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Page 1 of 37 I.

Introduction As we had our first exposure at the hospital, specifically at the ward, we were faced with and therefore, were able to observe different cases. These cases opened various opportunities for us to experience different ways of rendering treatments for our clients. During our clinical rotation, we had the chance to interact with different patients and one of them which caught our attention was PATIENT X- 70 years old, who currently has Cerebrovascular Accident or more commonly known as stroke. What is Cerebrovascular Accident? Cerebrovascular Accident (CVA) is an acute neurological injury whereby the blood supply to a part of the brain is interrupted, either by a clot or a sudden burst which occurs at the artery. The result of this is that the part of the brain perfuse by that artery no longer can receive oxygen carried by the blood and it dies with cessation of function from that part of the brain. In addition to tissue death, hemorrhages also cause damage from physical impingement of blood on the brain tissue. Stroke is a medical emergency and can cause permanent neurological damage or even death if not promptly diagnosed and treated. (www.fpnotebook.com/Neuro/CV/IschmcStrk.htm) To summarize this, stroke occurs when an artery to the brain becomes blocked or ruptured, resulting in death of an area of brain tissue (cerebral infarction), causing sudden symptoms. In addition to this, PATIENT X is also suffering from different health problems. The said problems will be discussed later on. In the meantime, due importance and attention will be given to Cerebrovascular accident since this is one of the most risky injuries, as we have witnessed in our client. Cerebrovascular accident is one of the most serious cases that a patient might experience. One reason for this is that problems associated with CVA will not only affect the patient, but also the people around him especially his family. The associated problems that are, or might occur are as follows: Self care feeding deficit, Risk for impaired swallowing, impaired verbal/ written communication, impaired physical mobility, and Self Bathing and Hygiene deficit.

Page 2 of 37 In this case study we were able to construct a nursing care plan for our client that will aid us in reducing his anxiety and help him, as well as his family, in rehabilitation and thus we could provide adequate nursing care related to his problem. II. Objectives of the study At the end of the study, the students would be able to: Acquire sufficient amount of knowledge regarding Cerebral Vascular Accident and its risk factors; and be able to assist the family in identifying the necessities concerning a CVA patient. Identify the problems that a CVA patient will be experiencing in the future; and be able to prioritize its main concerns to provide the patient and the family with possible alternatives and solutions to the problem. Gain experience; enhance skills and attitude to become more compassionate and competitive health care professionals imbued with the highest set of ethical, moral, and social values Recognize needs of health care services, thus take initiative in helping to improve its quality. At the end of the study, the client would be able to: Apply health teachings provided by the nurses in order to reduce or eliminate identified health problems Identify health problems present and are able to prioritize its main concern to promote optimal level of functioning. See her potential regardless of her disabilities. Apply health teachings provided by the student nurses in order to reduce or eliminate identified health problems. They will utilize and maximize the use of resources available for the continued enhancement of the clients rehabilitation process. General Goal: At the end of the study, the clients family would be able to:

Page 3 of 37 After the study, there would be an exchange of learning between the student nurses, other health care professionals and the client, thus developing interpersonal relationship. III. Significance of the Study Student nurse As 3rd year nursing students, it is an opportunity for us to be able to observe and experience how to be a part of a health team that renders sufficient services for a CVA patient and other cases that has relation to health. This exposure helped each and every one of us to maximize our potential and respond to people in need of our service. It has developed our skills and potentials in communicating with other people and sharing with them what we have learned so far about promoting health. This helped us to know our own competence level in handling different cases especially a case concerning with CVA patient. We ourselves learned to be more objective and be a risk-taker to achieve our highest aspirations and goals in life. The Client and his family This study enabled us to provide the client and his family with basic information on how to promote and protect their health and enhance their level of functioning. It motivated the family to become active in responding to environmental forces with the focus of maintaining a healthy lifestyle and accepting its importance in order to assist the client with his basic needs and suitable lifestyle. It facilitated the client and the family to adapt in a new lifestyle that is more appropriate to the whole family given that one of the members of the family has impairment and needs rehabilitation. Clinical Instructor This study enabled Clinical Instructor to evaluate each trainee according to their level of competency regarding different cases in the ward especially CVA management with ease and content for recognizing how the trainees coped and

Page 4 of 37 responded to the needed requirements. This also enabled them to know how the students had been guided and reacted to what theyve taught and recommended in order to accomplish the goal of the activity. IV. Patients Profile Name: Address: Age: Gender: Religious Affiliation: Occupation: Marital Status: Chief Complaint: Final Diagnosis : Additional Diagnosis: V. Nursing History A.Past Health History Childhood Illness: The patients daughter and son cant remember any childhood illness of their father. His son Immunizations: verbalized Si tatay malakas yan, hindi sakitin The patients daughter and son cant also remember any immunizations of their father. Her daughter verbalized Siguro hindi kumpleto si tatay ng bakuna, kasi hindi pa naman ata uso Allergies: Accidents: Hospitalizations: Medications used: nung kapanahunan niya ang bakuna! None None None The patients daughter and son cant also remember any medications of their father before Foreign Travel: patient X illness occur. The patients daughter verbalized Nag-stay siya sa states from 1994-2001(7 years)..Dun na nga lang siya nagkaron ng sakit..Pagdating niya dito Mrs. X Marikina city 70 years old F Catholic Physician married Left sided weakness Cerebrovascular disease s/p Right MCA Infarct, s/p Right Hemicraniectomy & Tracheostomy Hypertensive Cardiovascular Disease, Bronchial Asthma, not in Acute Exacerbation

Page 5 of 37 sa Pilipinas naka stretcher na siya B. History of Present Illness Patient X has been positive for hypertension for 15 years and was diagnosed for kidney stones two years ago. He was an alcoholic and smoker for four years having ten sticks per day. Patient X has slurred speech for three years now. Patient X felt dizzy before he had stroke. C. Family History Diabetes Mellitus High Blood Pressure / Hypertension VI. A. Patterns of Functioning Psychological Health Patient X has four children, two of them verbalized that Minsan nakikita ko siyang nahihirapang huminga, pero may nebulizer naman...at minsan nanginginig yung mga kamay niya His son verbalized Dati sobrang depressed si tatay dahil sa pagkakahiwalay nila ni nanay, kaya nagkabisyo(umiinom ng alak at naninigarilyo) siya.. Patient X usually responds to verbal and physical stimuli but obviously the response is not that active. Problem in grooming is also noticeable. Interpretation: Neurologic deficits are frequently seen in patients with stroke. One of this is a motor deficit which is the weakness of the body. Another one is an emotional deficit which is depression. (Medical Surgical Nursing by Smeltzer & Bare) Analysis: Patient X has tremors which is maybe, caused by the weakness of his body. Since Patient X has CVA, maybe it is normal that he have tremors. And also because of that weakness he cant respond actively to stimulus and he cant groom himself properly. Being a widower is a factor thats why he is depressed. Having a CVA maybe adds as a factor in his depression. B. Socio-Cultural Patterns

Page 6 of 37 Patient X was a factory worker before he went to U.S. for 7 years. As the daughter verbalized Dati madalas siyang naglalakad,exercise narin niya yun..pero nung nasa US na siya hindi na siya masyadong naglalakad. Patient X was already a widower with four children left. Interpretation: Neurologic deficits are frequently seen in patients with stroke. One of this is a motor deficit which is the weakness of the body. (Medical Surgical Nursing by Smeltzer & Bare) Analysis: Patient X has limited a movement, because of CVA, thats why it weakens more his body. C. Spiritual Patterns Patient X is a Roman Catholic therefore there is an existence of values with regard to the people around him. He doesnt believe in any superstitions, thus theres no special practices desired. Interpretation: No interpretation seen in references. Analysis: Patient X spiritual patterns is normal even though he have CVA because other people without CVA have the same pattern with him. VII. Activities of Daily Living Before Hospitalization 1. Nutrition Daughter verbalized: wala siyang ganang kumain ADL Doesnt have any restrictions but doesnt have the urge to eat. During Hospitalization Daughter verbalized: Gustonggusto niyang kumain pero ayaw niya yung pinapakain sa NGT kasi wala daw lasa Osteorized feeding with NGT 1800kcal/day, low salt, low fat in six Interpretation Older people need fewer calories and dietary changes in view of the risk of coronary heart disease, osteoporosis, and hypertension. (Fundamental s of Nursing by Kozier) Analysis Lack of nutritional intake

Page 7 of 37 divided feeding with strict aspiration precaution. Eat soft diet 2. Daughter Daughter Elimination verbalized: verbalized: Mayat-maya Ganun umiihi o parinMayatnagbabawas maya naman yan..nakakatatlong ang palit ng palit nga siya ng diaper short sa isang araw Continuous Continuous

Fecal Elimination: Constipation is a common problem in elder to reduce activity levels, inadequate amounts of fluid and fiber intake and muscle weakness. Many older people believe that regularity means a bowel movement everyday. Elders should be adviced that normal patterns of elimination vary considerably. For some a normal pattern may be every other day; for others; twice a day. (Fundamental s of Nursing by Kozier) Urinary elimination: With age, the

Inappropriate for his age and to his illness

Page 8 of 37 number of functioning nephons decreases to some degree, impairing the kidneys filtering abilities; places the elder at higher risk for toxicity from medications if excretion rates are longer. Complaints of urinary urgency and urinary frequency are common. The capacity of bladder and itd ability to completely empty diminished with age. (Fundamental s of Nursing by Kozier) As age Inadequate advances, exercise muscle tone and bone density decreases, joint lose flexibility, reaction time slows, and bone mass decreases. (Fundamals of Nusing by Kozier)

3. Exercise

Daughter verbalized: Dati madalas siyang naglalakad Walking

Daughter verbalized: Hindi siya masyadong kumikilos nung 1st 3 days.. Son verbalized: kanina inalalayan ko siya mag CR Limited movements

Page 9 of 37 Can dangle feet on bed Sponge bath everyday Not too neat Unable to fix himself

4. Hygiene

Daughter verbalized: Pag nasa bahay yan gusto niya tuwing sabado lang naliligoayaw niya sa ibang araw..gusto niya pa mainit na tubig ang ang pampaligo,yung medyo maligamgam Improper hygiene is established Son verbalized: Umiinom ng alak at naninigarilyo si tatay Unhealthy

He has improper hygiene practice.

He must take a bath everyday with a luke warm water, assisted by relatives

5. Substan ce Abuse


He has unhealthy habits. He should at least gradually stop abusing such substance. The older adult sleeps about 6 hours a night. Many elders awaken more often takes them longer to go back to sleep. For men, more time is needed to achieve an erection and to ejaculate; more direct genital stimulation is required to achieve an erection; the volume of

Excessive use of vices

6. Sleep and rest

Daughter verbalized: Panay ang tulog niyan sa bahay.. Able to take rest and sleep

Enough sleep and rest but sometimes awaken to take medications or to eat. NONE

Disturbed sleeping patterns

7. Sexual Activity


No sexual activity

Page 10 of 37 ejaculated fluid decreases; and the intensity of contractions with orgasm may decrease. The retractory period after orgasm is longer. ( Fundamental s of nursing by Kozier, page 978) VIII. Physical Assessment General appearance 1. Posture and gait Relaxed, Erect posture; coordinated movement Slouched, Normal bent posture; posture due tremors to age and illness Posture becomes forward leaning and stooped, which shift the center of gravity forward. To compensate with for this shift, the knees flex slightly for support and the base of support is widened. Gait becomes wide based, short stepped and shuffling. (Fundamentals of Nursing by Kozier) Norms Actual Findings Analysis Interpretation

2. Skin color Varies from light to deep Light brown; brownNormal skin because of

Page 11 of 37 brown 3. Personal hygiene Clean; neat; no body or breath odor Not too neat; no body or breath odor Normal personal hygiene due to limited movement to be neat. And because of weakness due to CVA, he cant properly groom himself. colored macules age Flat tan to brown colored macules. (Fundamentals of Nursing by Kozier) A motor deficit is frequently seen in patients with stroke and that is the weakness of the body. (Medical Surgical Nursing by Smeltzer & Bare) Older people need fewer calories and dietary changes in view of the risk of coronary heart disease, osteoporosis, and hypertension. (Fundamentals of Nursing by Kozier) Age over 65 years and above is a risk factor for stroke (Hebert(1995) Arch Intern Med.) Stroke is the common cause

4. Nutritional status Healthy diet

1800kcal/day Appropriate , low salt, diet for his low fat diet illness and soft diet

5. Age appropriatenes s

65 and above

77 years old


6. Verbal behavior

Understandabl e, moderate pace

Slurred speech

Normal due to inserted NGT

Page 12 of 37 of aphasia or unable to form words that are understandabl e. (Medical Surgical Nursing by Smeltzer & Bare) Stroke is the common cause of aphasia or unable to form words that are understandabl e. (Medical Surgical Nursing by Smeltzer & Bare) 37 Celsius 70 (60100)bpm 16 (15-20)bpm Possible increased systolic and diastolic (Fundamentals of Nursing by Kozier) In older adults, their hair is generally thinner, grows more slowly and loses its color as a result of aging tissue. Men often lose their scalp hair and may become

7. Non verbal behavior

Cooperative; responses are appropriate

Cooperative; responses are appropriate by means of nodding

Normal because of illness and age

Measurements 1. Temperature 2. Pulse rate 3. Respiration rate 4. Blood pressure

37 Celsius 70 (60100)bpm 16 (15-20)bpm Possible increased systolic and diastolic

36.3 Celsius 76 bpm 21 bpm 150/90 mmHg

Normal Normal Increased respiration rate Normal

Body Parts 1. Head

Bristle-like hair; No tearing; sensorineural hearing loss; sense of smell diminish because of decrease number of olfactory fibers; tooth loss

Thin hair; Teary eyes; Cant hear clearly; Sense of smell diminish because of NGT; loss of tooth

Appropriate for his age

Page 13 of 37 completely bald. (Fundamentals of Nursing by Kozier) 2. Neck Coordinated movements with no discomfort Muscle weakness and tremor; Limited range of motion (upand-down nodding movement Appropriate for his age and illness A motor deficit is frequently seen in patients with stroke and that is the weakness of the body. (Medical Surgical Nursing by Smeltzer & Bare) Nails grow slowly and thicken (Fundamentals of Nursing)

3. Upper Extremities

Nails grow slowly and thicken

Thick nails and uncutted

Appropriate for his age but it must be properly cutted to promote good hygiene Normal skin because of age

Varies from light to deep brown

Light brown; browncolored macules

Flat tan to brown colored macules. (Fundamentals of Nursing by Kozier) Breathing rate are unchanged at rest (Fundamentals of Nursing by Kozier) Constipation is a common problem in elder

4. Chest and Breathing rate back are unchanged at rest

Increased respiration rate

Appropriate for his age and because of his illness Inappropriat e for the elders

5. Abdomen

Stool passes at a slower rate

Stool passes at a fast rate Inappropriat as evidenced e for his age by often urge and to his

Page 14 of 37 to defecate illness population and to patients with CVA. (Fundamentals of Nursing by Kozier) A motor deficit is frequently seen in patients with stroke and that is the weakness of the body. (Medical Surgical Nursing by Smeltzer & Bare) It may be absent in adults without pathology or overridden by voluntary control. (Fundamentals of Nursing by Kozier)

6. Lower extremities

Coordination changes

Reduced speed

Appropriate for his age and illness

It may be (-) Babinski absent in adults reflex without pathology or overridden by voluntary control.

Appropriate for his age.


Laboratory and Diagnostic Examination Results HEMATOLOGY (08-06-08)

Test Creatinine

Normal 0.6-1.2 mg/100ml

Result 125.0

Interpretation Significant increase Normal my signify chronic Page 15 of 37 glomerulonephritis, nephritis, congestive heart failure, muscle disease (Ultimate Learning Guide by Carl Balita) Signifant increase my signify an increace in intake either orally or parenterally. Normal


138-144m mEq/l





Significant decrease my signify Addisons disease, sodium-1 osing nephropathy, vomiting, diarrhea, fistulas, tube drainage, burns, renal insufficiency with acidosis, starvation with acidosis, paracentesis, ascites, CHP (Ultimate Learning Guide By Carl Balita) Significant increase Normal may signify Diabetic ketosis, renal failure, Addisons disease Significant decrease my signify Thiazide diuretics, Cushing Syndrome, Cirrhosis with ascites, hyperaldosteronism, steroid theraphy, malignant hypertension, poor dietary habits, chronic diarrhea, diaphoresis, renal tubular necrosis, malabsorption syndrome, vomotting (Ultimate

Page 16 of 37

Test RBC(Red Blood Cell)

Normal M:4.5-6.2 million/ul

Result 3.73x10 /L

Interpretation Increase: Polycythemia vera, anoxia dehydration Decrease: Leukemia, hemorrhage, lupus erythematosus (Ultimate Learning Guide by Carl Balita) Increase: Dehydration, polycythemia Decrease: Anemia, hemorrhage leukemia (Ultimate Learning Guide by Carl Balita) Same as hemoglobin (Ultimate Learning Guide by Carl Balita) Increase: Polycythemia, poatsplenectomy, anemia Decrease: Leukemia, asplastic anemia, cirrhosis, multiple myeloma (Ultimate Learning Guide by Carl Balita) Increase: Leukemia, bacterial infection, severe

Analysis Normal

Hgb (Hemoglobin)



Hct (Hematocrit)

M:0.42 52L/L


Lower than the normal range Normal


160380x10 /L

197x10 /L

WBC (White Blood Cell)



8.87x10 /L


Page 17 of 37 sepsis Decrease: Viral infection, overwhelming bacterial infection, lupus erythematosus (Ultimate Learning Guide by Carl Balita) Increase: Allergic disorder, parasitic infestation, eosinophilic leukemia Decrease: ACTH, cortisone or epinephrine; endocrine disorder (Ultimate Learning Guide by Carl Balita) Lymphocytes 0.25-0.35 0.35 Increase: Chronic lumphocytic leukemia, infectious mononucleosis, chronic bacterial infection, viral infection Decrease: Leukemia, systematic lupus, erythematosus (Ultimate Learning Guide by Carl Balita) SEROLOGY (08-06-08) Test Result Interpretation Analysis Normal





Page 18 of 37 Troponin I (-) Increase: Hyperthyroidism, thyroxine Dercrease: Hypothyroidism (Ultimate Learning Guide by Carl Balita) URINALYSIS (08-06-08) COLOR: Light yellow CHARACTERISTICS: Hazy SPECIFIC GRAVITY: 1.020 Test Albumin Sugar Pus cells RBC Epithelial Cells A. Urates/ Phosphates Bacteria Normal

Result (-) (-) 1-2/hpf 0-1/hpf Few Few Few

ARTERIAL BLOOD GAS RESULTS (08-06-08) Test Normal Result pH 7.35-7.45 7.474 pCo 35-45 92.9 pO 86-100 92.9 CO content 23-27 25.7 HCOS 22-27 24.7 O Sturation 95-100 97.5% Base excess 1-2 2.0 O2F1O2 21% ULTARSOUND (8-6-8) Roent Genograpic Report INTERPRETATION: Left ventricular cardiomegaly Atheromatous aorta Asteodegenerative change

Page 19 of 37 RESULT: No active lung infiltrate seen Pulmonary vascular markings are within normal limits Hearth is enlarge with left ventricular form Aorta is calcified Diaphragm is unremarkable Osteophytes and syndesmophytes are seen in the lateral margins of the visualized spine. Chest wall are seen ULTRASOUND (2-6-08) KUB: There are microlitiasis with in the calyceal coplex of the left kidney. The cortimedullar structures are intact bilaterally. The collection system is not dilated. R kidney:98x56x58mm L Kidney: 96:54:54mm The urinary bladder is distended with 4mm thick walls with luminal gravity dependent is sludge IMPRESSION: Microlitiasis, left kidney, non obstructing Normal right kidney Urinary bladder sludge ULTRASOUND(2-8-07) Whole Abdomen There is increase in echotexture of the left kidney with the calyces filled with granular sludge. Likewise, the urinary bladder is noted with gravity dependent sludge with smooth mucosal outlines. The right kidney is normal. R kidney 96x57x51mm CT=15mm L kIdney 101x54x52mm Ct=10mm

Page 20 of 37 The liver, spleen, pancreas conform with the standard of size, shape and echotextual. No masses noted. The gallbladder is slightly contracted with no luminal echoes. Wall is smooth The intrahepatic and extrahepatic bile ducts are not dilated There is significant gaseous distention of the upper abdomen IMPRESSION: Evidence of renal parenchyma disease, left with calyceal microlitiasis Urinary bladder sludge Rest of the abdomen are normal LABORATORY CULTURE AND SENSITIVITY TEST: Report: No significant pathogen isolated after 72 hours of incubaton X. Medication

Page 21 of 37

Generic/Trade Dosage/ Name Frequency Simvastatin 20 mg/ tab at hour sleep

Classification Lipid-regulating drug

Indication Reduction of elevated total LDL cholesterol levels in patients with hypercholesterolemia . Reduction of total mortality and coronary event rates in patients with congestive heart disease.

Contraindication Acute liver disease or unexplained persistent elevations or serum-aminotransferase concentration or to those with porphyrin. Pregnancy and lactation.


75 mg/tab 2 tabs now then 1 tab od

Anticoagulants/ Antiplatelets/ Thrombolytics

Reduction of atherosclerotic events ( MI, stroke and vascular death) in patients with atherosclerosis documented by

Hypersensitivity Severe liver impairment Active pathological bleeding

Nursing Responsibilities GI disturbances, Assess liver Headache, Skin function test rashes, prior to therapy Dizziness, and periodically Blurred vision, thereafter. Insomnia. Reversible Teach patient increases in proper use, serumpossible sideaminoferase effects, concentrations, appropriate Hepatitis, interventions Pancreatitis, and adverse Hypersensitivity symptoms to reactions, report. Myopathy. Evaluate therapeutic response and adverse reactions on a regular basis. GI bleeding, Assess for Purpura, symptoms of Bruising, stroke, MI Hematoma, during Epistaxis, treatment Hematuria, Eye bleeding, Instruct patient Side-Effects

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recent stroke. Pregnancy and lactation


to take drugs as directed by the physician


Neb every 6 hours

Respiratory drug

Chronic control of sings and symptoms of bronchial asthma. Maintenance treatment of asthma as prophylactic therapy in adult and pediatric patients.


30 cc at hour sleep

Gastrointestinal/ Constipation hepatobiliary drug Treatment of Hepatic encephalopathy

Caution patient to report diarrhea, skin rashes, subcutaneous bleeding, chills, fever, sore throat. Primary Neck pain, Monitor treatment of cough, patients status respiratory condition before asthmaticus or infection, therapy other acute rhinitis, sinusitis, reassess episodes of stridor, gastro regularly. asthma where enteritis, oral intensive candidiasis, Assist client measures are abdominal pain, during required. dry mouth, nebulization. vomiting, Hypersensitivity dyspepsia. Patients who Abdominal Assess require a low discomfort patients lactose diet. associated with condition before flatulence and therapy and Galactosemia or intestinal reassess disaccharide cramps. regularly deficiency Nausea, thereafter to

Page 23 of 37


40 mg TIV od shifted to oral

Gastric antisecretory drug

Duodenal and gastric ulcer, moderate and severe reflux esophagitis Eradication of H. pylori in patients with peptic ulcers

Intestinal obstruction. Hypersensitivity, moderate to severe hepatic or renal dysfunction

vomiting, diarrhea on prolonged use. Headache, diarrhea, edema, fever, onset of depression, blurred vision.

monitor drugs effectiveness. Instruct patient to take drug as prescribed and at approximately the same time each day. Inform patient of possible adverse effects and to report the reactions. Inform client of possible drug interactions (aspirin) that could cause gastric irritation. Assess for allergic reactions. Instruct patient to take drug with full glass of water.

Clindamycin Dalacin C

300 mg/ Anti-infectives tab 1 tab every 6 hours

Infections caused by susceptible anaerobic and gram (+) aerobic bacteria. Upper and lower RTI, skin and soft tissue and intra-abdominal

Hypersensitivity to lincomycin or clindamycin

Diarrhea occasionally with acute colitis, abdominal pain, GI upsets, Jaundice and hematopoetic

Page 24 of 37


changes. Teach patient aspects of drug therapy: entire course of medication. Assess patients blood pressure before therapy and monitor regularly. Assess for allergic reactions. Teach patient to comply with dosage schedule and not to discontinue drug even if feeling better. Teach patient proper use, possible side effects and appropriate interventions.

Perindopril Conversyl

2 mg/tab 1tab od

Cardiovascular drug

Essential hypertension. Prevention of stroke recurrence in combination with indapamide in patients with a history of cerebrovascular disease.

Children, pregnancy and lactation.

GI disorders, dizziness, headache, mood and sleep disorders, taste disorders, cramps, localized skin rashes.


600 mg/ tab 1 tab dissolves in glass of water.

Respiratory drug Mucokinetics/ expectorants

Treatment of respiratory affections characterized by thick And viscous hypersecretions.


Pyrosis, nausea,vomitin g

Page 25 of 37

Acute and chronic bronchitis.

Instruct patient to take drug as directed by the physician. Assess for signs of hypersensitivity. Instruct patient to increase fluid intake.


1 cap TID

Urinary Antiseptics Disinfectants

UTI, post op prophylaxis of calculi.

1st trimester of pregnancy.

Drowsiness, weakness, headache, vertigo, dizziness, visual Assess for disturbances signs of drug adverse reactions.

Teach patient information about the drug. Azithromycin 500 mg/ tab 1 tab on 3 days Anti-infectives Treatment of infections of the upper RTI, skin and soft tissues, and genital infections. Hypersensitivity to Azithromycin and other macrolides. Rarely, hypersensitivity reactions such as skin redness with or without Pregnancy and itching, lactation. photosensitivity, joint pains, Assess for patients history of drug (azithromycin) use. Instruct patient to take

Page 26 of 37

swelling, abdominal pains, appetite loss, nausea, vomiting, rarely diarrhea, constipation and flatulence.

medication exactly as prescribed by the physician. Teach patient information about the drug: effects, side effects, symptoms of hypersensitivity.

Page 27 of 37 XI. Pathophysiology

Cerebrovascular System

Etiology: Thrombosis Embolism Systemic hypoperfusion Venous thrombosis

Risk Factors: Hypertension Diabetes Smoking Age over 65 years High cholesterol Smoking

Molecular or cellular changes: Ischemic cascade

Gross/Anatomical Physical Changes: Motor loss Communication loss Perceptual disturbances Sensory loss Cognitive impairment Psychological effects

Clinical Manifestations improved: Ambulatory Food taken orally

Effect on bodily functions: Sudden numbness or weakness of face, arm, leg or paralysis Sudden loss of sensation Sudden confusion, trouble speaking or understanding Sudden/persistent loss of consciousness

Clinical Manifestations: Altered smell, taste and hearing Decreased reflexes, gag, swallow, Muscle weakness of the face, arms Altered breathing Trouble walking Altered movement coordination Dizziness

Cerebrovascular Accident

Page 28 of 37 XII. Ecologic Model Unhealthy lifestyle of the client along with the risk factors present around him such as family history of hypertension and diabetes, contributed to the severity of the main problem which is Cerebrovascular Accident. Therefore, the group compares his condition to a wheel ecologic model because there are several factors affecting his illness. Risk factors influence the health of the client and since there is presence of different risk factors, it is really hard to distinguish the leading cause or the main cause of Cerebrovascular accident. Moreover, lifestyle which is defined as the habits, attitudes, tastes, moral standards, economic level. Together constitute the mode of living can determine the health of an individual. Mr.X, with the influence of his parents, had a healthy lifestyle during his early age. His parents made sure that he had enough nutritious food intakes. However, when he grew up and started working in a factory, his lifestyle had changed. He started sleeping late and did not get enough period of rest. Moreover, he started smoking and drinking. Cigarette smoking on human health has serious effects which can be deadly. There are approximately 4000 chemicals in cigarettes, hundreds of which are toxic. The ingredients in cigarettes affect everything from the internal functioning of organs to the efficiency of the body's immune system. On the other hand, Steady drinking over many years leads to permanent changes in the brain. One of the permanent effects of alcohol on the brain is to reduce the amount of brain tissue and to increase the size of the ventricles instead. Another way in which alcoholic drinks affect the brain is through depriving it of food substances such as vitamins. This is because heavy drinkers often neglect their diet, which can lead to vitamin deficiencies. Thiamine, one of the 'B' vitamins is most commonly missing from the diet and can lead to serious mental disturbance. Also, because of the alcohol intake of the patient, his throat became irritated and there was a damage of lining of his esophagus and the muscles in his body became weaker.

Page 29 of 37 In addition to this, Mr.X, 76 years old, from a Filipino family with history of hypertension and diabetes mellitus which may append to the severity of the problem. Furthermore, lack of exercise can be more risky to his health since previous studies have shown that good cardiorespiratory fitness has protective effects on atherosclerotic cardiovascular diseases, including coronary heart diseases (CHDs), hypertension, and stroke. Good cardiorespiratory fitness and physical activity may reduce the risk of stroke by affecting modifiable risk factors, including hypertension, obesity, and dyslipidemia. In conclusion the group was able to prove that his illness,

Cerebrovascular Accident was caused by several factors particularly his unhealthy lifestyle. Based on the patient's biographic data . We recommend Mr. X to continue his medication as well as to have a continuous check-up as ordered by the doctor and to practice a healthy lifestyle such as exercise and proper diet. XIII. Prioritized List of Nursing Problems

DATE August 7,2008


CUES Subjective: Objective: Inability to handle utensils Inability to ingest food safely Feeds through the use of NGT Weakness in the muscles of the face Abnormal swallowing mechanisms Slurred speech

JUSTIFICATION Page 30 of 37 According to Maslows Hierarchy of Needs, in order to become a selfactualized person, the physiological needs which include hunger, thirst, bodily comforts and health must be met first. Therefore, among the problems identified from the client, Self- Care feeding deficit must be prioritized first because food and water are two essential needs to sustain life. If a person does not know how to perform feeding, then a person might be deprived of taking adequate food. Physiological Needs are to do with health maintenance of the human body. A person with ineffective tissue perfusion or a decrease in oxygen resulting in the failure to nourish the tissues at the capillary level must be given proper treatment to restore his condition into a normal level, thus providing him his bodily comfort and health needs.

Ineffective Cerebral Tissue Perfusion


Objective: Extremity weakness, paralysis Difficulty in swallowing Weak pulses

Impaired Physical Mobility

Subjective: Nakakatayo lang sya kung may nahahawakan o alalay, as verbalized by his daughter. Objective: Limited range of motion Uncoordinated or jerky movements Functional Level3 : requires help from

Limitation in independent, purposeful physical movement of the body or one or more extremities, also known as Impaired Physical Mobility is a physiological need that must be attained in order to help a person meet other basic needs. Our client who has a limited range of motion must be assisted to increase strength of affected body part to promote optimal

Page 31 of 37 XIV. Nursing Care Plan

Page 32 of 37

Nursing Problem Analysis Goal/Objectives Self-care deficit Scientific : After 2 weeks of (feeding) nursing intervention, Muscle client will be able to: Subjective: Weakness on 1. Utilize maximum face, arms and level of Objective: legs functional Inability to abilities handle Immediate 2. Maximize use of utensils cause: available Inability to ingest Stroke resources for a food safely more effective Feeds through Intermediate rehabilitation the use of cause: process NGT High blood 3. Minimize risk Weakness in the pressure and factors such as muscles of the High smoking and face cholesterol intake of salty Abnormal and fatty food swallowing Root cause: 4. Gain full support mechanisms Unhealthy from family Slurred speech lifestyle members and the rest of the health team 5. Demonstrate behavioral/lifest yle changes to improve health

Nursing Interventions 1. Determine individual strengths and potential of the client 2. Assist client with necessary adaptations to accomplish tasks 3. Discuss with support group risk factors and its possible effects 4. Encourage rest period before and after meals 5. Determine food preferences of client 6. Consult with dietician to provide healthy diet 7. Provide medications prescribed by doctor prior to feeding 8. Provide positive feedback for clients efforts

Rationale 1. To recognize ability of client to perform and participate in own care 2. To enhance capabilities and promote independence 3. Enhances supporting recovery and health promotion 4. To minimize fatigue 5. To determine the appropriate diet 6. To minimize chances of elevated blood pressure and cholesterol level 7. To enhance comfort and restore normal body process 8. To provide guidance and support

Evaluation After nursing intervention, the client was able to respond to interventions and was able to demonstrate positive behavior changes.

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Discharge Plan Medication 1. Simvastatin 20 mg/tab at hs 2. Clopidogrel 75 mg/tab, 1 tab od 3. Combivent nebq6 4. Lactulose 30cc at hs 5. Pantoprazole 40mg oral od 6. Clindamycin (Dalacin C) 300mg/tab, 1tab q6 7. Perindopril (Coversyl) 2mg/tab, 1tab od (HOLD) 8. NAC(Fluimucil) 600mg/tab, 1tab in 1/2glass of H2O 9. Rowafirex TID 10. Azithromycin 500mg/tab, 1tab on 3 days Excercise Advise client to do active range of motion exercises first so not to surprise his body. Here are some: Range of motion exercises Neck Breathe with the movements, breathing out when your head moves down, breathing in when it moves up. Don't let your shoulders or torso (upper body) sway to the side. Don't do movements that your doctors or therapists have advised against. 1. Turn your head slowly to the right, then to the left. Repeat two to four times. 2. Tilt your head toward one shoulder, then toward the other shoulder. Repeat two to four times.

Page 34 of 37 Arms 1. Sit upright, arms supported on your lap, palms upward. Bend your fingers inward towards your palm, then unbend. 2. Next, as your fingers bend inward, flex your wrist. Keep fingers relaxed. Do not clench fist. 3. Bend your arm at the elbow, bringing fingertips towards shoulder. Keep fingers relaxed. Do not clench fist. 4. Maintaining this position, bring elbow up and then draw imaginary circles in space with your elbow. 5. Now unfold your arm at the elbow and reach towards the ceiling. 6. Slowly fold your arm down to rest your hand in your lap as in the initial position. Repeat two times, unfolding to shoulder, reaching to ceiling, returning to lap. Fingers

Massage each hand, one at a time. Take your time; go in between each finger. Enjoy this one! Open and close fingers slowly.

Chest and torso

Sit in a chair. With hands on your waist, tilt to the right, return to center, then tilt to the left and return to center. Exhale as the movement goes down; inhale as the movement comes up. Don't allow your torso (upper body) to tilt forward. Don't try to hold your head up; instead, let it relax to the side.


Rock and roll: Sit straight in your chair with your hands on your hips. Gently rock your hips from side to side.

Page 35 of 37 When client has no feeling of discomfort with the following exercise, try to give him muscle strengthening activities like walking about 5 to 10 minutes or jog in place. Advise family to support client in doing these activities to allow fast recovery. Treatments If client can't speak refer them to get him a speech and language therapy to help client relearn language skills and also help if client have problems with swallowing. Physical therapists work on problems with movement, balance, and coordination. Occupational therapists help you practice eating, bathing, dressing, and writing, and other daily tasks. A recreational therapist to help client return to activities that he enjoyed before the stroke. A psychologists or counselor to help him deal with such emotions. Other health professionals, such as a dietitian help you plan a healthy diet. Health Teaching Teach client about the risk factors that he can control like high blood pressure and cholesterol, physical inability, obesity, smoking and drinking liquors. Ask the client to monitor vital signs specially blood pressure. Teach client about preventive measures like regular check up and screenings, exercise, healthy diet, maintaining healthy weight, decreasing stress level and no smoking and drinking. Follow up After 1 week. Diet Advise client to eat: Healthy Fats (raw nuts, olive oil, fish oils, flax seeds, avocados)

Page 36 of 37 Colorful, nutrient-loaded fruits and vegetables Fiber rich foods (whole grains and legumes)It binds cholesterol, enabling the body to remove it. Fish (especially tilapia, catfish). Cold water fish like wild salmon, herring, mackerel and sardines are a great sources of omega-3 fat, to reduce the risk of stroke again. If client is unable to eat seafood, advise him to try to consume more soybean products (like tofu), canola oil, walnut and flaxseed, which contain alpha-linolenic acid (LNA), because it can turn into omega-3 fatty acid after it is digested. Advice client to decrease consume of these foods or refrain from eating: Damaged fats (Trans fats from partially hydrogenated foods, deep fried foods); Saturated fats (whole-fat dairy; red meat). Processed food (foods that come in a package); foods high in sodium Red meat Fruit juices, soda High glycemic refined carbs. It causes the body to overproduce cholesterol and raises the bodys insulin level. High insulin levels are a big risk in heart disease. Sex Advise client not to engage or refrain from sexual activity. with the

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Bibliography Books Doenges, M, Moorhouse, MF, Murr, A: Nurses Pocker Guide, Edition 11. F.A. Davis, Philadelphia, 2008. Kozier, B. et al: Fundamentals of Nursing 7th Edition. Pearson Education South Asia Pte Ltd. 2004 Smeltzer & Bare: Brunner &Suddarths Textbook of Medical-Surgical Nursing, 10th Edition. Lippincott Williams &Wilkins, 2004 Internet http://www.medicinenet.com http://stroke.ahajournals.org/cgi/content/full/36/4/820 http://www.salagram.net/AlcoholEffects.htm


= = = = = = = = = = =

70/F inch/ lb. /mmhg 73/MIN (O.818S) *S 0.092S -25DEG 0.392S/0.432 0.47Sv 0.60Sv unconfirmed