HOLY ANGEL UNIVERSITY

ANGELES CITY

COLLEGE OF NURSING

TRANSIENT ISCHEMIC ATTACK

A CASE STUDY

March 5, 2009

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INTRODUCTION 1. D !cr"#$"%& %' $h ("! a! When an area of the brain loses its blood supply it stops working, the part of the

body it controls also stops working. This is what happens with a Transient Ischemic Attack, better known as TIA. When the brain loses blood supply, it tries to restore blood flow. If blood supply is restored, function may return to the affected brain cells, permitting return of function to the affected body part. Transient ischemic attack is also known as a mini-stroke, a hemorrhagic stroke, or an ischemic stroke. Some people call a TIA a mini-stroke, because the symptoms are like those of a stroke but do not last long. enerally, a TIA happens when platelets in the blood clump together in your arteries !a blood clot" making blood flow to a part of the brain be blocked or reduced. After a short time, blood flows again and the symptoms go away. Symptoms usually last only 1# - 1$ minutes and clear up within %& hours. With a stroke, the blood flow stays blocked, and the brain has permanent damage. TIAs sometimes happen before strokes, and they are considered a warning sign of stroke. It is estimated that more than '##,### TIAs occur each year in the (nited States. The highest incidence for a second stroke is within the first se)en days after a TIA. The pre)alence for cerebral infarct after TIA is 11* at the ages of $$ to +&, %%* between the ages of +$ to +,, %-* at the ages of .# to .& years, '%* between .$ to ., years and &#* at ages -# to -$ years. TIA/s are the precursor in 1$* of all strokes and if unrecogni0ed, can represent the greatest morbidity and mortality for stroke patients in the first thirtyninety days after their first TIA. 1ifty-percent of patients who e2perience a TIA fail to notify their healthcare pro)ider. Appro2imately one-third of TIA/s would re)eal as a true ischemic e)ent by diffusion-weighted magnetic resonance imaging. Within the first year of ha)ing their first TIA, %$* of patients will die. It has been estimated that only ,* of the general population is familiar with typical TIA symptoms, and as few as %%* of primary health care workers e)en know the definition of a TIA. This education gap poses a great challenge for health workers when eliciting a history from patients and families.

While TIA itself has short term effects, the significance is that this can herald a ma3or stroke, which is why it re4uires timely and aggressi)e treatment to pre)ent death and disability. It has been shown that stroke and TIA patients alike decrease their secondary stroke risk considerably by learning about their own cardio)ascular health maintenance, risk assessment and lifestyle beha)iors. TIA is a common marker of cerebro)ascular disease which, when correctly diagnosed and managed, can lead to the pre)ention of significant morbidity and mortality. 2. N)r! *C &$ r ( O+, c$"- ! (pon the completion of this case study, the student-nurses shall ha)e5 6escribed and e2plained what transient ischemic attack is. 7e)iewed the anatomy and physiology of the organs in)ol)ed. Identified the risk factors contributing to the occurrence of the disease. 82pounded on the laboratory and diagnostic procedures done with the patient, their purposes, and specific nursing responsibilities before, during and after the procedure. 8numerated the different medications administered for the disease their indications, contraindications, side effects, and specific nursing responsibilities. 1ormulated significant nursing diagnoses, with their significantly related nursing care plans.

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II. NURSING HISTORY 1. . r!%&a/ H"!$%r0 a. D 1%2ra#h"c Da$a 9rs. Attack was born in :ue0on ;ity on 1ebruary 1., 1,-#. She is %, years old, a 1ilipino citi0en, married and has one child. She li)es with her family, residing at <andan, Angeles ;ity. She was admitted in a pri)ate hospital on 1ebruary %%, %##, at 1%5#$ in the morning with a chief complaint of syncope. She was discharged four days after the admission. +. S%c"%*Ec%&%1"c a&( C)/$)ra/ Fac$%r! 9rs. Attack finished her college degree at 7epublic ;entral ;olleges with the course 8ducation. She has her 3ob as a cashier in a casino. She and her family were bapti0ed as 7oman ;atholics. They regularly attend Sunday masses and no)enas together. With minor illnesses such as fe)er, cough and colds, self medication is applied. Although they seek the ad)ice of their physician, they also belie)e in the albularyo and the manhihilot. 2. Fa1"/0 H a/$h*I//& !! H"!$%r0 9rs. Attack/s father had a cerebro)ascular accident in the year %### and was then bedridden for almost nine years. Also, one of her first degree relati)es, her aunt !her mother/s sister", had her cerebro)ascular accident in the year %##1 and is suffering from hypertension. =ther than these incidents, there were no other reported illnesses within her family and relati)es. 3. H"!$%r0 %' .a!$ I//& !! 9rs. Attack was confined in the same hospital two years ago !year %##." with a diagnosis of astroenteritis and was healed and discharged after few days of confinement. =ther than that, there were no known related ailments and past illnesses with the present one. 4. H"!$%r0 %' .r ! &$ I//& !! a. Ch" ' C%1#/a"&$5 Syncope +. S 6) &c %' $h a## ara&c %' !"2&! a&( !01#$%1! )# $% $h $"1 #a$" &$ 7a! a(1"$$ (.

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>efore going to bed at almost before midnight, 9rs. Attack e2perienced sudden chest pain and left-sided weakness followed by loss of consciousness. She was brought to the hospital already awake and was admitted minutes after midnight.

III. .HYSICAL ASSESSMENT 1. A!! !!1 &$ (%& )#%& a(1"!!"%&5 F +r)ar0 22, 2009 8c%#" ( 'r%1 char$9 EENT5 anicteric sclerae, pink palpebral con3uncti)a L)&2!5 ;lear >S, no rales H ar$5 ?777, no murmur, soft full e4ual pulses A+(%1 &5 flabby, ?A>S, 2. C #ha/%ca)(a/ a!! !!1 &$5 F +r)ar0 2:, 2009 H a( S;"& E0 ! Ear! <inna recoils after folding Absence of discharge Without any obstructions With ear piercing With dark brown iris With white sclera <upils e4ually round and reacti)e to light accommodation !<877@A" With pink palpebral con3uncti)a 6ry and warm to touch With fair skin comple2ion With good skin turgor With long hair, black and e4ually distributed Without palpable lumps With ucombed hair

N%! a&( S"&)! ! With thick nasal hair Absence of scar Absence of discharge <ositioned at the centerAmidline

M%)$h a&( Thr%a$ N c; <r a!$ Symmetrical in shape A+(%1 & With presence of hori0ontal scar on the hypogastric region !from past caesarian section incision" With presence of striae 1labby U## r a&( L%7 r E=$r 1"$" ! . Absence of palpable masses Absence of swelling Without stiffness present Without swollen lymph nodes With pinkish lips With complete number of teeth With pink gums Without halitosis

With long and polished toenails and fingernails With numbness and inability to mo)e the left lower e2tremity

CRANIAL NERVES5 =@1A;T=7B5 able to smell alcohol in cotton. =<TI;5 able to read the newspaper at a readable distance. =;(@=9=T=75 accommodation. T7=;C@8A75 able to follow the up and down mo)ement of the pen. T7I 89I?A@5 able to open mouth against resistance. A>6(;8?S5 able to follow the left and right mo)ement of the pen. 1A;IA@5 able to tasteD no difficulty in swallowing. A(6IT=7B5 able to repeat whispered words @=SS=<CA7B? 8A@5 able to mo)e the tongue in all directions. EA (S5 able to say FaaahhGD with gag refle2. A;;8SS=7B5 able to ele)ate the shoulders against resistance. CB<= @=SSA@5 able to protrude tongue. pupil e4ually round and reacti)e to light and

IV. DIAGNOSTIC AND LA<ORATORY .ROCEDURES D"a2&%!$"c> La+%ra$%r0 .r%c ()r I&("ca$"%&! %r .)r#%! ! Da$ Or( r ( Da$ R !)/$! 7 r r / a! ( 1ebruary %%, %##, R !)/$! N%r1a/ Va/) ! 8U&"$! )! ( "& $h h%!#"$a/9 '.+-$.# mmoA@ A&a/0!"! a&( I&$ r#r $a$"%& %' R !)/$!

<otassium

;reatinine

Sodium

To determine the amount of <otassium present in the blood. <otassium 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 >(? !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.

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6ecreased le)els of potassium indicate hypokalemia.

1ebruary %%, %##,

#.+&

#.$-1.+, mgAdl

?ormal

1ebruary %%, %##,

1&1

1'.-1&$ mmoA@

?ormal -low le)el of blood sodium means you ha)e 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

lucose5 1>S

>(?

lucose, formed by digestion of carbohydrates and the con)ersion of glycogen by the li)er, is the primary source of energy for most cells. The >(? test is primarily used, along with the creatinine test, to e)aluate kidney function under a wide range of circumstances and to monitor patients with acute or chronic kidney dysfunction or failure

1ebruary %%, %##,

-'.-

.+-111 mgA dl

sodium le)el means you ha)e hypernatremia, almost always due to e2cessi)e loss of water !dehydration" without enough water intake. ?ormal

1ebruary %%, %##,

..#

.-%1 mgAdl ?ormal -Increased >(? le)els suggest impaired kidney function. This may be due to acute or chronic kidney disease, damage, or failure. -@ow >(? le)els are not common and are not usually a cause for concern. They may be seen in se)ere li)er disease, malnutrition, and sometimes when a patient is o)erhydrated

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(ric Acid

The uric acid 1ebruary test is used to %%, %##, learn whether the body might be breaking down cells too 4uickly or not getting rid of uric acid 4uickly enough. The test also is used to monitor le)els of uric acid when a patient has had chemotherapy or radiation treatments.

$.#.

%.$-. mgAdl

!too much fluid )olume", but the >(? test is not usually used to diagnose or monitor these conditions. ?ormal - Cigher than normal uric acid le)els mean that the body is not handling the breakdown of purines well. The doctor will ha)e to learn whether the cause is the o)er-production of uric acid, or if the body is unable to clear away the uric acid. - @ow le)els of uric acid in the blood are seen much less commonly than high le)els and are seldom considered cause for concern. Although low )alues can be associated with some kinds of li)er or kidney diseases, e2posure to to2ic compounds, and rarely as

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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. ;holesterol To determine your nutritional status or to screen for certain li)er and kidney disorders as well as other diseases >lood tests for triglycerides are usually part of a lipid profile used to identify the risk of de)eloping heart disease. As part of a lipid profile, it may be used to monitor those who ha)e risk factors for heart disease, those who ha)e had a heart attack, or those who are being treated for high lipid andAor 1ebruary %%, %##, 1-.., up to %## mgAdl ?ormal

Triglycerides

1ebruary %%, %##,

11$.#

'$-1'$ mgAdl

A normal le)el for fasting triglycerides is less than 1$# mgAd@ !1..# mmolA@". It is unusual to ha)e high triglycerides without also ha)ing high cholesterol. 9ost treatments for heart disease risk will be aimed at lowering @6@ cholesterol. Cowe)er, the type of treatment used to lower @6@ cholesterol may

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triglyceride le)els.

S =TAAST

used to detect li)er damage.

1ebruary %%, %##,

1'

$-'$ uA@

S <TA A@T

To detects li)er in3ury.

1ebruary %%, %##,

.-$+ uA@

<otassium

To determine the amount of <otassium present in the blood. <otassium is an important electrolyte that helps regulate

1ebruary %', %##,

'..

'.+-$.# mmoA@

differ depending on whether triglycerides are high or normal. ?ormal Eery high le)els of AST !more than 1# times the highest normal le)el" are usually due to acute hepatitis, often due to a )irus infection. ?ormal Eery high le)els of A@T !more than 1# times the highest normal le)el" are usually due to acute hepatitis, often due to a )irus infection. In acute hepatitis, A@T le)els usually stay high for about 1H% months, but can take as long as 'H+ months to come back to normal. ?ormal -Increased potassium le)els indicate hyperkalemia. 6ecreased le)els of potassium indicate

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the flow of fluids in and out of the cells

hypokalemia -6ecreased le)els of potassium indicate hypokalemia. Da$ Or( r ( Da$ R !)/$! 7 r r / a! ( R !)/$! N%r1a/ Va/) ! 8)&"$! )! ( "& $h h%!#"$a/9 A&a/0!"! a&( "&$ r#r $a$"%&

D"a2&%!$"c> La+%ra$%r0 .r%c ()r

I&("ca$"%&! %r .)r#%! !

HCT

Cematocrit test measures the amount of space !)olume" 7>; take up in the blood.

1ebruary %%, %##,

'+.,

'.-&.

6ecreased hematocrit indicates anemia, such as that caused by iron deficiency or other deficiencies N%r1a/ -Abnormal results of any of the blood gas components may mean that your body is not getting enough

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>lood gas are used to e)aluate your o2ygenation and acidAbase status.

1ebruary

'&'

1&#-&&#

measurements %%, %##,

1&

o2ygen, is not getting rid of enough carbon dio2ide, or that there is a problem with kidney function. If left untreated, these conditions create an imbalance that could e)entually be life ?<C 6etermines the number of circulating W>;s per cubic ml of whole blood. It is an indicator of immune function and helps to determine infection or inflammation 1ebruary %%, %##, -An ele)ated number of white blood cells is called leukocytosis. This can result from bacterial infections, inflammation, leukemia, trauma, intense ..+ &.'-1#.# threatening. N%r1a/

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e2ercise, or stress. A decreased W>; count is called leukopenia. It can result from many different situations, such as chemotherapy, radiation therapy, or diseases of the immune system.

Gra&)/%c0$ ! 6etermines the le)el of granulocytes in the blood. An ele)ated le)el means that there is hgh bacterial infection 8=10>19 L01#h%>

1ebruary %%, %##,

+%

&&.%--#.%

The result is wihtion normal range

Small

1ebruary

&.. '-

%.#--.%--&-

The result is

1+

1%&%c0$ !

agranulocytic leukocytes originating from fetal stem cells. It is especially helpful in the e)aluation of the patient with infection. 9easures the amount of hemoglobin in blood and is a good measure of the bloods ability to carry o2ygen throughout the body.

%%, %##,

within normal range

HG<

1ebruary %%, %##,

11.%

1%-1+

>elow-normal hemoglobin le)els may lead to anemia that can be the result of iron deficiency

N)r!"&2 R !#%&!"+"/"$" ! '%r </%%( Ch 1"!$r05 A. < '%r $h #r%c ()r 5 1. ;heck the 6octor/s order. %. Identify the patient. '. ;heck the )ital signs.

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&. 6ecrease patient/s an2iety by e2plaining the procedure and why it has to be performed. $. 1or blood sample, instruct that the medical technician will perform )enipuncture to e2tract blood. +. Acknowledge 4uestions regarding the safety of the procedure. <. D)r"&2 $h #r%c ()r 5 1. If the test is to be done at bedside, remain with the patient. %. Assist with the collection of specimen if allowed. C. A'$ r $h #r%c ()r 5 1. ;heck the site for bleeding, cyanosis, or swelling. %. Apply pressure and warm compress. '. ;heck )ital signs for any changes. &. 6ocument the data !attach result in the chart". D"a2&%!$"c> La+%ra$%r0 .r%c ()r (rinalysis Da$ Or( r ( R !)/$! Da$ R !)/$! 7 r r / a! ( To obtain 1ebruary %', 9acroscopic5 clinical %##, ;olor5 yellow information, to Specific detect renal and ra)ity51.#1$ metabolisc Sugar5 negati)e disease, Appearance5 diagnosis of slightly turbid disease or 7eaction5 pC disorder on +.# kidneys or Albumin5 urinary tract. negati)e I&("ca$"%&! %r .)r#%! A&a/0!"! a&( I&$ r#r $a$"%& %' R !)/$! 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 9icroscopic5 there is a <us cells5 1-% problem that 7ed ;ells5 #-1 needs to be 8pithelial cells5 addressed. few 9ucus threads5 rare

N)r!"&2 R !#%&!"+"/"$" ! '%r Ur"&a/0!"!5 A. < '%r $h .r%c ()r

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1. 82plain the procedure to the patient/s significant other. %. =btain materials needed in the procedure. '. Ad)ise the significant other to wash perineal area prior to collection of specimen. <. D)r"&2 $h .r%c ()r 1. ;ollect a fresh urine specimen in a urine container. %. =btain clean catch midstream urine if possible. C. A'$ r $h .r%c ()r 1. Transfer the urine specimen to the laboratory promptly. %. 6ocument the procedure. '. Attach the result in the patient/s chart. D"a2&%!$"c> La+%ra$%r0 .r%c ()r >rain Scan Da$ Or( r ( R !)/$! Da$ R !)/$! 7 r r / a! ( To identify 1ebruary %'. @acunar Infarct, structural %##, subcortical lesions whether portion, left )ascular or parietal lobe tumors. I&("ca$"%&! %r .)r#%! A&a/0!"! a&( I&$ r#r $a$"%& %' R !)/$! <lain multiple a2ial )iews of the head re)eals a small, hyperlucent focus on the subcortical portion of the left parietal lobe. The )entricles and cistern are not dilated. The midline structures are not displaced. The sella turtica, posterior fossae and basal skull structures are intact.

N)r!"&2 R !#%&!"+"/"$" ! '%r <ra"& Sca&5 A. < '%r $h #r%c ()r 5 1. 82plain the procedure to the pt and the S=.

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%. =btain the consent. '. 7estrict food and fluids. <. D)r"&2 $h #r%c ()r 5 1. Stay with the patient. C. A'$ r $h #r%c ()r 5 1. 6ocument the procedure. %. Attach the result in the patient/s chart

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V. THE .ATIENT AND HER ILLNESS 1. A&a$%10 a&( .h0!"%/%20 The systems in)ol)ed in gi)ing part to the de)elopment of TIA are the circulatory system and the ner)ous system. The circulatory system is a network that carries blood throughout the body. The human circulatory system supplies the cells of the body with the food and o2ygen they need to sur)i)e. At the same time, it carries carbon dio2ide and other wastes away from the cells. The circulatory system also helps regulate the temperature of the body and carries substances that protect the body from disease. In addition, the system transports chemical substances called hormones, which help regulate the acti)ities of )arious parts of the body. =ne of the parts of the circulatory system is the heart. It is a hollow, muscular organ that pumps blood. It consists of two pumps that lie side by side. These pumps rela2 when taking in blood and contract as they send out blood. The left side of the heart is a stronger pump than the right side. The stronger pump recei)es blood from the lungs and sends it to cells throughout the body. The weaker pump recei)es blood from the cells throughout the body and sends the blood to the lungs. Another of the parts of the circulatory system are the blood )essels. They form a complicated system of connecting tubes throughout the body. There are three ma3or types

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of these )essels. Arteries carry blood from the heart. Eeins return blood to the heart. ;apillaries are e2tremely tiny )essels that connect the arteries and the )eins. The blood consists chiefly of li4uid called plasma, and three kinds of solid particles known as formed elements. <lasma is made up mostly of water, but it also contains proteins, minerals, and other substances. The three types of formed elements are called red blood cells, white blood cells, and platelets. 7ed blood cells carry o2ygen and carbon dio2ide throughout the body. White blood cells help protect the body from disease. <latelets release substances that enable blood to clot. <latelets thus aid in pre)enting the loss of blood from in3ured )essels. The ner)ous system is a )ery comple2 system in the body. It has many, many parts. The ner)ous system is di)ided into two main systems, the central ner)ous system !;?S" and the peripheral ner)ous system. The spinal cord and the brain make up the ;?S. Its main 3ob is to get the information from the body and send out instructions. The peripheral ner)ous system is made up of all of the ner)es and the body. =ne of the parts of the ;?S is the brain. It keeps the body in order. It helps to control all of the body systems and organs, keeping them working like they should. The brain also allows us to think, feel, remember and imagine. In general, the brain is what makes us beha)e as human beings. wiring. This system sends the messages from the brain to the rest of the

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The brain communicates with the rest of the body through the spinal cord and the ner)es. They tell the brain what is going on in the body at all times. This system also gi)es instructions to all parts of the body about what to do and when to do it. There are fi)e main senses - touch, smell, taste, hearing and sight. These are the e2ternal sensory system, because they tell you about the world outside your body. Bour senses tell you what is happening in the outside world. Bour bodyIs sense organs constantly send signals about what is happening outside and inside it to your control center - the brain. The cerebrum is part of the forebrain. The cerebral corte2 is the outer layer of the cerebrum. ;ertain areas of the cerebral corte2 are in)ol)ed with certain functions. Sensory areas such as touch, smell, taste, hearing and sight recei)e messages from the skin, nose, mouth, ears and eyes. We feel, taste, hear and see when these messages are recei)ed by the sensory parts of the brain. The second main part of the ner)ous system is the peripheral ner)ous system. The ner)ous system is made up of ner)e cells or neurons that are JwiredJ together throughout the body, somewhat like communication system. ?eurons carry messages in the form of electrical impulses. The messages mo)e from one neuron to another to keep the body functioning. ?eurons ha)e a limited ability to repair themsel)es. (nlike other body tissues, ner)e cells cannot also be repaired if damaged due to in3ury or disease.

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2. .a$h%#h0!"%/%20 A. <%%;*<a! ( a. Sch 1a$"c D"a2ra1 .r ("!#%!"&2 'ac$%r! - age - se2 - history of TIAAstroke K CT? on the family - sedentary lifestyle - personal CT? .r c"#"$a$"&2 'ac$%r! - cigarette smoking - 6iabetes 9ellitus - thromboembolism - stress

6ecrease blood supply on the brain leads to hypo2ia, thus Ischemia occurs on the brain. Short-term ischemia leads to temporary neurologic deficits or a TIA If blood flow is restored, brain tissue will re)erse the damage within minutes if blood flow is not restored, brain tissue sustains irre)ersible damage of infarction wAin minutes the e2tend of infarction depends on the location and si0e of the occluded artery %&

and the ade4uacy of collateral circulation to the area it supplies.

Ischemia 4uickly alters cerebral metabolism thus decrease cerebral perfusion leading to further damage to the brain.

@ead to damaging both hemispheres of the brain thus leading to paralysis of the body, speech, and 8; changes of the heart

A cascades of biochemical processes occurs within minutes of cerebral ischemia, thus membrane depolari0ation occurs

7esults to influ2 of calcium and sodium @eads to cytoto2ic edema and cell death area resultsD @eads to secondary neuronal in3ury If edema subsides, client may regain some function %$ The area of edema after ischemia may lead to temporary neurologic deficits

+. S0&$h !"! %' $h D"! a! +.1. D '"&"$"%& %' $h D"! a! The definition of TIA continues to e)ol)e. Traditionally, TIA has been defined as the presence of neurologic symptoms of )ascular etiology in one area of the brain lasting less than %& hours. Implicit in this definition is neuronal in3ury that is not permanent in nature. Cowe)er, there are se)eral problems with this definition. It is now clear through newer diagnostic modalities such as diffusion-weighted magnetic resonance imaging !97I" that this time- and symptom-based definition can be clinically misleading. It assumes a complete correlation between the resolution of symptoms and normali0ation of tissue reperfusion, which often underestimates the potential tissue damage detected by diffusion-weighted 97I. ?early $#* of patients who meet the classic definition of TIA ha)e in fact suffered subclinical strokes with detectable cerebro)ascular infarction. A more accurate definition of TIA has been proposed by the Transient Ischemic Attack Working roup formed by Albers and ;aplan5 Fa brief episode of neurologic dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than one hour, and without e)idence of acute infarctionG. +.2. .r ("!#%!"&2>.r c"#"$a$"&2 Fac$%r! .r ("!#%!"&2 Fac$%r! A2 5 Ad)ancing age is one of the most significant risk factors of stroke. S =5 Stroke has higher incidence in men due to physical needs and built. H"!$%r0 %' TIA>S$r%; @ HTN "& $h 'a1"/05 stroke. S ( &$ar0 /"' !$0/ 5 <ersons with a sedentary life style are at higher risk for stroke than those with acti)e life styles. H"!$%r0 %' HTN5 Cigh blood pressure increases the pressure inside arteries, causing damage. )essels !atherosclerosis". .r c"#"$a$"&2 Fac$%r! 82cessi)e pressure on the walls of speeds up hardening and narrowing of the arteries enetic predisposition of

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C"2ar $$ !1%;"&25 Smoking in3ures blood )essel walls and speeds up hardening of the arteries !atherosclerosis". As a result, the heart works greater increase the risk of harder, and blood pressure may increase. Cea)y smokers are at risk for TIA and stroke. 6aily cigarette smoking can stroke by %L times. many serious health problems, including hardening of the arteries !atherosclerosis" and heart problems, eye problems that can lead to disease and kidney blindness, circulation and ner)e problems, and kidney failure. Thr%1+% 1+%/"!15 A blood clot or other tissue in the blood !such as fat" from a part of the body other than the brain can tra)el through blood )essels and become wedged in a smaller brain artery. This free-roaming clot or tissue is called an embolus !emboli is plural". 8mboli often form in the heart. They also commonly form in the neck arteries or within the aorta. S$r !!5 +.3. S"2&! a&( S01#$%1! 7"$h Ra$"%&a/ >lurred )ision in both eyes, brief blindness, or double )ision <arietal and temporal lobe strokes may interrupt )isual fibers of the optic tract and route to the occipital corte2 and impair )isual acuity. 6ifficulty speaking It is caused by cranial ner)e dysfunction from a stroke in )ertebrobasilar artery or its branches. It may result from the weakness or paralysis of the muscles of the lips, tongue, and laryn2 or form loss of sensation. Weakness, sometimes on only one side of the body The deficit is usually caused by a stroke in the anterior or middle cerebral artery, leading to infarction of motor strip of the frontal corte2. Eertigo !a whirling or spinning feeling", headache, confusion They occur due to decreasing o2ygen le)el or total o2ygen depri)ation. @oss of consciousness D"a+ $ ! M //"$)!5 <eople who ha)e diabetes are at increased risk for

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It occurs due to impaired =2ygen absorption, altering or disturbing brain cell metabolism and functioning. ;hest pain Anything that compresses a ner)e root !like a disc or multiple discs" due to cardiac ischemia will hurt.

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<. C/" &$*C &$ r ( a. Sch 1a$"c D"a2ra1 .r ("!#%!"&2 'ac$%r! - history of C<? on Aunt !9other/s side" - history of stroke !Aunt and 1ather" .r c"#"$a$"&2 'ac$%r! - use of birth control pills - increased fatty food on diet - stress

1romation of @acunar infarction Infarct causing decrease blood supply n the brain

62. >rain Scan !#%-%%-#," @acunar infarction, subcortical portion, left parietal lobe

6ecrease blood supply leads to =% and glucose supply brain thus Cypo2ia occurs

Cypo2ia can cause Ischemia which may lead to temporary neurologic deficits or a TIA also known as Transient Ischemic Attack

Ischemia 4uickly alters cerebral metabolism %,

decrease cerebral perfusion affects blood flow n the body

@eading to Cypo2ia on the brain will cause further damage if not be re)ersed and will furtherresult to higher damaged to the brain

@eading to hypotension

leading to syncope and chest pain, and left sided weakness of the body

@eading to Transient Ischemic Attack

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<. S0&$h !"! %' $h D"! a! +.1. .r ("!#%!"&2>.r c"#"$a$"&2 Fac$%r! .r ("!#%!"&2 'ac$%r! H"!$%r0 %' H.N a&( !$r%; %& A)&$ 81%$h rA! !"( 9 @ h"!$%r0 %' !$r%; %& 'a$h r5 enetic predisposition of stroke. .r c"#"$a$"&2 Fac$%r! U! %' +"r$h c%&$r%/ #"//!5 Taking birth control pills increases the risk for TIA because they are said to interfere with peripheral blood flow most especially when they are taken by cigarette smokers. I&cr a! ( 'a$$0 '%%( %& (" $5 Too much cholesterol in the blood is not healthy because it can build up in the walls of arteries, narrowing and hardening blood )essels !atherosclerosis". S$r !!5 A person with a stress reaction e2periences symptoms of an2iety when e2posed to )ery stressful e)ents. It is a factor in your en)ironment that causes your mind or body to be tense. Bou may react to the stress by feeling tension, an2iety, fear, anger, frustration or depression and e)en loss of body function. +.2. S"2&! a&( S01#$%1! 7"$h Ra$"%&a/ Weakness, left side of the body The deficit is usually caused by a stroke in the anterior or middle cerebral artery, leading to infarction of motor strip of the frontal corte2. @oss of consciousness =ccur due to impaired =2ygen absorption, altering or disturbing brain cell metabolism and functioning. ;hest pain Anything that compresses a ner)e root !like a disc or multiple discs" due to cardiac ischemia will hurt.

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VI. THE .ATIENT AND HER CARE 1. M ("ca/ Ma&a2 1 &$ A. IVF M ("ca/ Ma&a2 1 &$ G & ra/ ( !cr"#$"%& I&("ca$"%&!> #)r#%! Da$ %r( r (, (a$ # r'%r1 (, (a$ cha&2 ( %r D>C #%-%1-#, C/" &$A! r !#%&! $% $r a$1 &$

IE1 6$?9 It is a sterile, nonpyrogenic, hypertonic solution of balanced maintenance electrolytes and $* de2trose in3ection in water for in3ection. The solution is administered by intra)enous infusion for parenteral maintenance of routine daily fluid and electrolyte re4uirements with minimal carbohydrate calories.

It is indicated for parenteral maintenance of routine daily fluid and electrolyte re4uirements with minimal carbohydrate calories from de2trose. 9agnesium in the formula may help to pre)ent iatrogenic magnesium deficiency in patients recei)ing prolonged parenteral therapy.

The patient was able to maintain a normal hydration status.

a. 1. N)r!"&2 r !#%&!"+"/"$" !5 .RIOR TO INSERTION5 When inserting an IE line to a patient, always prepare all the materials to be used prior to the insertion. Wash hands thoroughly before performing the procedure.

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Identify the correct patient by checking the name on the chart or by asking directly the patient. 82plain the procedure to the patient.

DURING ADMINISTRATION5 Insert the IE catheter accordingly. 7egulate and monitor infusion rate. 9onitor patient/s therapeutic response to treatment. ;heck the IE insertion site for signs of infiltration, bulging, heat, pain and redness. <. Dr)2! Dr)2!

AFTER ADMINISTRATION5

Ac$"%&

I&("ca$"%&

eneric ?ame5 <otassium ;hloride >rand ?ame5 Malium 6urule

-7eplaces potassium and maintains potassium le)el

-To pre)ent hypokalemia

Da$ %r( r (, (a$ # r'%r1 (, (a$ cha&2 ( %r D>C 6ate =rdered5 #%-%%-#,

C/" &$A! R !#%&!

The patient/s potassium le)el returned to normal range. There is impro)ement in the affected !paraly0ed" areas.

eneric ?ame5 ;iticoline >rand ?ame5 Soma0ine

-increases the neurotransmission le)els because it fa)ors the synthesis and production speed of dopamine in the striatum, acting then as dopominergic agonist through the inhibition of tyrosine hydro2ilase.

To increase brain metabolism

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eneric ?ame5 9annitol >rand ?ame5 =smitrol

-Increases osmotic pressure of glomerular filtrate, inhibiting tubular reabsorption of water and electrolytesD drug ele)ates plasma osmolalityD increasing water flow into e2tracellular fluid.

-to pre)ent oliguria or acute renal failure

The patient/s urinary function returned to normal.

eneric ?ame5 omepra0ole >rand ?ame5 7isek

inhibits secretion of gastric acid by irre)ersibly blocking the en0yme system of hydrogenApotassium adenosine triphosphate !CNAMN AT<ase", the proton pump of the gastric parietal cell. - Inhibits the binding of adenosine diphosphate !A6<" to its platelet receptor, impeding A6<-mediated acti)ation and subse4uent platelet aggregation, and irre)ersibly modifies the platelet A6< receptor.

To pre)ent gastoesophageal reflu2 and peptic ulcer.

The patient did not e2perience reflu2 and did not manifest ulcerations.

eneric ?ame5 ;lopidogrel bisulfate >rand ?ame5 <la)i2

- to reduce #%-%'-#, thrombotic e)ents in patients with atherosclerotisis documented by recent stroke, 9I, or peripheral arterial disease

The patient/s blood circulation impro)ed and was increased.

eneric ?ame5

-increases the

to increase

#%-%&-#,

There is

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;iticoline ?a >rand ?ame5 ;holiner)

neurotransmission le)els because it fa)ors the synthesis and production speed of dopamine in the striatum, acting then as dopominergic agonist through the inhibition of tyrosine hydro2ilase.

brain metabolism

impro)ement in the affected !paraly0ed" areas.

+. 1. N)r!"&2 r !#%&!"+"/"$" !5 <EFORE ADMINISTRATION5 D. D" $ ;heck and clarify 6octors order <repare e4uipments 1# 7/s of drugs <erformed skin testing ;heck for the patient/s medication card and chart. <erformed hand washing

DURING ADMINISTRATION5 7ead the name, amount, and e2piration date three times ;heck for patient/s identification 82plain the procedure to the client

AFTER ADMINISTRATION5 6ocument Watch out for any side effects

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T0# %' D" $

G & ra/ ( !cr"#$"%&

I&("ca$"%&! >#)r#%!

Da$ %r( r (, (a$ !$ar$ (, (a$ cha&2 ( %r D>C

C/" &$A! r !#%&! a&(>%r r ac$"%& $% $h (" $

@ow salt and low fat

To pre)ent the #%A%%A#, problems that result from the need to withhold food.

- The patient complied with the doctor/s order.

c. 1. N)r!"&2 r !#%&!"+"/"$" !5 .RIOR TO INITIATION OF DIET5 82plain why diet is desired to client.

DURING INITIATION OF DIET5 Instruct patient and S= to eat healthy foods to promote wellness e2cept those allergic to the patient. AFTER INITIATION OF DIET5 D. Ac$"-"$0 T0# %' E= rc"! G & ra/ ( !cr"#$"%& I&("ca$"%&! >#)r#%! Da$ %r( r (, (a$ !$ar$ (, (a$ cha&2 ( %r D>C C/" &$A! r !#%&! a&(>%r r ac$"%& $% $h ac$"-"$0 82plain to the patient foods that are good for fast reco)ery. Instruct S= to obser)e strictly the diet to impro)e the nutrition of the patient.

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T)r&"&2 = rc"!

Turning the client side to side on bed e)ery % hours

To pre)ent )enous stasis, thrombophlebitis, pressure ulcer formation and respiratory complication. To increase muscle strength.

#%A%'A#,

;ompliance

F/ ="%&* =$ &!"%& = rc"!

1le2ion and e2tension the unaffected e2tremities.

#%A%&A#,

;ompliance

(.1 N)r!"&2 R !#%&!"+"/"$" ! #r"%r $% ()r"&2 a&( a'$ r !$ar$ %' $h ac$"-"$0 1. 82plain the significance of the acti)ity. %. Assist the patient and the S= in doing the procedure. '. <lace pillows to pre)ent falls.

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VII. NURSING CARE .LAN .r%+/ 1 N%. 1 C) ! N)r!"&2 D"a2&%!"! SO P Ineffecti)e =O >ody peripheral weakness tissue perfusion rAt <aralysis impaired of left transport of lower e2tremities the =% across al)eolar and >< of capillary 1##A+# membrane A8> paralysis of left lower e2tremity

Sc" &$"'"c E=#/a&a$"%& >ecause there/s an decrease in o2ygen supply in our body it fails to nourish the tissues at the capillary le)el resulting to tissue perfusion

N)r!"&2 O+, c$"- ! After 1 hour of ?<I, pt/s condition in circulation of the left lower e2tremity will ha)e progress.

N)r!"&2 Ra$"%&a/ "&$ r- &$"%&! 8ncourage 8nhance early )enous ambulation return when possible 8le)ate C=> at night To increase gra)itational blood flow Ceat increases the metabolic demands of already compromise d tissue Smoking causes )asoconstric tion and further compromise d perfusion 7ATI=?A@8

E=# c$ ( O)$c%1 The pt/s condition in circulation of the lower e2tremity shall ha)e progressed.

82ercise caution in use hot water bottles or heating pads 8ncourage to minimi0e places that are high in smoke

.r%+/ 1 N%. 2 ;(8S

?(7SI? 6IA ?=SIS

S;I8?TI1I; 8Q<@A?ATI=?

?(7SI? =>R8;TIE8

?(7SI? I?T87E8?TI=?S

8Q<8;T86 =(T;=98 '-

S O F6i ko magalaw Stong left foot koT Wala ring pakiramda m hanggang waistTG = O The pt. manifested the ff5 with limited ability to perform gross motor skills with difficulty in turning with slowed mo)ement needs assistance upon ambulatio n

Impaired physical mobility rAt neuromuscular impairment A8> paralysis of the lower left e2tremity.

6ue to the impairment of blood flow in the brain/s neurologic branches, dysfunction occurs resulting to ineffecti)e impulses sent to different body parts specifically the e2tremities. ?umbness and inability to mo)e the affected area occurs and decreases the pt/s ability to perform desired and necessary acti)ities.

After 1U of nursing inter)ention, the pt. will be able to participate in A6@/s and with the desired acti)ities.

Assist in self-care acti)ities.

To promote independence and enhancement of self-concept. To pre)ent fatigue and o)ere2ertion. To pro)ide time to rechannel energy and to pre)ent e2ertion and o)ere2haustion. To promote safety and to pre)ent in3ury. To pre)ent stasis of blood and to reduce the risk of pressure ulcers. To aid in supplementing normal body functions.

8ncourage energyconser)ing techni4ues. <ro)ide pt. with ample time to perform mobilityrelated tasks.

The pt. shall ha)e participated in A6@/s and with the desired acti)ities.

<lace pillows on the right side of the bed. ;hange lying position e)ery % hours.

=ffer fluids and reinforce nutritious foods.

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 with paralysis of the left lower e2tremity <75 $&bpm .r%+/ 1 N%. 3 CUES SHP = H left e2tremity weakness - inability to mo)e purposefully NURSING DIAGNOSIS Acti)ity Intolerance related to neuromuscular impairment as e)idenced by left sided weakness and inability to mo)e without S= support secondary to disease process. SCIENTIFIC O<CECTIVE EB.LANATION The patient is suffering from ;erebro)ascular Accident wherein there is a sudden loss of brain function resulting from a disruption of the blood supply to a part of the brain. As a result, brain cells are star)ed of o2ygen causing some cells to die and lea)ing other cells damaged. 9aking the patient unable to mo)e the left side After % hours of ?ursing inter)ention the patient will demonstrate beha)iors that will impro)e her present condition.

7einforce low salt, low fat diet.

To assure compliance with daily diet regimen and to pro)ide a continuous reco)ery state.

INTERVENTION RATIONALE

EVALUATION The pt shall ha)e demonstrated beha)iors that will impro)e her present condition.

Assist with acti)ities and monitor c lient/s use of assisti)e de)ice Ad3ust acti)ities

to protect client from in3ury

to pre)ent o)ere2ertio <lan care with rest n periods between to reduce acti)ities fatigue <romote comfort measures and pro)ide relief of pain

to enhance ability to participate

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of her body most especially the left side of the body. Thus, the patient was unable to turn side to side, sit or stand and mo)e on bed without support @eading the patient to suffer Acti)ity Intolerance.

in acti)ities

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VIII. DISCHARGE .LAN O<CECTIVE After ?<I, the pt. will be able to comply and )erbali0e understanding on pro)ided health teachings and home maintenance management. CONTENT E= rc"! Ad)ise to5 6o deep breathing e2ercises. Ca)e ambulation with assistance and support as tolerated. <erform A6@s in)ol)ing hygiene and self-care. Tr a$1 &$ Instruct to5 ;omply strictly with drug treatment regimen. H a/$h T ach"&2! 6emonstrate to5 <lace pillows on bed when asleep to pre)ent in3ury and other accident precautions. Support the affected part to pre)ent de)elopment of pressure ulcers. <ro)ide ade4uate rest TIME ALLOTMENT 1 hour TEACHING STRATEGIES @ecture-discussion and demonstration EB.ECTED OUTCOME The pt. shall ha)e complied and ha)e )erbali0ed understanding on pro)ided health teachings and home maintenance management.

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periods. <ro)ide energy conser)ation techni4ues. 9ake up acti)ities that increase the well being. O)$*.a$" &$ Instruct to5 7eturn a week after discharge as ordered by the physician. D" $ 7einforce to5 9aintain a low salt, low fat diet. Increase fluid, fruit and )egetable intake.

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IB. LEARNING DERIVED FROM THE STUDY ;onfusions between Transient Ischemic Attack and Stroke were identified by the student-nurses wherein TIA is a sign of a possible impending stroke. <roper diet modification and increase in acti)ities will reduce the risk of ha)ing an attack. Also, health care workers ha)e a great responsibility towards making the disease known to patients and the population as a whole. Taking care of an ill patient is our responsibilities being a nurse. We ha)e to gi)e the proper care they need, identifying the problem to gi)e appropriate inter)entions in their disease. We/)e encountered different kinds of diseases, beha)ior of each patient, and knowing the causes of each diseases. >eing a nurse is not that easy because we are dealing in the life of the patient. ?urses must be competent or knowledgeable enough in doing the care in a patient because one mistake of it can cause more complications or death to the patient. In this case study we/)e learned the causes, factors or signs and symptoms of the disease, how it was started and what are the appropriate inter)entions and medications gi)en to the patient. We/)e learned and more appreciated the meaning of the disease. This is the essence of being a nurse, though we are encountering some patients 4uite not good to deal with. 7elated learning e2periences help us more to apply what we/)e learned from the lectures and discussions within the four corners of the classroom. =ne can ne)er really appreciate what was learned until was e2perienced.

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