GLOBAL CITY INNOVATIVE COLLEGE

Associate in Health Science Education Fort Bonifacio, Taguig City, Metro Manila College of Nursing and Allied International Health Studies

An Experiential Case Analysis of Stroke In Partial Fulfillment of the Requirements In Related Learning Experience 106

Presented to: Mr. Basilio Jacinto RN MAN Presented by: Manalo, Dianne Eve

St

N-412 Semester SY 2011-2012

NURSING HEALTH HISTORY A. BIOGRAPHIC DATA Name: Mrs. A P Address: balayan muntinlupa Age: 52 yrs old Sex: F Race: Filipino Marital Status: Married Occupation: Housewife Religious Orientation: Roman Catholic Health Care Financing: Phil health B. CHIEF COMPLAINT Nanghina ang kaliwag bahagi ng akng katawan, as verbalizes by the patient C.HISTORY OF PRESENT ILLNESS One day prior to admission, the patient felt weak on the left side of her body, she also has high blood pressure that day, so they decided to go to the hospital for further management and treatment D. PAST HISTORY The client received 2 immunizations only (BCG and DPT) because the family is not aware of its importance. The client commonly had cough and fever. The childhood diseases that she acquired are mumps, measles, and chicken pox and sore eyes .There were no known food or medication allergy. Client has no history of accidents or injuries. She does not smoke or drink alcohol E. FAMILY HISTORY OF ILLNESS The clients father and mother have a history of hypertension.

HEALTH PERCEPTION PATTERN BEFORE HOSPITALIZATION DURING HOSPITALIZATION The client experienced The client still feels left sided body weakness on the left side of her weakness body when she does some household task like gardening. She manages it by having a period of rest in bed. She is still uncomfortable with her state of health because it greatly affects her daily activities. She cannot perform the things she likes and usually do. Client believed that proper diet, exercises, and adequate financial support are the things needed to maintain proper health diet and no vices are factors of having a healthy body. She does not perform self-breast examination. When signs and symptoms arise they sought medical consultation. The client also believed in albularyo and use herbal medicines such as lagundi, guava leaves, pito-pito(7 different kinds of leaves).

G. NUTRITIONAL AND METABOLIC PATTERN PRIOR TO HOSPITALIZATION The clients typical food intake is composed of rice, meat, and fish. Occasionally she eats vegetables and fruits. Shes fond of eating processed food like corned beef, anything with preservatives, tocino, chicharon and fried dish (porkchop, chicken). She used a lot fish sauce,

MSG when cooking. Her appetite was good and drinks 6 glasses of water daily. Client wound heals well and she wears complete upper and lower dentures but this doesnt affect her food intake.

H. ELIMINATION PATTERN BEFORE HOSPITALIZATION Client usually defecates at least 2-3 times of soft and watery stool consisting of small amounts which is light brown color with presence of blood (fresh blood), with discomfort or difficulties and experienced excessive sweating. Client urinates 6x a day which is yellowish- orange color w/out any discomfort.

DURING HOSPITALIZATION Client usually defecate at least 1-2x a day semi formed stool with the presence of blood which is light brown to brown. She has difficulty in defecation with excessive sweating. Client urinates 4x a day which is yellow in color w/out any discomfort.

I. ACTIVITY-EXERCISE PATTERN BEFORE HOSPITALIZATION The client said that her activities at home were limited because she has experience high blood pressure. She spends her days with minimal cleaning like gardening and watching TV. She also played with her grand daughter and grandsons. She walks short distances as form of her exercise.

DURING HOSPITALIZATION Client shows tiredness and limited movement. A client doesnt perform any routine exercise. In the hospital the client instructed to Perform ROM by the health care provider. 3-FEEDING 3-GROOMING 3-TOILETTING 3-GENERAL MOBILITY 4-COOKING 3-BED MOBILITY 4-BATHING 3-DRESSING 4-HOME MAINTENANCE

J.SLEEP-REST PATTERN BEFORE HOSPITALIZATION DURING HOSPITALIZATION The client sleeps for 8-9 The client sleeps is lessen to 6 hours usually from 8pm-5am but hours due to abdominal pain and not continuous because of prompt interrupted when the health care abJdominal pain. She doesnt take provider give medication and any sleep medications. She also monitor her vital signs during the night. She takes naps in the does take naps during afternoon. afternoon for about 1 hour. The client sleeps inadequately at night. K. COGNITIVE-PERCEPTUAL PATTERN The client does not have any hearing difficulty and cant remember past events She has a visual problem far-sightedness. Through demonstration she could easily learn things. Abdominal pain is the one which alters her comfort and she manages it with taking prescribed medications. L. SELF PERCEPTION AND SELF CONCEPT PATTERN The client said that her condition was not improve, she still experience left sided body weakness and high blood pressure. Client feels that she lose some weight. Financial problems and health condition usually makes her worried. When these things are encountered the client diverts her attention through talking to a family member and praying. M. ROLE-RELATIONSHIP PATTERN The client lives in extended family. They live peacefully even there are hardship and difficulties that arrives to their lives. By means ofgood conversation they can easily fixed family problems. When family experienced difficulty of caring for the client they just take it as trials given by god. They have harmonious relationships with the family and their neighbors. N. SEXUALITY-REPRODUCTIVE PATTERN The client is done in stage of menopausal. There is no sexual activity. According to the client, decreased sexual activity is not a problem because they were already old. They spent most of their time by taking care of each other and with that they are showing their love for one another. O. COPING STRESS TOLERANCE PATTERN The client was observed to be withdrawn but the behavior improved as evidenced by her socialization with other people. When things are not so well, she finds her husband to be the most helpful person in talking things

over. When big problems encountered, she always prays and ask assistance with the Lord. Some of the time they failed to attain what they want and try other alternatives in solving it. P. VALUE-BELIEF PATTERN The client is a Roman Catholics usually go to the church to attend mass every Sundays, first Friday of the month and novena. She is very active in participating religious activities. She helps spread the word of god through catechism.

LAB EXAM DONE

ACTUAL NORMAL FINDINGS FINDINGS

ANALYSIS AND INTERPRETATIO N

NURSING RESPONSIBILITIE S Make a request Explain the procedure to the patient

Hematology July 10, 2011

HEMOGLOBIN HEMATOCRIT RBC WBC NEUTROPHILS

138 0.43

125-160 g/dl 0.38-50 %

Normal findings Normal findings Normal findings

Tell the patient that this test requires blood sample Explain to the patient that he may experience discomfort from needle puncture and tourniquet Note any recent procedures that may interfere with the results If the patient has an allergic reaction to latex, avoid the use of equipment containing latex Restrict medications that may affect test result. If they must be continued note this on the lab request Instruct patient to cooperate fully and follow instructions

5.25 4.5-5.5 mil/mm3 8.44 5-10 g/L 0.86 0.40-0.60 %

Normal findings Increased neutrophils may indicate possible infection Slight decrease in lymphocyte indicates defective lymphatic circulation Normal findings

LYMPHOCYTES

0.12 0.20-0.40 %

EOSINOPHILS MONOCYTES BASOPHILS PLATELET COUNT MCV

0.1 0.02 0.00 265 81 0.00-0.01 % 150-350 g/l 86-100 fl Low MCV may indicate hypochromic anemias 0.01-0.06 % 0.02-0.08 % Normal findings Normal findings Normal findings

NCP 1 Assessment Subjective: Client said, namamanhid yung kanang kamay ko, pero nagagalaw ko naman siya medyo hirap lng ako. Objective: Limited range of motion (client cant fully extend his right arm and hold up his right shoulder) Limited ability and difficulty to perform gross motor skills like extending and lifting of the right arms Unsteady gait Slowed movement Right arm Diagnosis Impaired physical mobility r/t neuromuscul ar damage involvement (Right arm numbness) as evidenced by motor control Planning Long term: After 4 days of nursing intervention, client will be able to physical mobility Expected outcome: Demonstrat e resumption of activities Participate in ADLs Maintain or muscle control Short term: After 8 hrs of nursing intervention, client will be able to participate in therapeutic regimen Expected outcome: Verbalize understandi ng of the situation Intervention Independent: 1. Determine degree of immobility 2. Observe movement when client is unaware 3. Support affected part with pillows 4. Give rest periods to activities 5. Encourage adequate fluids and right diet as necessary to the client Rationale Independent: 1. To establish comparative baseline 2. To note any incongruence with the reports of abilities 3. Reduce risk of pressure ulcers 4. To help reduce fatigue Evaluation Long term goals met: Client is able to physical mobility as evidenced by resumption of activities, participation in his ADLs and right arm numbness Short term goals met: The client is able to participate on the therapeutic regimen as evidenced by verbalization of understanding of the situation, therapy, and he is able to participate in the interventions rendered by the nurse

and O2 demand

ASSESSMEN T SUBJECTIVE :

NURSING DIAGNOSI S

PLANNIN G

INTERVENTIO N

RATIONAL E

EVALUATIO N

Disturbed GOAL GOAL tactile sensory At the end Identify patient To assess At the end of na perception of the shift with condition causative the shift mamanhid related to patient that can affect factors patient and Interventi and binti ko altered and sensing, significant Assessment Diagnosis Planning Rationale Evaluation on and sensory significant interpreting others was (As reception others will communicating able to verbalized by as Ineffective verbalize Subjective: After 1 stimuli Independen After 8 hours verbalize the patient) Mahirap evidenced airway awareness hour of t -to promote of awareness of nursing huminga as by clearance of nursing sensory Evaluate client effective -Place intervention, sensory OBJECTIVE: verbalized by decreased to needs. related interventiosensory in an lung the client needs the patient. response airway n the client orthopnic awareness expansion. manifested Numbness of on spasm as OBJECTIV stimulus of a painful will position. lessened GOAL MET the right side stimuli Objective: characterizE experiencehot/cold, -to difficulty of of the body -irritable ed by lessened dull/sharp, encourage breathing as OBJECTIVES diminished Patient will of -Encourage excretion of evidenced by difficulty gait/mobility To note Altered sense -restless breath bebreathing free deep secretions.thedecreased use whether Kept patient of balance sounds. from injury Determine as breathing response is of safe and free accessory -nasal flaring evidenced response to exercise. -to avoid appropriate muscles when from injury. Decreased by painful stimuli allergic to stimulus, breathing, response to -use of decreased reactions immediate, absence of painful accessory use of -Keep room and prevent nasal flaring, or delayed stimuli when muscle accessory well irritation. and presence breathing muscles ventilated of calm during and free -to breathing. -wheezing breathing. Promote a from dust determine sound upon stable or pollution. effectivene is Touching inhalation After 8 environment ssan of hours of -Monitor nursing important nursing Provide tactile intervention respiratory part of interventiostimulation as s. caring. patterns, n, the care is given including patient will rate, depth verbalize and effort. decreased effort in Encourage breathing. relatives to Dependent bring familiar -Give objects, talk to supplement and touch the al oxygen client frequently as prescribed Record via nasal So that perceptual cannula. caregivers deficit on chart are aware Administere Provide safety d medicines To prevent measures as as ordered. injury needed (side rails)

Drug

Dosage, route, frequen cy 75 ml, Q6

Action

Indicatio n

Contraindicat ion

Advers e reactio n Seizure -Edema -Heart Failure -Urine retentio n Blurred Vision -chills

Nursing respons ibilities

Generic name: Mannitol Brand name: Osmitrol Drug classificatio n: Diuretics

Increase osmotic Pressure of glomerular filtrate, inhibiting tubular reabsorbption of water and electrolytes,dr ug elevates plasma osmolality, increasing water flow exracellular fluid

To reduce intracellul ar or intracrani al pressure

Contraindicate d to patient hypersensitive to drug

-monitor vital sign -to relieve thirst give frequent mouth care -dont give electrolyt e free solution withbloo d

INTRODUCTION A stroke is a serious medical condition that occurs when the blood supply to part of the brain is cut off. Like all organs, the brain needs the oxygen and nutrients provided by blood to function properly. If the supply of blood is restricted or stopped, brain cells begin to die. This can lead to brain damage and possibly death. Strokes are a medical emergency and prompt treatment is essential because the sooner a person receives treatment for a stroke, the less damage is likely to happen. Types of stroke There are two main causes of strokes: ischaemic (accounting for over 80% of all cases): the blood supply is stopped due to a blood clot

haemorrhagic: a weakened blood vessel supplying the brain bursts and causes brain damage There is also a related condition known as a transient ischaemic attack (TIA), where the supply of blood to the brain is temporarily interrupted, causing a

'mini-stroke'. TIAs should be treated seriously as they are often a warning sign that a stroke is coming. The best way to prevent a stroke is to eat a healthy diet, exercise regularly and avoid smoking and excessive consumption of alcohol. Diet A poor diet is a major risk factor for a stroke. High-fat foods can lead to the build-up of fatty plaques in your arteries and being overweight can lead to high blood pressure. A low-fat, high-fibre diet is recommended, including plenty of fresh fruit and vegetables (five portions a day) and whole grains. You should limit the amount of salt that you eat to no more than 6g (0.2oz) a day because too much salt will increase your blood pressure. Six grams of salt is about one teaspoonful. There are two types of fat: saturated and unsaturated. You should avoid food containing saturated fats because these will increase your cholesterol levels. Foods high in saturated fat include:

meat pies sausages and fatty cuts of meat butter ghee: a type of butter that is often used in Indian cooking lard cream hard cheese cakes and biscuits foods that contain coconut or palm oil.

However, a balanced diet should include a small amount of unsaturated fat, which will help reduce your cholesterol levels. Foods high in unsaturated fat include:

oily fish avocados nuts and seeds sunflower, rapeseed, olive and vegetable oils

Exercise

Combining a healthy diet with regular exercise is the best way to maintain a healthy weight. Having a healthy weight reduces your chances of developing high blood pressure. Regular exercise will make your heart and blood circulatory system more efficient. It will also lower your cholesterol level and keep your blood pressure at a healthy level. The recommended level of cholesterol is 5mmol/litre (5 millimoles per litre of blood). Blood pressure is measured using two figures. One figure represents the pressure of the heart as it contracts to pumps blood around the body. This is known as the systolic pressure. The second figure represents the pressure of the heart as it expands and fills with blood, while waiting for the next contraction. This is known as the diastolic pressure. For most people, a healthy blood pressure is a systolic pressure of 90-120 millimeters of mercury (mmHg) and a diastolic pressure of 60-80mmHg. Or, as blood pressure is normally expressed, a level between 90/60mmHg and 120/80mmHg. For most people, at least 150 minutes (2 hours and 30 minutes) of moderateintensity aerobic activity (i.e. cycling or fast walking) every week is recommended. If you are recovering from a stroke, you should discuss possible exercise plans with the members of your rehabilitation team. Regular exercise may be impossible in the first weeks or months following a stroke but you should be able to begin exercising once your rehabilitation has progressed.