LICEO DE CAGAYAN UNIVERSITY COLLEGE OF NURSING

RN Pelaez Blvd., Kauswagan Cagayan de Oro City

In Partial Fulfillment for the Requirements in NCM104 Related Learning Experience

Cerebrovascular Disease
Submitted by:

A Care Study on:

Bali-os, Apple Rose L. Go, Leona Camille P. Maceda, Jessa T. Mutilan, Princess Nirmen Roa, Mae Ann L. Salcedo, Justine Ann R.

Submitted to:

Mrs. Ma. Dolores D. Mercado, RN, MN, MAN

TABLE OF CONTENTS

I.Introduction a.Overview of the Case b.Objective of the Study c.Scope and Limitation of the Study II.Health History a.Profile of Patient b.Family and Personal Health History c.Chief Complaint & History of Present Illness III.Developmental Data IV.Medical Management a.Medical Orders and Rationale b.Laboratory Results c.Drug Study V.Pathophysiology with Anatomy and Physiology VI.Nursing Assessment (System Review & Nursing Assessment II) VII.Nursing Management a.Ideal Nursing Management (NCP) b.Actual Nursing Management (SOAPIE) VIII.Referrals and Follow-up

IX.Evaluation and Implications X.Documentation a. Documentation of evidence of care for 1 week rotation b. Organization/ Grammar/ Bibliography I. INTRODUCTION

Being a nursing student, it is our duty to provide quality of care to our patient and to be able to learn new something that can improve or enhance our skill in different situation. It was our 1st and 2nd day duty at Cagayan de Oro Medical Center, which we were assigned in Medical Ward. We look forward for a diagnosis that would relate to our concept this term which is Neural Disturbances. Cerebrovascular disease is a group of brain dysfunctions related to disease of the blood vessels supplying the brain. Hypertension is the most important cause.

Cerebrovascular disease includes all disorders in which an area of the brain is temporarily or permanently affected by bleeding or lack of blood flow. Cerebrovascular diseases included stroke, carotid stenosis, vertebral stenosis and intracranial stenosis, aneurysms and vascular malformations. Restrictions in blood flow may occur from vessel narrowing (stenosis), clot formation (thrombosis), blockage (embolism), or blood vessel rupture (hemorrhage). Lack of sufficient blood flow (ischemia) affects brain tissue and may cause stroke. Stroke is the third leading cause of brain death. Each year, an estimated 30,000 people in the Philippines experience a ruptured cerebral aneurysm and as many as 6 percent may have an unruptured aneurysm.

a. Overview of the Case This care study presents a condition of a patient in Medical Ward of Cagayan de

Oro Medical Center, having a diagnosis of Cerebrovascular Disease Thrombotic: Cerebral Aneurism with a chief complaint of behavioral changes.

b. Objective of the Study This study aims to allow the authors to apply the different concepts, practices and principles of family health care process and to apply the nursing process in the promotion and prevention of health in a hospital setting. It also aims in rendering care and reaching out patient in a hospital based to answer their problems and needs in a best way to alleviate health promotion and prevention which is necessary in comprehensively assessing the patient's health status and condition. It also focuses on the following aims: to establish rapport with the patient and their significant persons to gain cooperation and trust. Gather systematically the pertinent information in relation to their health condition and other significant matters. to conduct a thorough assessment of the patient in order to formulate appropriate nursing care plan based on accurate and complete data; to formulate nursing diagnosis, develop outcomes and plan nursing care with specific goals for a patient with Chronic Kidney Disease. to generate and implement nursing care and evaluate outcomes for effectiveness and achievement of care. to impart health teachings about necessary information pertaining to the disease condition. to evaluate changes in condition after giving interventions. to add up additional knowledge and understanding in the nursing profession.

c. Scope and Limitation of the Study

The extent of the study includes the overall data gathered during the interview and observation as manifested by the patient and his complaints. It also deals with the several factors observed during the assessment within the span of time given. The information gathered was based on the manifestations observed and complaints of the patient. Interventions were rendered gradually depending on the objective assessment of the student. The following information only involves the exact words and answers supported by the patient. The limitation of the study includes the place of interaction itself which was in Cgaayn de Oro Medical Center, Medical Ward. The study was actual hands-on exposure and interaction with the patient during the two (2) days clinical duty.

II. Health History (EDIT) II. HEALTH HISTORY A. Profile of the Patient Name: Age: Sex: Birth date: Religion: Civil Status: Nationality: Occupation: Abanil, Jinggoy 52 years old Male July 4, 1957 Roman Catholic Married Filipino Involved in Media

Address:

Balingasag

Date of Admission: Time of Admission: Admitting Physician:

June 16, 2009 7:00 a.m Dr. Gamolo

Vital Signs Assessment Temperature: Pulse Rate: Respiratory Rate: Blood Pressure: Height: Weight: Allergy: 36.1C 79 bpm 16 cpm 130/80 mmHg 57 87 kg No know food allergy

B. Family History and Personal Health History The Corporal family resides in Olingani Dipolog City Mr. and Mrs. Corporal have twin child. The couples income is approximately P40,000 thousand up per month. The patient has a hereditary disease of diabetes. The patient also known allergy in anti- biotic drug.

C. History of Present Illness Morning prior to admission while travelling on his way to dipolog noted dizziness with graded shortness of breath with increasing severity, he brought to PMP where

Endotrachial tube intubations was done in 1 hour after patient did self extubation. Patients then advised for related to hemodialysis thus transferred here to the procedure. D. Chief Complaint A case of Corporal, Edwin, fifty two years old, male, from Olingani, Diplolog City, was admitted for the first time at Polymedic General Hospital last June 16, 2009 due to dizziness and shortness of breath.

III. DEVELOPMENTAL DATA Sigmund Freuds Psychosexual Theory of Development

Sigmund Freud introduced the theory of psychosexual development in which the personality develops in five overlapping stages from birth to adulthood. He proposes that the underlying motivation to human development is an energy form or life instinct, which he calls libido. The libido changes its location of emphasis within the body from one stage to another. Therefore, a particular body are has special significance to a client at a particular stage. Freud has five developmental stages, but on the case of our patient, he belongs to the fifth and last step of Freuds Stages of Development which is Genital, from 13 years old and onwards. This step is characterized as the energy is directed toward attaining a mature sexual relationship. This stage involves a reactivation of the pre-genital impulses. These impulses are usually displaced, and the individual passes to the genital stage of maturity. An inability to resolve conflicts can result in sexual problems, such as frigidity, impotence, and

the inability to have a satisfactory sexual relationship. The patient lived with his wife and his children. He lives independently away from his parents and can decide independently on his own.

Erik Eriksons Psychosocial Theory of Development

Erik H. Erikson adapts and expands Freuds theory of development to include the entire life span, believing that people continue to develop throughout life. He describes eight stages of development. In contrast to Freud, Erikson believes the ego to be the conscious core of the personality. Erikson envisions life as a sequence of levels of achievement. Each stage signals a task that must be achieved. The resolution of the task can be complete, partial, or unsuccessful. Erikson believes that the greater the task achievement, the healthier the personality of the person; failure to achieve a task influences the persons ability to achieve the next task. These development tasks can be viewed as a series of crises, and successful resolution of these crises is supportive to the persons ego. Failure to resolve the crises is damaging to the ego. After attaining one stage, the person may fall back and need to approach it again. Eriksons created ten stages of development in which the patient belongs to the 9th stage, which is Late Adulthood, from 60 to 75 years old, Integrity vs. Despair. The patient has a sense of fulfillment about life and a sense of unity with self and others.

Robert Havighursts Developmental Task Theory

Robert Havighurst believes that learning is basic to life and that people continue to learn throughout life. He describes growth and development as occurring during six stages, each associated with from six to ten tasks to be learned. Havighurst believes that once a person learns to talk, it is mastered for life. Havighurst promoted the concept of developmental tasks in the 1950s. A developmental task is a task which arises at or about a certain period in the life of an individual, successful achievement of which leads to his happiness and to success with later tasks, while failure leads to unhappiness in the individual, disapproval by society, and difficulty with later tasks. Havighurst has six stages of developmental task in which the patient belongs to the sixth stage, which is Late Maturity. The tasks for this stage was achieved by the patient in which the patient is a very responsible parent and happily married with his wife who helped him went through many obstacles in his life.