PART I PATIENT ASSESMENT DATA BASE HEALTH HISTORY Patient: Mrs.

. T Age: 43y/o Sex: Female Nationality: Filipino Civil Status: Married Religion: Born Again Christian Rank in the Family: Wife, mother Source of History: Patient and SO Occupation: Book keeper Employer: Hasik Bagong Buhay Christian School Address: Tagpuan, Bayog, Los Banos, Laguna Inclusive Date of Confinement: Admission Date and Time: Feb. 28, 2010; 5am Discharge Date and Time : March 6, 2010; 12nn Attending Physician: Dr. Emmanuel Lantican Initial Diagnosis: TC CVA Final Diagnosis: CVA Chief Complaint: Ilang araw ng sumasakit ang k kaliwang bahagi ng aking ulo; nangingimay din ang aking kamay at paa

A. HISTORY OF PRESENT ILLNESS: 3mons. PTC Mrs. T, during their annual Physical examination she found out that her BP is 130/90, but she was not alarmed, because she did not experienced any discomforts. 3 weeks PTA the patient experienced frequent stabbing pain on the left side of her head, she did not consulted a doctor instead took paracetamol (biogesic) thinking that it was only a minor headache. Then 3 days (Thursday) PTC she suffered persistent headache with dizziness and chest pain, she consulted the health center and took her BP, the result was 160/100 then she was referred to LBDH ER, she was seen by ROD and was given Amlodopine, then was sent home, for a while, her condition got pretty well. On the next day she went to work and relieved an absent teacher, she again experienced stabbing headache and

numbness was felt on her right upper extremities, she once more consulted a doctor on LBDH at around 11-12pm, she was seen by Dr. lantican and was given Ambesyl, then again was sent home. For a while her numbness and headache was relieved. Then night PTA at round 8pm, her numbness persist on the right upper extremities with asymptomatic uncontrolled BP of 160/100 again consulted to LBDH, the ROD gave her Norten for hypertension then was sent home. Hours PTA she again experienced numbness on her right upper and lower extremities her husband decided to bring her to the hospital, she was seen by the ROD with negative motor response on right upper and lower extremities, she was then admitted under Dr. Lantican, LSLF diet was ordered. The NOD infused PNSS 1L x 16 as ordered. CBC, Na, K, Crea, SGPT, FBS, Lipid Profile, BU, CXR, 12 Lead ECG and Plain Cranial CT scan was ordered. The CT scan showed, Acute Subacute Left Cerebral Infarct. After 6days of confinement with due meds given and proper nursing intervention done, the patient was sent home, but since CVA has quite long prognosis, she has to undergo series of therapies to bring back her normal ADL. B. PAST HEALTH STATUS b.1 General health: she rates her health as stable. b.2 Prophylactic medical/Dental Care: no missing teeth: without dentures. b.3 Childhood Illness: cough, colds, fever, measles and chicken pox, the patient has not suffered from any major illnesses. b.4 Immunization: the patient is incomplete with her immunization. b.5 Major Illnesses/Hospitalization: She was only confined to the hospital when she gave birth to her children via Cesarean Section.

b.6 Current Medications Prescribed: N/A Non-Prescribed: Clusivol

Vitamin C Paracetamol b.7 Allergies Ingestants: X Injectants: X Inhalants: X She has no allergy to any foods or medicines. b.8 Habits Alcohol: X b.9 Family Health History F + M HPN B HPN S AW C AW Caffeine: X Drugs: X Contactants: X

Tobacco: X

Legend:

X male Y female + deceased AW Alive & well * Patient

F father M mother B brother S sister C children

CA Cancer (specify) SUI (suicide) DM Diabetes mellitus RF Renal failure PTB pulmonary tuberculosis CVA HPN Hypertension ? Unknown MI Myocardial Infarction Additional- if applicable

Both side of her parents have history of hypertension. Both have no known history of DM, Renal Failure or asthma. Her paternal grandmother suffered and died from CVA.

I.

HEALTH PERCEPTION- HEALTH MANAGEMENT PATTERN Before, she rate her health status as stable.

Mrs. T is quite health conscious, because she observes proper diet but lately she has been fond of drinking coffee. She just visits the doctor when she cannot tolerate the pain or cannot handle unnecessary things that she is experiencing. There has no difficulty on following nursing or medical interventions. She thinks that her illness is hereditary. She has no skin problems, lesions or dryness. She does not have any dental problems. She is a Phil.health member; it has been one of her medical source.

II. a. Appetite

NUTRITION-METABOLIC PATTERN BEFORE The patient has good appetite discomfort She usually eats vegetable, fish and eats chicken or pork occasionally She eats 5times a day She day She She She drinks almost 8 glasses a day. prefers to prepare their food at home has no eating or drinking discomforts has no diet restrictions Lunch Dinner Snacks DURING * has quite poor appetite due to eating * her diet is low fat and low sodium foods * she still eats 5times a day but with small servings * she still tries to drink at least 8 glasses a

B. Usual Daily Menu Breakfast

Rice Hotdog Egg

Rice Vegetable Fish Meat occasionally

Rice Vegetable Fish Meat occasionally

Bread Pastries Water or Juice

C. Metabolic (wt. Gain/Loss ) Before confinement: 55kg III.ELIMINATION PATTERN BEFORE DURING Has no defecating or voiding * has no defecating and voiding discomforts Discomforts Defecates and voids regularly * still defecates and voids regularly Has no excess perspiration or odor problems* has no excess perspiration or odor problems IV. ACTIVITY- EXERCISE PATTERN She sometimes do some jogging or walking for at least 20 meters back and forth when she has available time but she does not do it regularly. When having spare time she watches basketball game with her family since her husband is a basketball coach and her eldest son is a basketball player. She usually cleans their house before going to work. She works as a book keeper in a school and sometimes an elementary teacher reliever. She goes to work at 7am and goes back home at 4:30-5:00pm.

A. SELF-CARE ABILITY BEFORE: Feeding: 0 Toileting: 0

Dressing: 0 Bathing: 0

Home Maintenance: 0 Shopping: 0 Bed Mobility: 0 Grooming: 0 Cooking: 0 Gen. Mobility: 0

DURING: Feeding: III Dressing: II Bathing: II Legend: Toileting: III Home Maintenance: IV Bed Mobility: II Grooming: II Cooking: IV Shopping: III Gen. Mobility: III

Functional level Codes OFull self-care IRequires use of equipment or device IIRequires assistance or supervision from another person IIIRequires assistance or supervision from another person and equipment or device IVIS dependent and does not participate

B. Oxygenation/Perfusion b.1 Chest X-RAY (IF ANY)

b.2

Cardiac risk factors (if applicable) POSITIVE 1.Sedentary lifestyle NEGATIVE NOT KNOWN

2. 3. 4. 5. 6. 7. 8.

hypertension obesity hypervigilant personality hyperlipidemia family hx of heart disease diabetes cigarette smoking

V. SELF-REST PATTERN: BEFORE DURING She has a regular sleeping pattern * frequently falls asleep She sleeps 8hrs.a day; from 9pm-5am * easily disturbed when falling asleep She has no problem in falling asleep She does not take any medication to fall asleep She watches TV for relaxation and uses music therapy VI. COGNITIVE-PERCEPTION PATTERN BEFORE Has no hearing difficulty Does not wear eye glasses Has changes in memory due to Anesthesia injected during her CS delivery On her 2 children. 3 days PTA, she suffered frequent headache Particularly on the left side of the head When suffering from headache he takes biogesic or takes some nap She has good self-esteem, she is extrovert She is a friendly woman, and does not isolate herself from the crowd. DURING * she has no hearing difficulty * does not wear eyeglasses * has changes in memory due to anesthesia during her CS Delivery to her children * unable to speak audibly but able to respond through hand gestures. *able to understand instructions and and responds through nodding or hand gestures

VII. ROLE-RELATIONSHIP PATTERN BEFORE She is a loving and caring mother to her children and wife to her husband.

DURING * Her husband stated that he will do his best To take care of his wife.

VIII. SEXUALLY-REPRODUCTIVE PATTERN She is a mother of 2 boys. A loving wife to her husband. IX. COPING-STRESS TOLERANCE PATTERN When having problems especially family problems they usually solve it within their family, When she has misunderstanding with her husband, she just tend to be quiet, she just feels the pain and allow her anger to pass. They rarely talk about their problems they just keep it to themselves. They never forget the habit of praying.

X. VALUE-BELIEF PATTERN She does not believe on albularyos or Faith healers. She believes in the power of prayer. She goes to church every Sunday together with her family, because they believe that Sundays should be spent in the church to praise God. She is a Born Again Christian. She is actively participating in church activities, she spread the word of God through conducting Bible study.

Generic Name

Brand Name

Classification

Indications

Contraindications

Side Effects

Dosage and Frequency

Nursing Responsibilities

Celecoxi b

Celebre x

NSAID (nonsteroidal antiinflammatory drug)

Analgesic and antiinflammatory activities related to inhibition of the COX-2 enzyme, which is activated in inflammation to cause the signs and symptoms associated with inflammation; does not effect the COX-1 enzyme, which protects the lining of the GI tract and has blood clotting and renal functions

Contraindicated in the presence of significant renal impairment, pregnancy, lactation.

CNS: headache, dizziness, somnolenc e, insomnia, fatigue, tiredness, dizziness, tinnitus, ophthamol ogic effects

500mg tablet, 1 tablet, three times a day of as needed for pain

> Take immediately after meals. >Administer drug as ordered by the doctor. >Monitor patient for adverse reaction to drug. >If adverse reaction is resent stop administering drug and inform physician immediately. >tell patient to store drug in a cool dry place in a tightly closed container.

LEARNING OBJECTIVES

To be able to acquire knowledge about CVA and how to manage patients with CVA. To learn the Pathophysiology of CVA. To assess the precipitating and predisposing factor of the disease. To be able to determine nursing interventions on patients with CVA. To provide health teachings to the patients especially to significant others in caring for the sick member.

EVALUATION
Throughout our entire duty we were able to gain knowledge about CVA and how to handle patients with this disease. We were able to learn the Pathophysiology of the disease. We were able to assessed the precipitating and predisposing factor of CVA. We were able to determine and provide appropriate Nursing interventions. We were able to give health teachings to the patient and to the significant others.

DIET: Low Sodium Diet To avoid sodium retention Low Fat Diet helps to lose weight REFERRALS/ DISCHARGE PLANNING: Since CVA has long prognosis, the patient is advised to visit the hospital twice a week for therapy, and is advised to see her doctor once a month to assess her improvement. PROGNOSIS:

CVA has quite long prognosis, she has to undergo series of therapies to bring back her normal ADL.

PAMANTASAN NG CABUYAO College of Nursing

CASE STUDY
(CEREBROVASCULAR ACCIDENT )
SUBMITTED BY: GROUP 3 2-nrs-1

GROUP 3
Juson, Ingrid Lamo, angelyn Lantican, jaziel elika Leosala, pears myra Mabingnay, joana marie Opeda, Kevin Pajatin, Dianne grace Palon, Jamie rose Romolona, april Sangalang, krizia Susim, lezlie

Umali, ruffa may

ASSESSMENT S> Hindi siya gaano makakilos as verbalized by her nephew O >with generalized body weakness >has limited range of motion >decrease muscle strength on right side

DIAGNOSIS Self-care deficit: bathing/hygiene, dressing/grooming, toileting related to intolerance to activity as evidenced by decrease strength and endurance.

PLANNING After rendering proper nursing interventions, the patient will be able to perform self care activities little by little within level of own ability.

NURSING INTERVENTIONS >Noted other etiologic factors present, including language impairment >Assessed barriers to participation in regimen (such as lack of information) >Assisted with necessary adaptations like holding spoon & grasping objects. >Identified safety concerns such as fall. >Informed the family with other care options.

RATIONALE >It allows assessment of degree of disability

EVALUATION After rendering proper nursing interventions, the patient was able to perform minimal self care activities little by little within level of own ability

>Provides identification of causative factors >Gives encouragement to the patient to perform simple tasks >It reduces risk of injury >Enhances likelihood of finding individually appropriate situation to meet clients needs.

ASSESSMENT S> nahihirapan sya magsalita as verbalized by her nephew O > Speaks or verbalizes with difficulty > slurring of speech > difficulty expressing thoughts verbally.

DIAGNOSIS Impaired verbal communication related to left Cerebral infarct as evidenced by difficulty of verbalizing or speaking

PLANNING After giving proper nursing interventions, the patient will be able to establish method of communication in which needs can be expressed

NURSING INTERVENTIONS >Established relationship with the patient, listening carefully to patients verbal/ non verbal expressions >Kept communication simple, using all modes for accessing information: visual, auditory, and kinesthetic >Encouraged the patient to express needs by using hand gestures >Involved family/ SO in plan of care by encouraging them to communicate to the patient using simple and clear instructions.

RATIONALE >it allows assistance to patient in establishing means of communication

EVALUATION After giving proper nursing interventions, the patient was able to establish method of communication in which needs can be expressed

>For further understanding of communication

>allows the identification of the patients needs. >It promotes wellness and help SO to determine patients needs.

ASSESSMENT

DIAGNOSIS Risk for injury related to altered mobility

PLANNING After giving proper intervention the patient will be able to demonstrate behaviors that will protect self from injury.

INTERVENTION >Ascertained knowledge of safety needs/injury prevention and motivation. >Assessed muscle strength, gross and fine motor coordination. >Provided information regarding disease/condition(s) that may result in risk of injury (E.g. immobility) >Referred to other resources as ordered. (e.g. physical therapy)

RATIONALE >It prevents injury during hospitalization and at home.

>It evaluates of risk inherent in the individual situation. >Provides assistance to client to correct individual risk factors.

EVALUATION After giving proper nursing interventions, the patient was able to demonstrate behaviors that will protect self from injury.

>It promote wellness

ASSESSMENT

DIAGNOSIS Risk for impaired skin integrity related to physical immobilization

PLANNING After rendering proper nursing intervention the patient and the SO will be able to demonstrate behaviors/techniques to prevent skin breakdown.

INTERVENTION
>Noted reduced mobility associated with the disease and problems of self care >Emphasized skin hygiene using mild nondetergent soap, drying gently & thoroughly and lubricating with lotion as indicated. >Changed in position on a regular schedule, encouraged participation with active & assistive ROM exercises. >Provided adequate clothing/covers; protect from drafts. >Kept bed clothes dry & bed free of wrinkles or crumbs. >Provided protection by use of pads or pillows. >Provided info. to the client/SOs about the importance of regular observation & effective skin care in preventing problems.

EVALUATION After rendering proper nursing intervention, the patient and her SO >For maintenance of skin was able to integrity at optimal level. demonstrate behaviors/technique to prevent skin breakdown.
>For assessment of causative/ contributing factors >For maintenance of skin integrity & for demonstration of position techniques. >It prevents vasoconstriction. >It prevents bedsores & to demonstrate proper bed making to the SO. > For increase circulation and alter/eliminate excessive tissue pressure. > It promotes wellness

RATIONALE