ST.

PAUL UNIVERSITY MANILA

St. Paul University System

College of Nursing and Allied Health Sciences

NURSING CARE STUDY

(Application of Nursing Process)

I. ASSESSMENT
A. General Information
Client’s initials: T.D.L. Rm/Wd: FMW d Date Admitted: July 6,2010
Age: 5 3y/o Sex Female CS Widowed Nat Filipino Rel Roman Catholic
Educ. Attainment: Gradeschool graduate Occupation: food vendor d
Admission complaint/s Loss of balance, vomiting, non-communicative, facial asymmetry
Admission diagnosis CVA d
Admitting VS: T P __79 dBeats/min R 26 Breaths/min
Breaths/min: BP 180/150 mmHgdd

B. Nursing History (Based on the Functional Health Pattern by Gordon)

1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN
1.1 Client’s description of her/his health:
Before Admission:
“Okay naman sya. Araw-araw sya nagtitinda. Sigla-sigla pa nga nyan eh,”
as verbalized by the client’s significant other.

At present:
At present, the client feels weak and always sleepy. He is very warm to
touch and has an elevated blood pressure.

1.2 Health Management:

Self: The client usually eats fish and avoids eating fatty foods.

1.3 History of present illness

“Mataas na talaga BP nyan dati pa kaso lang ayaw nya uminom ng gamot.
Takot,” as verbalized by the client’s significant other.

1.4 Past illnesses:

The client’s past illnesses is hyperternsion.

1.5 History of hospitalization (when, where and why):

“Ngayon lang yan naospital takot nga kasi yan magpacheck-up. Sa clinic
ko lang yan dinadala,” as verbalized by the client’s significant other.

1.6 History of illness in the family:

“Yung papa ko mataas din BP. Yung kapatid kong namatay may asthma,”
as verbalized by the son.

1.7 Expectations of hospitalization:

The client’s son expects that her mother will be cured and will feel better
after the hospitalization.

1.8 Anticipation of problem with caring, for self upon discharge:

“Hindi ko na alam kung sino ang mag-aalaga sa kanya pag-uwi. Baka
yung mga anak na nya muna kasi nakaratay din ang anak ko. Kaso ang
problema hindi mababait ang anak nya,” as verbalized by the client’s
significant other.
1.9 Knowledge
The client has no knowledge of the importance of the treatments
prescribed to her before. She only knew the importance of it when she was
admitted to OSMUN.

2. NUTRITION AND METABOLIC PATTERN

2.1 Usual food intake (before admission)

Breakfast
Before her admission, the client usually eats binatog for her
breakfast.

During admission, the client eats foods that are low in fat and salt
and high in fiber.

Lunch
Before admission, the client’s usual intake is 1 cup of rice and a
viand which is usually fish.

During admission, the client eats foods that are low in fat and salt
and high in fiber.

Supper
Before admission, the client’s usual intake is 1 cup of rice and a
viand which is usually fish.

During admission, the client eats foods that are low in fat and salt
and high in fiber.

Snacks
Before admission, the client’s snack is usually binatog.

During admission, the client does not have snacks.

Preferences
The client’s favorite foods are binatog and fish.

2.2 Usual fluid intake (type, amounts)

The client’s usual fluid intake is 8-10 glasses of water in one day.

2.3 Any food restrictions:

The client cannot eat fatty foods because of her hypertension.

2.4 Any problems with ability to eat:

The client has no problems with regards to ability in eating.

2.5 Any supplements (vitamins, feedings)

The client does not have any supplements.

3. ELIMINATION PATTERN
3.1 Bladder:

Usual frequency/day: Color: Yellow

The client usually urinates four to five times a day

Complaints on the usual pattern of urination:

The client has no complaints on the usual pattern of urination.

Home remedies:
There are no home remedies used.
 3.2 Bowel:
Usual pattern/day (time, frequency, color and consistency)
The client’s usual excretes once a day. Color is brown.
Consistency is not that hard and not that watery.

Complaints of usual pattern of bowel movement

There are no complaints on the usual pattern of bowel movement.

Home remedies:
There are no home remedies used.

3.3 Any assertive device:

There are no assertive devices used by the client.

3.4 Skin: (condition)

The client’s skin is uniform in color and slightly dry.

4. ACTIVITY EXERCISE PATTERN

4.1 Usual daily/weekly activities

The client considers her job (food vendor) as her daily exercise.

4.2 Any limitations of physical activity

The client has no limitations in any physical activity that she does.

4.3 History of dyspnea or fatigue

There is no history of dyspnea.

5. SLEEP-REST PATTERN

5.1 Usual sleep pattern: Hours slept

The client usually sleeps once a day 7 hours

No. of pillows Sleep routines

2 pillows changes clothes, brushes her
teeth, prays in front of the
altar before sleeping

5.2 Any problems regarding sleeping

The client does not have any problems regarding sleeping.

5.3 Usual remedies:

There are no remedies used.

6. COGNITIVE-PERCEPTUAL PATTERN

6.1 Any deficits in sensory perception (hearing, sight, touch)

The client does not have any deficits in sensory perception.

6.2 Ability to read and write. Any difficulty in learning?

The client can read and write but has difficulty in understanding
English.

6.3 Any complaints? (e.g. pain)

There are no complaints.

7. SELF-PERCEPTION PATTERN
 7.1 What the client is most concerned about
The client is concerned about being discharged and is looking
forward to go home.

7.2 Present health goals

The client strives and participates well in her therapeutic regimen
for her recovery.

7.3 Effect of present illness to self:

The effect of present illness to the client is difficulty in speaking
and verbalization. She also experience right-sided body weakness.

8. ROLE-RELATIONSHIP PATTERN

8.1 Language spoken

The client speaks Tagalog.

8.2 Manner of Speaking

The client speaks in a very soft voice. During hospitalization, the
client still speaks softly but verbalizes incomprehensible sounds.

8.3 Significant person to client

For the client, the significant person is her live-in partner and her
son.

8.4 Complaints regarding family

There financial problems within the family. Also, some of her
children do not respect her.

8.5 Living with (members of family)

The client is living with her significant person.

9. SEXUALITY-SEXUAL FUNCTION

9.1 Anticipated change in sexual relations because of illness

Before and during hospitalization, the client and her significant
person is not interested in sexual activities due to old age.

9.2 Knowledge of sexual functioning

The client cannot verbalize her answer clearly.

10. COPING-STRESS MANAGEMENT PATTERN

10.1 Decision making ability

The client was able to make independent decisions.

10.2 Any significant stress in the past year

Her stress comes from improper treatment of her children towards
her.

10.3 Management of stress

She verbalizes her problems to her significant person.

10.4 Expectations from nurses to provide comfort and security during

hospitalization
The client cannot verbalize her thought about this.

11. VALUE BELIEF SYSTEM

11.1 Source of strength or meaning:

 The client source of strength or meaning is God and his significant
person.

11.2 Importance of God to client:

According to the client’s significant person, God is important
because He is always merciful to His people.

11.3 Religious practices (type and frequency):

“Nagsisimba siya minsan. Gabi-gabi nagdadasal kami sa harap n
gaming altar,” as verbalized by the client’s significant person.

11.4 Request for religious person/practice

The client did not have any request.

12. DEVELOPMENTAL TASKS (Assess for achievement of developmental

tasks)

Sigmund Freud’s Five stages of Psychosexual Development

The client falls under the Genital Stage of Freud’s Psychosexual Theory. This is the last
stage on Freud’s psychosexual development. On this stage, the person’s main focus of energy is
towards full sexual maturity and maturity in a holistic aspect. She should have manifested sexual
maturity development and established a satisfactory relationship with her partner. The client had
achieved this stage for she had her children raised and already finished studying. Although, there
are some problems when it comes to their relationship, as a woman, she had achieved fullness
and contentment to life.

Erik Erickson’s Eight stages of Development

The client is already on early fifties and she falls under the category of Ego Integrity
versus Despair. This is the last stage on Erikson’s theory wherein the client, evaluates the things
she had done along the course of her life. This is one of the most crucial phases for a patient to
prepare him or herself towards the end. It is the make or break phase wherein, the patient may
realize or not if she had achieved to leave a legacy. In the case of T.D.L., she sees herself as
struggling to achieve that legacy by closing the gap she has with her family and recovering from
her present illness. It can also be noted that the client has a strong sense of determination in
recovering as evidenced by cooperation to therapeutic regimen and optimism through facial
expressions such as smiling and often verbalization of thoughts even though words are
sometimes incomprehensible.

Jean Piaget’s Phases of Cognitive development

T.D.L is under the Formal Operational Thought phase, wherein she was able to deal with
her past, present and future in a way she experienced things. Her achievement in finishing a
primary form of education, would equip her only the basic of abilities to deal with problems to
be encountered in her aging life. But surprisingly, she even managed to have a food business
wherein she used her common sense, firsthand experience and own unorthodox strategies to
develop it and make it prosper.

Kohlberg’s Stages of Moral Development

T.D.L. falls under the category of Post Conventional Level III and Stage 6 of Universal
Ethical Principle Orientation. Upon this stage, the patient will be able to abide and follow the
rules of the society not by means of forceful imposition but because of the self-want to have a
harmonious relationship with everyone and self.
II. PHYSICAL ASSESSMENT

General Survey

The client was conscious, drowsy and has right side body weakness,
looks pale, good skin turgor, and minimal conversant.

The client’s vital signs are as follows:

T- 36.2oC
RR- 20 Breaths/min
PR- 88 Beats/min
BP- 140/90
Body Parts Method of IPPA Normal Actual Findings
Assessment Findings
Skin Inspection Inspect skin Varies from light Skin tone was
color. to deep brown; fair in color.
from ruddy pink
to light pink; from
yellow overtones
to olive

Inspect uniform except in No hyper

uniformity of areas exposed pigmentation or
skin color. to the sun; areas hypo
of lighter pigmentation
pigmentation present. Skin
(palms, lips, nail color is uniform
beds) in dark- except in areas
skinned people exposed to the
sun.

Assess No edema There was

edema, if presence of
present. edema in the
right arm.

Inspect and no other lesions There was

palpate skin presence of
lesions lesions in the
right gluteal area

Palpate skin Uniform; Not Temperature

temperature. within normal was within
range normal range.

Note skin When pinched, Skin back to

turgor (fullness skin springs previous state
or elasticity) by back to previous when pinched.
lifting and state
pinching the
skin on an
extremity.

Hair Inspection, Inspect the There was an

Palpation evenness of Equally equal hair
growth over distributed hair distribution.
the scalp.

Nail Inspection Inspect Nails had

fingernail plate Convex convex
shape curvature; angle curvature when
of nail plate inspected.
about 160o

Inspect There was

fingernail and Smooth texture thickness in the
toenail texture fingernails and
toenails.

Inspect Fingernails and

fingernail and Highly vascular toenails had pink
toenail bed and pink in light- in color and
color skinned clients; normal.
dark-skinned
clients may have
brown or black
pigmentation in
longitudinal
streaks
Perform blanch Capillary refill
Summary of the abnormal findings

1. (+) Edema on right legs

2. (+) Bruises on right gluteal area
3. (+) tear on left ear
4. (-) constriction of right eye
5. Weak right side extension
6. Impaired verbal response

III. Laboratory Findings

Normal
Date Laboratory Results Interpretation
Values

Hematology HgB: 129 125-160 g/L NORMAL

Hct: 0.39 0.38 -0.50% NORMAL

INCREASED

White blood cell is increased

WBC : 10.13 5-10^9/L indicating an infection. Bacterial
infection may trigger the immune
system to produce more WBC to
defend the body against the
bacteria.
JULY 2, 2010

INCREASED

Neutrophile: Increased number of neutrophils is a

0.40-0.60%
0.76 necessary reaction by the body, as it
tries to heal or ward off an invading
infection or foreign substance.

Eosinophile:0.01 0.01-0.06% NORMAL

Basophile: 0 0.00-0.01% NORMAL

DECREASED
The Lymhpocytes are decreased
Lymphocyte: which indicates body does not have
0.20-0.40%
0.17 enough capacity to overcome an
infection. The body could not resist
much infection.
2,2010

Monocyte:0.06 0.02-0.08% NORMAL

JULY
 DECREASED
A decreased number of RBCs
results from either acute or chronic
blood loss. Acute blood loss is a
RBC : 4.33 4.5-5.5 10^4/L
rapid depletion of blood volume.
Chronic blood loss stems from
various conditions that often results
in some form of an anemia.
150-350
Platelet :165 NORMAL
10^9/L
MCV : 90 86-100 fL NORMAL
MCH : 29.8 26- 31pg NORMAL
MPV : 11.50 9-13 fL NORMAL
Significance:
Hematology tests determine whether specific blood levels are higher or lower than
normal and can be useful in the diagnosis of diseases such as anemia, leukemia, and
infection.

Nursing Responsibilities:

Before the Procedure:

1. Explain purpose and procedure to the patient and her relatives.
2. Inform the patient that a blood sample will be taken from her
3. Inform the patient that about 5 ml of blood would be taken from the patient
4. Tell the patient that there would be a little discomfort during the procedure.
5. Observe site for bleeding.
6. There is no food or fluid restriction

After the Procedure:

1. Observe for pallor, cyanosis and coolness of extremity. These signs may indicate
compromised circulation.
2. Encourage to increase oral fluid intake to promote venous return and ensure
sufficient urine production.
3. Monitor patient’s laboratory results of CBC.
4. Watch the patient for signs of difficulty of breathing.
5. Keep the patient at rest to avoid further oxygen consumption
6. Watch the patient for any signs of bleeding
7. Administer medications such as Vitamin C to prevent further blood vessel injury
which causes the increase in neutrophils.
8. Hydrate the patient by monitoring IV fluids accurately.

JULY 2, Capillary Blood

115 mg/dl 80-120 mg/dL NORMAL
2010 Glucose

Significance:
Capillary Blood Glucose test is used as a monitoring tool giving a guide to blood glucose
levels. It is useful in diagnosing diabetes in a client

Nursing Responsibilities:
1. Explain purpose and procedure to the patient and her relatives.
2. Inform the patient that a blood sample will be taken from her.
3. Instruct the client not to eat prior to the CBG monitoring.

CT SCAN
Remarks:
Acute parenchymal hemorrhage, left lenticulocapsular area wiht mild subfalcine herniation
frontal sinusitis
 Nursing Intervention:
1. Remove metallic objects from hair.
2. Asses for claustrophobia.
3. NPO 4-6 hours if contrast medium is used.
4. Observe for allergic reaction to iodinated contrast material.

IV. Data From Textbook

Cerebrovascular Accident or Stroke

A stroke is the rapidly developing loss of brain function due to disturbance in theblood supply to
the brain. This can be due to ischemia (lack of blood flow) caused by blockage
(thrombosis or arterial embolism) or due to ahemorrhage (leakage of blood). As a result, the
affected area of the brain is unable to function, leading to inability to move one or more limbs on
one side of the body, inability to understand or formulate speech, or inability to see one side of
the visual field.

A stroke is a medical emergency and can cause permanent neurological damage, complications,
and death. It is the leading cause of adult disability in the United States and Europe and it is the
number two cause of death worldwide. Risk factors for stroke include advanced
age,hypertension (high blood pressure), previous stroke or transient ischemic
attack (TIA), diabetes, high cholesterol, cigarette smoking andatrial fibrillation. High blood
pressure is the most important modifiable risk factor of stroke.

Intracerebral hemorrhage
Intracerebral hemorrhage usually results from rupture of an arteriosclerotic small artery that has
been weakened, primarily by chronic arterial hypertension. Such hemorrhages are usually large,
single, and catastrophic. Use of cocaine or, occasionally, other sympathomimetic drugs can cause
transient severe hypertension leading to hemorrhage. Less often, intracerebral hemorrhage results
from congenital aneurysm, arteriovenous or other vascular malformation, trauma, mycotic
aneurysm, brain infarct , primary or metastatic brain tumor, excessive anticoagulation, blood
dyscrasia, or a bleeding or vasculitic disorder.

Blood from an intracerebral hemorrhage accumulates as a mass that can dissect through and
compress adjacent brain tissues, causing neuronal dysfunction. Large hematomas increase
intracranial pressure. Pressure from supratentorial hematomas and the accompanying edema may
cause transtentorial brain herniation, compressing the brain stem and often causing secondary
hemorrhages in the midbrain and pons. If the hemorrhage ruptures into the ventricular system
(intraventricular hemorrhage), blood may cause acute hydrocephalus. Cerebellar hematomas can
expand to block the 4th ventricle, also causing acute hydrocephalus, or they can dissect into the
brain stem. Cerebellar hematomas that are > 3 cm in diameter may cause midline shift or
herniation. Herniation, midbrain or pontine hemorrhage, intraventricular hemorrhage, acute
hydrocephalus, or dissection into the brain stem can impair consciousness and cause coma and
death.

Diagnostic tests help doctors determine the source and location of the bleeding.

Computed Tomography Angiography (CTA) scan is a noninvasive X-ray to review the

anatomical structures within the brain to see if there is any blood in the brain. A newer
technology called CT angiography involves the injection of contrast into the blood stream to
view arteries of the brain.
Angiogram is an invasive procedure, where a catheter is inserted into an artery and passed
through the blood vessels to the brain. Once the catheter is in place, a contrast dye is injected into
the bloodstream and X-ray images are taken.

Magnetic resonance imaging (MRI) scan is a noninvasive test, which uses a magnetic field and
radio-frequency waves to give a detailed view of the soft tissues of your brain. An MRA
(Magnetic Resonance Angiogram) is the same non-invasive study, except it is also an
angiogram, which means it examines the blood vessels as well as the structures of the brain.

Blood pressure

- Is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of
the principal vital signs. During each heartbeat, BP varies between a maximum (systolic)
and a minimum (diastolic) pressure.[1] The mean BP, due to pumping by the heart and
resistance to flow in blood vessels, decreases as the circulating blood moves away from
the heart through arteries. Blood pressure drops most rapidly along the small arteries
and arterioles, and continues to decrease as the blood moves through the capillaries and
back to the heart through veins. Gravity, valves in veins, and pumping from contraction
of skeletal muscles, are some other influences on BP at various places in the body.
There are many physical factors that influence arterial pressure. Each of these may in turn be
influenced by physiological factors, such as diet, exercise, disease, drugs or
alcohol,stress, obesity, and so-forth.

Some physical factors are:

 Rate of pumping. In the circulatory system, this rate is called heart rate, the rate at which
blood is pumped by the heart. The volume of blood flow from the heart is called the cardiac
output which is the heart rate multiplied by the stroke volume. The higher the heart rate, the
higher the arterial pressure, assuming no reduction in stroke volume.
 Volume of fluid or blood volume, the amount of blood that is present in the body. The
more blood present in the body, the higher the rate of blood return to the heart and the
resulting cardiac output. There is some relationship between dietary salt intake and increased
blood volume, potentially resulting in higher arterial pressure, though this varies with the
individual and is highly dependent on autonomic nervous system response and the renin-
angiotensin system.
 Resistance. In the circulatory system, this is the resistance of the blood vessels. The
higher the resistance, the higher the arterial pressure upstream from the resistance to blood
flow. Resistance is related to vessel radius (the larger the radius, the lower the resistance),
vessel length (the longer the vessel, the higher the resistance), as well as the smoothness of
the blood vessel walls.
 Viscosity, or thickness of the fluid. If the blood gets thicker, the result is an increase in
arterial pressure. Certain medical conditions can change the viscosity of the blood.

Intracerebral hemorrhage
Signs and Symptoms Significance
headache  Due to increased intracranial
pressure
loss of consciousness 
nausea, vomiting  May be a side effects of a drug
and due to increase
intracranial pressure
delirium
focal seizures  Due to sudden, abnormal
electrical activity in the brain
difficulty in speaking  The frontal lobe may be
affected and it is where the
Broca’s area is located
lethargy or confusion  The frontal lobe may be
affected or damaged; result
from a sudden brain
dysfunction

CVA
Signs and Symptoms Significance
hemi paresis (right side)  A disturbance of voluntary
motor control on the right side
of the body reflected the
damage on the left side of the
brain.
headache  Due to increased intracranial
pressure
Flaccid paralysis
loss of consciousness  Due to loss of blood flow or
lack of oxygen to the brain
facial drooping 
Affectation on cranial nerve
VII; loss of voluntary muscle
movement on the face

slurred speech  The frontal lobe may be

affected and it is where the
Broca’s area is located
aphasia or dysarthria  The frontal lobe may be
affected or damaged
confusion  The frontal lobe may be
affected or damaged; result
from a sudden brain
dysfunction
blurred vision  Cranial nerve II was affected
which is the optic nerve
impaired swallowing.  The movement of the tongue is
facilitated by the hypoglossal
which is cranial nerve XII
Nausea and vomiting  May be a side effect of the
medications taken by the
patient and due to increase
intracranial pressure
Forgetfulness and limited  The frontal lobe may be
attention span affected or damaged
Transient urinary incontinence  The client does not have the
urge to void

PREDISPOSING
FACTORS:
PRECIPITATING Stress
FACTORS:
Age Hypertension

Race Lifestyle

Obesity

Chronic Hypertension

Increase blood flow in the brain

V. PATHOLOGY AND PHYSIOLOGY:
Changes in blood vessel diameter
INTRACEREBRAL HEMORRHAGE

Abnormal cerebral perfusion pressure

Compromised integrity of the arterioles

Weakened arterial walls

Formation of Chalchot-Bouchard
aneurysm

Rupture of anterior cerebral artery

Blood accumulation from ruptured anterior cerebral

artery

Edema and hematoma formation

 A

Compression of adjacent Presence of free blood in

brain tissues interstitial area

Increase in Intracranial
Pressure
B
Cell membrane
destruction
Decrease oxygenation in the brain
Electrolyte
Altered function of brain imbalance
arteries
Low
Potassium
level
Middle and Vertero-basilar
anterior cerebral system
cortex (Cerebellum) Thrombus
(Frontal, Parietal formation
and Temporal
lobe)
Loss of hearing

Right
hemiparesis,
facial
asymmetry,
global aphasia
VI. Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Hyperthermia related to Goal: Independent: Independent: Goal not met. After 8
“Parang mainit sya exposure to hot After 8 hours of hours of nursing
paghinawakan.” As environment as nursing intervention, 1. Provide well 1.To help in heat intervention, the
verbalized by client’s manifested by increase the patient will have a ventilated loss by convection patient’s body
son. in body temperature of normal body environment by and promote temperature decreases
38.30C and warm to temperature ranges opening the windows relaxation from 38.30C-37.90C.
touch. from 36.4-37.4 0C and and electric fan
cool to touch.
2. Assist client to
change into loose 2.To help in heat
Objectives: clothing loss by radiation and
Objective: After 4 hours of conduction and After 4 hours of nursing
nursing intervention the promote comfort intervention the patient
 Increase in body patient will be able to: 3. Perform tepid has:
temperature-  Maintain core sponge bath 3.To help in heat  decreased body
38.30C temperature within loss by evaporation core temperature
 Warm to touch normal range 4. Encourage to and conduction from 38.30C-
 Flushed skin (36.4-37.4 0C) increase oral fluid 4.To prevent 37.90C
 Not warm to intake dehydration by  still warm to
touch replacing the loss touch
water while the body
is compensating

5. Provide time for 5.To promote

rest and sleep comfort

Dependent: Dependent:
1. Administer 1.Decreases fever by
antipyretics as inhibiting the effects
ordered of pyrogens in the
Paracetamol hypothalamic heat
500mg/tab i tab for regulating centers
temp. > 37.8 q4 and by a
hypothalamic action
leading to sweating
and vasodilation.
 Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Risk for aspiration Goal: Independent: Independent: Goal met. After 8 hours
“hirap nga sya related to decreased After 8 hours of of nursing intervention,
makalunok kaya gag reflex secondary to nursing intervention, 1. Assess client’s ability 1. Helps to determine the patient is free from
malalambot na pagkain cerebrovascular the patient will be free to swallow and the effectiveness of aspiration.
ang binibigay naming.” accident as manifested from aspiration. strength of gag reflex protective
As verbalized by client’s by difficulty swallowing. mechanisms
son.
Objectives: 2. Elevate client to 2. To facilitate the
After 4 hours of highest or best entry of the food into
nursing intervention the possible position for gastrointestinal tract After 4 hours of nursing
Objective: patient will be able to: eating and drinking intervention the patient
 experience no 3. To aid swallowing has:
 decreased gag aspiration 3. Provide soft diet with effort  Experience no
reflex  cooperate in low salt, low fat and aspiration
 difficulty techniques to high in fiber food.  Cooperate in
swallowing prevent aspiration Thick liquids are techniques to
 inability to more easy to swallow prevent
elevate upper aspiration
body 4. Teach the client to 4. To break the food
chew slowly and properly for easy
thoroughly swallowing

5. Position head of bed

at least 30 degrees 5. To facilitate upper
and patient on right airway patency and
side lying after drain the secretion
feeding

6. Teach the relatives to

feed the client slowly
and watch for sign of 6.To educate the
difficulty in relatives and
swallowing and enhance client’s
breathing safety
 Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Peripheral Goal: Independent: Independent:

“Parang lagi daw siyang vasoconstriction After 8 hours of Goal Met:
nahihilo”, as verbalized secondary to CVA as nursing intervention the 1. Observe for other 1. To be able to After 8 hours of nursing
by client’s watcher. manifested by increase client will: possible factors reduce/avoid it. intervention, the client
Objective: in blood pressure of  have no further that cause the was able to:
210/120mmH, elevation in increase in client’s  maintain blood
 Blood pressure- respiratory rate of blood pressure. blood pressure 2. Changes in blood pressure without
210/120mmHg 31cpm, restlessness, pressure may anymore further
 Respiratory rate- pallor and being Objectives: 2. Monitor vital signs indicate changes in elevations.
31cpm lethargic. After 4 hours of regularly
client’s status that
 pale nursing intervention the specifically the
client’s blood may require
 lethargic client will be able to: Goal Partially Met:
 maintain blood pressure. prompt attention.
 restlessness After 4 hours of nursing
pressure and intervention, the client
respiratory rate was able to:
3. Monitor input and 3. It can be a good
within  have a decrease
acceptable output indicator of fluid
in blood pressure
limits imbalance, thus
from
allowing for 210/120mmHg
changes in drug to 140/90mmHg.
regimen However, the
client did not
4. Encourage
attain a
frequent position 4. To aid in respiratory
changes for client. decreasing venous within normal
pooling that may range.
be potentiated by
5. Advise client to vasodilators
 decrease intake of
caffeine, soft 5. Caffeine is a
drinks and cardiac stimulant
chocolates. and may adversely
affect cardiac
6. Note skin color, function
capillary refill time
and diaphoresis
6. Peripheral
vasoconstriction
may result in pale,
clammy skin with
prolonged
7. Auscultate for capillary time
heart sounds.

7. Hypertensive
patients often have
S4 gallops caused
8. Promote adequate
by atrial
rest periods
hypertrophy
9. Instruct client and
family members to
8. To provide
maintain low salt
low fat diet and to comfort
comply with fluid
requirements
9. Restrictions can
assist with
decrease in fluid
10. Advise to avoid retention and
 activities such as hypertension thus
isometric improving cardiac
exercises, rectal output
stimulation,
vomiting and
spasmodic 10. To prevent
coughing stimulation of a
valsalva response.
11. Encourage
relaxation
techniques

12. Provide
psychological
support 11. To reduce anxiety

12. promotes
13. Teach client and knowledge and
family on the
compliance to drug
drugs side effects,
contraindications regimen
and adverse
reactions
Dependent:
13. promotes
1. Administer due knowledge and
medications as compliance to drug
prescribed by regimen
physician such
as amlodipine
5mg, Losartan
5mg/tab and
 mannitol 75cc
through IV. 1. To prevent
vasoconstriction
and to lower blood
pressure.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Goal: Independent: Goals Met:

”Parang sumasakit Impaired skin integrity After 8 hours of Independent: After 8 hours of nursing
yang dyan sa may baba related to physical nursing intervention 1. Identify and intervention, the client
ng likod nya, may immobilization as the client will be able explain to client was able to:
parang sugat kasi”, as manifested by bed sore, to: the underlying
verbalized by the dry and scaly skin and  demonstrate cause of her 1. To prevent  Demonstrate
client’s watcher. presence of pain upon increased self- condition. misconceptions. feeling of
sitting. esteem and wellness in her
Objective: increased 2. Determine the skin condition by
 presence of bed ability to extent of damage looking relieved
sores at the right manage to the client’s as evidenced in
gluteal area situation integumentary the client’s
 dry and scaly system presented non-
skin Objectives: verbal cues.
 pain felt upon After 4 hours of 2. To serve as
sittinng nursing intervention 3. Ascertain attitude baseline data. After 4 hours of nursing
the client will be able of client about her intervention the client
to: condition. was able to:
 Positively
participate in  willingly
prevention participate in the
measures and 4. Inspect skin on a preventive
treatment daily basis. measures and
program treatment
 program done to
5. Keep the area her such as
clean and dry. changing of
position/turning
every 2 hours
6. Change wet linens 3. To identify areas and performing
promptly. to be addressed in sponge bath
teaching plan and
potential referred
7. Develop needs.
repositioning
schedule for client,
involving client in
reasons for and 4. To monitor any
decisions about changes/improvem
times. ent.

8. Encourage
mobilization.
5. To assist in body’s
natural process of
9. Discuss repair.
importance of skin
and measures to
maintain proper
skin functioning. 6. Moisture
potentiates skin
breakdown.
10. Assist client in
understanding and
following
preventive care
and daily
 maintenance. 7. To enhance
understanding and
11. Encourage client cooperation.
to try to
verbalize/show her
feelings through
facial expression
and actions.

12. Assist client to

learn stress
reduction and
alternate therapy
techniques.
8. To reduce pressure
13. Perform proper and promote
sponge bath to circulation.
client.

14. Remove all 9. To help client

unnecessary items understand
on bed. importance of
prevention and
treatment
measures for her
skin.

10. To enhance
commitment to
plan, optimizing
 outcomes.

11. To enhance
commitment to
plan, optimizing
outcomes.

12. To control feelings

of helplessness and
deal with situation.

13. To maintain skin

hygiene and
integrity.
 14. To prevent further
injury to client.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Self care deficit related Goal: Independent: Independent: Goals Met:
“Mahina yung kalahati ng to body weakness as After 8 hours of nursing After 8 hours of nursing
katawan niya kaya yan manifested by inability to intervention, the client will be able 1. Assess memory or 1. To see the intervention, the client was
hindi niya kaya linisan o wash own body parts to: intellectual developmental able to:
ayusin sarili niya”, as and put on or take off  Perform self-care activities functioning. level where client  willingly
verbalized by client’s her clothes and inability within level of own ability. has regressed or participate in the
relative. to maintain hygiene at a progressed. preventive
satisfactory level. Objective: measures and
Objective: After an hour of nursing 2. Determine client’s 2. To identify the treatment program
 unable to get off intervention the client will be able strengths and skills extent of done to her such as
from bed on her to: participation the changing of
own and wash her  Show an improvement in client can perform. position/turning
body parts her physical appearance every 2 hours and
 unable to put on or and grooming 3. Establish 3. To enhance performing sponge
take off her contractual client’s bath
clothes relationship with commitment to
 unable to maintain client. plan After an hour of nursing
self at a intervention the client was
satisfactory level 4. Promote able to:
 long nails participation in 4. To enhance  Demonstrate
 untidy hair problem client’s feeling of wellness
identification and commitment to in her skin
 foul smell
problem solving. plan condition by
 soiled and
crumpled linens looking relieved as
5. Develop plan of 5. To conform to evidenced in the
care appropriate to client’s normal client’s presented
the client’s schedule non-verbal cues.
situation

6. Provide 6. To enhance
communication coordination and
among those who continuity of care
are involved in
caring for her.

7. Provide privacy 7. To provide client’s

during personal right to privacy
activities.

8. Encourage self- 8. To accomplish

care and allow tasks to fullest
sufficient time for extent of ability
client

9. Assist with 9. To encourage

necessary client and build on
adaptation to successes
accomplish
activities of daily
living.

10. Raise the side rails 10. To prevent from

falls

11. Cut the nails short 11. To promote good

and comb client’s grooming and
 hair. comfort

12. Provide tepid 12. To promote proper

sponge bath and hygiene and
change client’s comfort
clothes and linens.

VII. Drug Study

 Drug
Generic name: Losartan
Brand name: Hyzaar
Generic name: Mannitol
Brand name: Osmitrol,
Resectisol
Generic name: Levetiracetam
Brand name: Keppra
Generic name: Clonidine
Brand name: Catapres
Mechanism of Action
Undergoes significant first pass in the
liver, where it is converted to an active
carboxylic acid metabolite thay is
responsible for most of the angiotensin
receptor blockade Reduce stroke risk
in clients with hypertension and left
ventricular hypertrophy.
Increases the osmolarity of the
glomerular filtrate, which decreases the Seizures, CHF, angina-chest like
reabsorption of water and increases
excretion of sodium and chloride. It
also increases the osmolarity of the
plasma, which causes enhanced flow
of water from tissues into the
interstitial fluid and plasma.
Precise Mechanism unknown. May act
in synaptic plasma membranes in the
CNS ti inhibit burst firing without
affecting normal neuronal excitability.
Thus, it may selectively prevent
hypersynchronization of epileptiform
burst firing and propagation of seizure
activity.
Stimulates alpha- adrenergic receptors
of the CNS, which results in inhibition
of the sympathetic vasomotor centers
and decrease nerve impulses. Thus,
bradycardia and fall in both SBP and
DBP occur.
Adverse Effects
Angina pectoris, CVA, ventricular
tachycardia, ventricular fibrillation
Side Effects
Diarrhea, dyspepsia, anorexia, dry
mouth, flatulence, taste perversion,
hypotension, dizziness, decreased
libido, tremor, vertigo, cough, nasal
congestion, sinusitis, epistaxis,
muscle weakness, dry skin,
photosensitivity, anemia
Adverse Effects
pain,
Side Effects
Fluid and electrolyte imbalance,
increase in heart rate, dry mouth,
thirst, diarrhea
Adverse Effects
Amnesia, psychotic symptoms,
withdrawal seizures
Side Effects
dizziness, headache, nervousness,
rhinitis, sinusitis, increased cough,
abdominal pain
Adverse Effects
CHF, angioneurotic edema,
Raynaud’s Phenomenon, severe
hypotension
Side Effects
Drowsiness, dry mouth, fatigue,
anorexia, malaise
Intervention
• Take only as directed with or without food.
Do not take with grape fruit. Avoid any OTC
agents unless directed.
• Regular exercise, proper low-salt diet, and
lifestyle changes may also contribute to
enhanced BP control.
• Do not change positions suddenly, dangle legs
before rising, and rest until symptoms subside
to prevent low BP.
• May cause photosensitivity reaction; use
precautions.
• Drug is administered IV to increase water
excretion or to decrease intracranial or
intraocular pressures.
• May experience increased thirst or dry mouth;
do not exceed amount of fluid provided.
• Increased SOB or pain in chest, back or legs
should be reported immediately.
• Take exactly as directed. May take with food
to decrease GI upset.
• May cause dizziness and sleepiness. Do not
engage in activities that require mental
alertness until drug effects realized. Rise
slowly from sitting or lying position.
• Report any unusual side effects or loss of
seizure control. Do not stop suddenly.
• Take the last dose of the day at bedtime to
ensure overnight control of BP.
• Do not engage in activities that require mental
alertness, such as driving car; may cause
drowsiness.
• Do not change regimen or discontinue drug
abruptly.
VIII. Discharge Plan

1. Medications to be taken at home

- Encourage client’s compliance with the treatment regimen. Failure to comply

may result to drug resistance and recurrence of infection.

- Multivitamins can be taken to provide a stronger immune system.

2. Diet

- A normal, well balance diet can be resumed when client returns home.
Emphasize the importance of eating fruits and vegetables in helping to
improve the immune system.

- Provide small frequent meals

- Increase oral fluid intake

- Ephasized having a diet containing low salt and low fat.

3. Activities

- Encourage the client to have plenty time for rest because it is important to
progress to full recovery

- In doing activities, start slowly and increase activity gradually to avoid injury
and over exhaustion.

- Avoid too aggressive activities, to avoid injury.

4. Home and self care

- Emphasize the important of keeping self protected and safe whenever outside
the house to prevent accidents.

- Remind patient monitor for and report for signs and symptoms of the disease.
- Emphasize importance of keeping schedule appointments with health care
providers.
- Remind patient to return to the hospital for follow-up check up.
- Relatives were taught how to take Blood Pressure to help monitor patient’s
condition.
IX. Health Teaching

HEALTH TEACHING
 Time Teaching
Topic Objectives Content Method of evaluation Evaluation
allotted strategy

• To clarify and give emphasis
• Diagnosis of the
to the diagnosis and
client, disease 20 mins.
treatments explained by the
process, treatment
doctor.
• To enumerate to the patient
the different medications
• Medications
ordered for and their
prescribed to the
frequencies and dosages
patient & Importance 15 mins.
• To ensure proper
of compliance to
understanding and
medications
compliance of the patient to
the medications.
• To let the significant ones of
the patient and the patient
• Proper nutrition and
15 mins. herself be knowledgeable
care for the patient
regarding the proper
nutrition and care.
• To let the patient and her
significant others be
• Lifestyle
20 mins. knowledgeable on what are
modifications
the things that will change
after the hospitalization
a. Overview of the disease and
its cause
b. Signs & Symptoms
a. Different medications
prescribed to the patient
b. Different dosages and
frequency of administration
of the drug
a. Importance of nutrition to
the patient
b. Different varieties of food
that would be appropriate for
the age of the patient
- Less use of condiments
- Limit intake of fatty
foods.
c. Attending to the needs of the
patient
a. The different activities that
should not be done by the
patient after hospitalization
- work overload
-sleeping late
-eating too much
-worrying too much
b. The suggested activities for
the patient after the
hospitalization
-proper exercise
• After 20 minutes of
health teaching the
client was able to
answer question
• Discussion • Question & Answer
asked about the
cause and signs and
symptoms of her
illness.
• After 15 minutes of
health teaching the
client was able to
answer the questions
• Discussion • Question & Answer
asked about the
medications she is
taking.
• After 15 minutes of
health teaching the
client was able to
answer the
questions asked
• Question & Answer about her diet. She
• Discussion
• Enumeration was able to
enumerate the
different foods
suitable for her, and
the necessary care
she needs.
• After 20 minutes of
health teaching the
client was able to
answer the
questions asked
about the reasons
why she needs to
• Question & Answer
• Discussion modify her
• Enumeration
lifestyle. The client
was able to
enumerate the
activities she can