache and several hours later onset of right sided body weakness associated with high B/P was manifested by patient, persistence of symptoms prompted her family to bring and rush her to BPMC to seek admission.

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HISTORY OF PAST ILLNESS Acute Disease: Cough& Colds, Fever Chronic Disease: None Age at the time of onset: unrecalled Medication: OTC drugs, herbal medicines, prescribed medicines Childhood Disease: chickenpox, mumps Surgery/Hospitalization: Last year 2010 for AGE Allergy (FDA):No known food and drug allergy (NKFDA) Family History: ( ) Heart Disease ( ) Renal Disease ( /) Hypertension ( ) Cancer ( /) Stroke ( ) Substance Abuse () Lung Disease( ) Others: (Specify) Dosage 30cc 1 tab. NGT 1gm IVTT 40mg NGT 25mg 1 tab. NGT 40mg 1 tab. 75cc 200mg in 20cc H2 Timing hs OD q12 OD for Breakfast q6 OD hs q8 OD

Medication Lactulose Citicholine Cefepime Pantoprazole Captopril Simvastatin Mannitol Acetylceistine

FINAL DIAGNOSIS: CVA, hemorrhagic FUNCTIONAL HEALTH PATTERNS Health Perception-Health Management Pattern (Pre-Hospitalization) Status of previous pregnancy: NSVD (G5P5A0L4) Types/kind of immunization received:Fully immunized mother Medical Checkup: Had medical chek-up last August 2010 for AGE Dental Check-up: Last January at Impasug-ong Health Center Smoking and use of beverages: None Any faith in quack doctors: Yes, she believes in quack doctors

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Use of herbal meds: Yes, such as Tawa-tawa, sambong, and mayana Health Center visits:Seldom, only if there is cough and cold Activity of Daily Living (ADL) (Pre-Hospitalization) Meal Pattern (Kind and amount consumed, Condition of Appetite): Consumes whole share of food with good appetite; is fond of eating fried and salty food such as dried fish and bagoong. Fluid intake (amount per day, types of fluid): consumes almost 4 glasses of water and likes to drink cola in almost meal. Personal Hygiene Habits: takes a bath every other day Sleep and Rest: experienced adequate rest and sleeps before the hospitalization, sleeps at 8:30am and wakes up at 7:30am Leisure activities: Playing mahjong and bingo at the neighborhood. Nutritional/Metabolic Pattern Prescribed Diet: low fat low sodium / soft diet Appetite: ( ) Good ( ) Fair ( / ) Poor Changes in eating habits: ( ) No ( / ) Yes Amount: before she consumes 2 plates of rice but now she could hardly finish 1 bowl of lugaw. Appetite Changes? ( ) No ( / ) Yes Time Period:3x a day Weight Loss/gain:2 kg,from weight of 58 kg to 56 kg Special diet: Comments/Nursing Problem Identified: Alteration in Nutrition: less than body requirements related to motor difficulties with feeding, chewing and swallowing caused by neuromuscular impairment as evidenced by weight loss of 2 kg. Teeth: Permanent Removable Permanent ( ) Bridge () Own ( ) Prosthesis ( / ) Dentures (Check below) ( /) Upper ( ) Lower ( ) Upper () () ()

( ) Lower () Removable Comments/ Nsg Problem Identified: Risk for injury Related factor: Presence of dentures during attack ELIMINATION PATTERN BladderOliguria ( ) No difficulty ( ) Dysuria ( ) frequency ()

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anuria

( /) Incontinence ( ) UTI

( ) Nocturia ( ) Stones

( ) Hematuria ( /) Catheter

()

Comments/Nursing Problem Identified: The patient is having an incontinence so the The patient is almost in 7 days catheter (FBC attached to urobag. * Risk for ascending infection Related factor: presence of catheter.

Bowel( ) No difficulty ( /) constipation ( ) diarrhea ( ) Incontinence ( ) Ileostomy ( ) Colostomy ( / ) Laxative aids:Lactulose 30cc Comments/Nursing Problem Identified: Alteration in normal bowel elimination; constipation related to diminished motor function and immobility as evidenced by abdominal distention, hypoactive bowel sounds and absence of stool passage for 2 days. SLEEP/REST PATTERN ( ) No difficulty ( /) Yes (describe):The significant others noticed that the patient seems to be restless and not feeling rested during sleeping hours (night), they estimated the average sleeping hours of the patient to 3-4 hours, before prehospitalization patient have an average sleep of 8-10 hours, from 8:00 pm to 5:00 am. Use of sleeping aids (/) No ( ) Yes Comment/Nursing Problem Identified: Disturbance in sleeping pattern related to abnormal physiological status caused by neurological dysfunction as evidenced by difficulty of falling or remaining asleep, restlessness and average sleeping hours of 3-4 hours. ACTIVITY/EXERCISE Activities of Daily Living (I=Independent, A=With Assistance, D= Dependent) Eating: (D) Bathing: Grooming: (D) Toileting: Activity Level (D) (D) Dressing: (D) Ambulating: (D) ( /) Sedentary

() Active

Comments/Nursing Problem Identified: Altered physical mobility related to neuromuscular impairment, decreased strength and endurance on the affected side as evidenced by inability to purposefully move

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within physical environment, limited ROM and being dependent in doing ADL such as eating, grooming, toileting, dressing , bathing. COGNITIVE PERCEPTION PATTERN

Glasses

(/) No

( ) Yes ( ) Yes ( ) Right ( ) Left

Contact Lens Prosthesis

Hearing Aids (/) No

(/) No ( ) Yes ( ) Right ( ) Left (/) No ( ) Yes ( ) Right ( ) Left

Vision:
Comments/Nursing Problem Identified: The patient have fixed and dilated pupil at the right part of the affected site. BEHAVIOR PATTERN (COPING/VALUES) Behavior ( ) Relaxed ( / ) Moderately anxious () mildly anxious () Very anxious

Psychiatric History: Comments/Nursing. Problems Identified: Situational Low self-esteem related to cognitive and perceptual impairment, perceived loss of control in some aspects of life and loss of independent function as evidenced by patient showing frustration on her current situation. SUBSTANCE ABUSE Tobacco (/ ) No ( ) Yes Cigarette/Cigar/Pipe:_____________ Drugs (/) No ( ) Yes Type: _________ /day/wk Alcohol (/ ) No ( ) Yes Amount: Comments/Nursing Problem Identified: _No nursing problems identified. PAIN ( ) No (/) yes (describe): The Pain felt by patient with stroke is both from physical and psychological pain caused by emotional and psychological stress and also discomfort caused by increase ICP such as headache . Present pain management: _Developing positive coping mechanism towards pain and discomfort felt thru health teachings about the disease process, treatments and more information toward self-care to S.O. for patient, also administration of analgesic such as PCM IVTT for fever, Mannitol to decrease ICP, proper positioning( turning to sides at interval) and emphasizing proper hygiene.

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Comments/Nursing Problem Identified: Alteration in comfort: pain related to emotional , psychological stress and discomfort caused by increase ICP as evidenced by patient showing irritability and restlessness. SEXUALITY/REPRODUCTION PATTERN Date of last menstrual period (LMP):The patient is already on menopause Date of last Pap smear:None Is patient pregnant? (/ ) No ( ) Unsure ( ) Yes, no. of weeks: Breast (cyst, lumps, discharge) (/) No ( ) Yes,(describe) Testicular/prostate problem: (describe)____ Birth Control: (/) NA ( ) NA ( ) No ( ) Yes

(/) No ( ) Yes (method)

Comments/Nursing Problem Identified:No problems identified

_______________________________________________________________________

PHYSICAL ASESSMENT Direction: Write A in the box to denote asymptomatic findings. Write S in the box to indicate symptomatic findings and write Symptoms and related laboratory and/or diagnostic result in the Space provided. ________________________________________________________________________

NEUROLOGICAL ASSESSMENT:

Alert and oriented to person, place and time Pupils equally round and reactive to light parenthesis(weakness) or paralysis Extremities. No difficulty of speech or swallowing noted

S _______________________ Right sided body weakness noted (hemiparesis) Visual disturbance (blurred) Slurred speech and impaired swallowing noted sleep disturbances (GCS= 9) eyes 2, verbal 2, motor 5

S RESPIRATORY ASSESSMENT: Resp. 12 to 22 breaths per minute rest respiration Quite &regular. Breath sound in both lung fields clear >tachypneic 26cpm Nail beds and lips pink > pallor nailbeds and lips noted 10

>shortness of breath noted > Crackles heard on both lungs upon auscultation >On O2 at 2-3LPM

S CARDIOVASCULAR ASSESSMENT: Regular apical pulse. Heart rate 60 to 100 >tachycardic P = 115bpm No complaints of chest pain. No edema >increased B/P of 130/90, 180/100 mmhg S PERIPHERAL-VASCULAR ASSESSMENT: Extremities are pink, warm and movable within Normal ROM. Peripheral pulses palpable No edema, no complaints of numbness/calf Tenderness. >flushed warm skin noted T=38.2 >with limited ROM at right side of the body (affected part) >Diminished pulses at the affected Side( right side)

S GENITOURINARY ASSESSMENT: Voiding without discomfort or difficulty. Urine clear >with FBC attached urobag draining Frequency with own pattern. No usual vaginal or to a dark yellow colored urine(600 cc) Penile irritation/discharged noted. ________________________________________________________________________ S MUSKULOSKELETAL ASSESSMENT: Presence of inflammation. Normal ROM of all joints. >generalized body weakness noted No muscular weakness. >limited ROM at affected side No complaints of back pain. >altered muscle tone (1) ______________________________________________________________________ S SKIN ASSESSMENT: Skin color within patients norm, skin warm dry and >flushed warm skin noted due to Intact. Decubiti/burns present? (/) NO ( ) Yes elevated temperature T=38.2 Pls. complete skin assessment record >redness noted at bony prominences ______________________________________________________________________ 10

SKIN SITE TYPE SIZE STAGE (BURN &DECUBITI) N/A

___________________________________________________________________________

ROLE REGULATION PATTERN AND DISCHARGE PLAN Occupation:Housewife With whom does patient lived? Children Anticipating returning home? ( ) yes ( /) no still for further observation Person(s) available to assist at home: children Is referral to social welfare service needed by the client and family? Yes Comments: The family specially the one who will be the caregiver has a big role for the clients fast recovery specially that the goal of a patient with stroke is to promote positive and effective coping in terms of physiologic and psychologic needs. The family should be cooperative with treatment plan of the patient so that there will be a good prognosis . ANTICIPATED PATIENT AND FAMILY TEACHING (Medication, disease process, activity, hygiene, etc.) Health Teaching given to significant others to patient as to: >Stress the importance of compliance with the medication regimen. >Inform specially the watchers on the prescribed diet and some dietary restrictions, diet is low salt, low fat. >Always provide safety, raise the side rails of the bed to prevent falls. >Importance of proper positioning of the patient, turn to sides every 2 hours. >Hygienic measures such as proper hand washing of the watchers and caregivers to prevent infections and complications. >Provide oral care to the patient. >Perform passive and active exercises at both extremities as tolerated. >Inform about taking measures to prevent further injuries and complication. >Advise watchers to report any unusualities noted. PRIORITY NURSING PROBLEMS IDENTIFIED ***Ineffective airway clearance related to decreased gag reflex caused by neurological dysfunction and presence of secretions as evidenced by being tachypneic=26cpm , shortness of breath, pallor lips and nailbeds.

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***Ineffective tissue perfusion; Cerebral related to interruption of blood flow caused by hemorrhage and cerebral vasospasm as evidenced by altered LOC (Lethargic) with GCS of 9 and change in vital signs; B/P=180/100-130/90 mmHg, RR=26cpm, PR=115bpm, Temp.38.2. ***Altered physical mobility related to neuromuscular impairment, decreased strength and endurance at the affected side as evidenced by inability to purposefully move within physical environment, limited ROM and being dependent in doing ADLs. ***Alteration in nutrition; less than body requirements related to motor difficulties with feeding, chewing and swallowing as evidenced by reduced appetite and decreased weight from 58 kg to 56 kg. *** Impaired verbal communication related to loss of facial or muscle tone and control caused by neuromuscular impairment as evidenced by impaired articulation, inability to modulate speech, and inability to comprehend spoken language. Patient/ S.O. Signature: __Patient _C_____________________ Date: __________November 8, 2011____________________ Name of Hospital: _Bukidnon Provincial Medical Center (BPMC) Date of Assessment: November 8, 2011

NURSING SYSTEM REVIEW CHART Name: _C Date: _11-08-11 Vital sign: Pulse: 115bpmBP: 180/100Temp:_38.2RR: 26cpm

EENT:
Impaired vision Blind Gums hard hearing deaf Burning edema lesion Assess eyes, ears, nose Throat for abnormality no problem teeth > blurred vision >Slurred speech noted >difficulty of swallowing or decreased gag reflex >pallor lips noted

/ /

RESPIRATORY:
Asymetric tachypnea Apnea rales cough barrel chest Bradypnea shallow Ronchi Sputum diminished dyspnea orthopnea labored wheezing pain cyanotic crackles Assess respiratory .rate rhythm, depth, pattern, breath sounds Comfort no problem >tachypneic RR-26cpm >dyspneic >pallor nailbeds and lips noted >shortness of breath noted >on 02 at 2-3 LPM

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CARDIOVASCULAR:
Arrhythmia tachycardia numbness >tachycardic P-115 bpm_ Diminished pulses edema fatigue >elevated B/P180/100 mmhg Irregular bradycardia murmur >generalized body weakness noted Tingling absent pulses pain Assess heart sounds, rate rhythm, pulse, blood pressure, clear fluid Retention, comfort no problem

GASTRO INTESTINAL TRACT:

Obese distention mass dysphagia rigidly pain Assess abdomen, bowel, habits, and swallowing Bowel, sound, comfort no problem >difficulty in swallowing due to diminished gag reflex >decreased motility,constipated for 2 days >distended abdomen noted >Hypoactive bowel sounds noted upon auscultation

GENITOURINARY AND GYNE:

pain urine color vaginal bleeding hematuria discharge nocturia Assess urine frequency, color, odor, comfort, Gyne-bleeding, discharge, no problem >on FBC attached to urobag with dark yellow colored urine

NEURO:
Paralysis atuporous unsteady seizures Lethargic comatose vertigo tremors Confused vision grip Assess motor function, sensation, LOC, strength, grip, gait, Coordination, orientation, speech no problem >Altered LOC-lethargic GCS=9 >blurred vision dilated and fixed pupils at the affected side of the face > Right sided body weakness noted > Slurred speech noted

MUSCULOSKELETAL AND SKIN:

Appliance stiffness itching petechiae hot drainage prosthesis swelling wound rash skin color flushed atrophy pain ecchymosis diaphoretic moist Asses mobility, motion, galt,alignment, joint Skin color, texture,turgor, integrity no problem >flexion of elbow and wrist noted >skin is warm to touch, flushed skin with elevated temperature of 38.2 degree celcius >Redness at bony prominences > diaphoresis noted >limited ROM at the affected site

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