58895420 case-study2-final-revised-na-tlga-to

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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.

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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.
At the end of the study, the client’s family would be able to:
• 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 client’s
rehabilitation process.
General Goal:

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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

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

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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. Patterns of Functioning
A. 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 can’t
respond actively to stimulus and he can’t groom himself
properly. Being a widower is a factor that’s why he is depressed.
Having a CVA maybe adds as a factor in his depression.
B. Socio-Cultural Patterns

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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, that’s 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 doesn’t believe in any
superstitions, thus there’s 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
ADL
Before
Hospitalization
During
Hospitalization
Interpretation
Analysis
1. Nutrition Daughter
verbalized: “wala
siyang ganang
kumain…”
Doesn’t have any
restrictions but
doesn’t have the
urge to eat.
Daughter
verbalized:
“Gustong-
gusto 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
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)
Lack of
nutritional
intake

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divided
feeding with
strict
aspiration
precaution.
Eat soft diet
2.
Elimination
Daughter
verbalized:
“Maya’t-maya
umiihi o
nagbabawas
yan..nakakatatlong
palit nga siya ng
short sa isang
araw…”
Continuous
Daughter
verbalized:
“Ganun
parin…Maya’t-
maya naman
ang palit ng
diaper…”
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

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number of
functioning
nephons
decreases to
some degree,
impairing the
kidney’s
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
it’d ability to
completely
empty
diminished
with age.
(Fundamental
s of Nursing 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
As age
advances,
muscle tone
and bone
density
decreases,
joint lose
flexibility,
reaction time
slows, and
bone mass
decreases.
(Fundamals of
Nusing by
Kozier)
Inadequate
exercise

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Can dangle
feet on bed
4. Hygiene Daughter
verbalized: “Pag
nasa bahay yan
gusto niya tuwing
sabado lang
naliligo…ayaw
niya sa ibang
araw..gusto niya
pa mainit na tubig
ang ang
pampaligo,yung
medyo
maligamgam…”
Improper hygiene
is established
Sponge bath
everyday
Not too neat
Unable to fix
himself
He has
improper
hygiene
practice.
He must take
a bath
everyday
with a luke
warm water,
assisted by
relatives
5.
Substan
ce
Abuse
Son verbalized:
“Umiinom ng alak
at naninigarilyo si
tatay…”
Unhealthy
NONE He has
unhealthy
habits.
He should at
least gradually
stop abusing
such
substance.
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.
The older
adult sleeps
about 6 hours
a night. Many
elders awaken
more often
takes them
longer to go
back to sleep.
Disturbed
sleeping
patterns
7. Sexual
Activity
NONE NONE 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
No sexual
activity

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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 Norms
Actual
Findings
Analysis Interpretation
1. Posture and
gait
2. Skin color
Relaxed, Erect
posture;
coordinated
movement
Varies from
light to deep
Slouched,
bent posture;
tremors
Light brown;
brown-
Normal
posture due
to age and
illness
Normal skin
because of
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)

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3. Personal
hygiene
4. Nutritional
status
5. Age
appropriatenes
s
6. Verbal
behavior
brown
Clean; neat; no
body or breath
odor
Healthy diet
65 and above
Understandabl
e, moderate
pace
colored
macules
Not too neat;
no body or
breath odor
1800kcal/day
, low salt,
low fat diet
and soft diet
77 years old
Slurred
speech
age
Normal
personal
hygiene due
to limited
movement
to be neat.
And
because of
weakness
due to CVA,
he can’t
properly
groom
himself.
Appropriate
diet for his
illness
Normal
Normal due
to inserted
NGT
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

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7. Non verbal
behavior
Cooperative;
responses are
appropriate
Cooperative;
responses
are
appropriate
by means of
nodding
Normal
because of
illness and
age
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)
Measurements
1. Temperature
2. Pulse rate
3. Respiration
rate
4. Blood
pressure
37 Celsius
70 (60-
100)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
37 Celsius
70 (60-
100)bpm
16 (15-20)bpm
Possible
increased
systolic and
diastolic
(Fundamentals
of Nursing by
Kozier)
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;
Can’t hear
clearly;
Sense of
smell
diminish
because of
NGT; loss of
tooth
Appropriate
for his age
In older adults,
their hair is
generally
thinner, grows
more slowly
and loses it’s
color as a
result of aging
tissue. Men
often lose their
scalp hair and
may become

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2. Neck
3. Upper
Extremities
4. Chest and
back
5. Abdomen
Coordinated
movements
with no
discomfort
Nails grow
slowly and
thicken
Varies from
light to deep
brown
Breathing rate
are unchanged
at rest
Stool passes at
a slower rate
Muscle
weakness
and tremor;
Limited
range of
motion (up-
and-down
nodding
movement
Thick nails
and uncutted
Light brown;
brown-
colored
macules
Increased
respiration
rate
Stool passes
at a fast rate
as evidenced
by often urge
Appropriate
for his age
and illness
Appropriate
for his age
but it must
be properly
cutted to
promote
good
hygiene
Normal skin
because of
age
Appropriate
for his age
and
because of
his illness
Inappropriat
e for the
elders
Inappropriat
e for his age
and to his
completely
bald.
(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)
Nails grow
slowly and
thicken
(Fundamentals
of Nursing)
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

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6. Lower
extremities
Coordination
changes
It may be
absent in adults
without
pathology or
overridden by
voluntary
control.
to defecate
Reduced
speed
(-) Babinski
reflex
illness
Appropriate
for his age
and illness
Appropriate
for his age.
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)
IX. Laboratory and Diagnostic Examination Results
HEMATOLOGY (08-06-08)

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Test Normal Result Interpretation
Creatinine 0.6-1.2
mg/100ml
125.0 Significant increase
my signify chronic
glomerulonephritis,
nephritis,
congestive heart
failure, muscle
disease (Ultimate
Learning Guide by
Carl Balita)
Normal
Sodium 138-144m
mEq/l
137.4 Signifant increase
my signify an
increace in intake
either orally or
parenterally.
Significant decrease
my signify
Addison’s 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)
Normal
Potassium 3.5-5.0mEq/l 3.67 Significant increase
may signify Diabetic
ketosis, renal
failure, Addison’s
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
Normal

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Test Normal Result Interpretation Analysis
RBC(Red Blood
Cell)
M:4.5-6.2
million/ul
3.73x10 /L Increase:
Polycythemia
vera, anoxia
dehydration
Decrease:
Leukemia,
hemorrhage,
lupus
erythematosus
(Ultimate
Learning Guide
by Carl Balita)
Normal
Hgb
(Hemoglobin)
M:14-
18g/100mL
12.00g/dL Increase:
Dehydration,
polycythemia
Decrease:
Anemia,
hemorrhage
leukemia
(Ultimate
Learning Guide
by Carl Balita)
Hct (Hematocrit) M:0.42—
52L/L
0.35L/L Same as
hemoglobin
(Ultimate
Learning Guide
by Carl Balita)
Lower
than the
normal
range
Platelet 160-
380x10 /L
197x10 /L Increase:
Polycythemia,
poatsplenectomy,
anemia
Decrease:
Leukemia,
asplastic anemia,
cirrhosis, multiple
myeloma
(Ultimate
Learning Guide
by Carl Balita)
Normal
WBC (White
Blood Cell)
5-10x10 /L 8.87x10 /L Increase:
Leukemia,
bacterial
infection, severe
Normal

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sepsis
Decrease:
Viral infection,
overwhelming
bacterial
infection, lupus
erythematosus
(Ultimate
Learning Guide
by Carl Balita)
Eosinophils 0.03-0.05 0.03 Increase:
Allergic disorder,
parasitic
infestation,
eosinophilic
leukemia
Decrease:
ACTH, cortisone
or epinephrine;
endocrine
disorder
(Ultimate
Learning Guide
by Carl Balita)
Normal
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)
Normal
SEROLOGY (08-06-08)
Test Result Interpretation Analysis

of 38
Troponin I (-) Increase:
Hyperthyroidism,
thyroxine
Dercrease:
Hypothyroidism
(Ultimate Learning
Guide by Carl Balita)
Normal
URINALYSIS (08-06-08)
COLOR: Light yellow
CHARACTERISTICS: Hazy
SPECIFIC GRAVITY: 1.020
Test Result
Albumin (-)
Sugar (-)
Pus cells 1-2/hpf
RBC 0-1/hpf
Epithelial Cells Few
A. Urates/
Phosphates
Few
Bacteria 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

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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

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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

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Generic/Trade
Name
Dosage/
Frequency
Classification Indication Contraindication Side-Effects
Nursing
Responsibilities
Simvastatin 20 mg/ tab
at hour
sleep
Lipid-regulating
drug
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.
Acute liver
disease or
unexplained
persistent
elevations or
serum-amino-
transferase
concentration or
to those with
porphyrin.
Pregnancy and
lactation.
GI disturbances,
Headache, Skin
rashes,
Dizziness,
Blurred vision,
Insomnia.
Reversible
increases in
serum-
aminoferase
concentrations,
Hepatitis,
Pancreatitis,
Hypersensitivity
reactions,
Myopathy.
Assess liver
function test
prior to therapy
and periodically
thereafter.
Teach patient
proper use,
possible side-
effects,
appropriate
interventions
and adverse
symptoms to
report.
Evaluate
therapeutic
response and
adverse
reactions on a
regular basis.
Clopidogrel 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
GI bleeding,
Purpura,
Bruising,
Hematoma,
Epistaxis,
Hematuria, Eye
bleeding,
Assess for
symptoms of
stroke, MI
during
treatment
Instruct patient

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recent stroke.
Pregnancy and
lactation
Diarrhea to take drugs as
directed by the
physician
Caution patient
to report
diarrhea, skin
rashes,
subcutaneous
bleeding, chills,
fever, sore
throat.
Combivent 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.
Primary
treatment of
status
asthmaticus or
other acute
episodes of
asthma where
intensive
measures are
required.
Hypersensitivity
Neck pain,
cough,
respiratory
infection,
rhinitis, sinusitis,
stridor, gastro
enteritis, oral
candidiasis,
abdominal pain,
dry mouth,
vomiting,
dyspepsia.
Monitor
patient’s
condition before
therapy
reassess
regularly.
Assist client
during
nebulization.
Lactulose 30 cc at
hour sleep
Gastrointestinal/
hepatobiliary
drug
Constipation
Treatment of Hepatic
encephalopathy
Patients who
require a low
lactose diet.
Galactosemia or
disaccharide
deficiency
Abdominal
discomfort
associated with
flatulence and
intestinal
cramps.
Nausea,
Assess
patient’s
condition before
therapy and
reassess
regularly
thereafter to

of 38
Intestinal
obstruction.
vomiting,
diarrhea on
prolonged use.
monitor drug’s
effectiveness.
Pantoprazole 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
Hypersensitivity,
moderate to
severe hepatic
or renal
dysfunction
Headache,
diarrhea,
edema, fever,
onset of
depression,
blurred vision.
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.
Clindamycin
Dalacin C
300 mg/
tab
1 tab every
6 hours
Anti-infectives 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
Assess for
allergic
reactions.
Instruct patient
to take drug
with full glass of
water.

of 38
infections. changes.
Teach patient
aspects of drug
therapy: entire
course of
medication.
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.
Assess
patient’s 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.
Fluimucil 600 mg/
tab
1 tab
dissolves
in ½ glass
of water.
Respiratory
drug
Mucokinetics/
expectorants
Treatment of
respiratory affections
characterized by thick
And viscous
hypersecretions.
Hypersensitivity Pyrosis,
nausea,vomitin
g
Teach patient
proper use,
possible side
effects and
appropriate
interventions.

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Acute and chronic
bronchitis. Instruct patient
to take drug as
directed by the
physician.
Assess for
signs of
hypersensitivity.
Rowatinex 1 cap TID Urinary
Antiseptics
Disinfectants
UTI, post op
prophylaxis of calculi.
1st
trimester of
pregnancy.
Drowsiness,
weakness,
headache,
vertigo,
dizziness, visual
disturbances
Instruct patient
to increase fluid
intake.
Assess for
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.
Pregnancy and
lactation.
Rarely,
hypersensitivity
reactions such
as skin redness
with or without
itching,
photosensitivity,
joint pains,
Assess for
patient’s history
of drug
(azithromycin)
use.
Instruct patient
to take

of 38
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.

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XI. Pathophysiology
Clinical
Manifestations
improved:
Ambulatory
Food taken
orally
Cerebrovascular
System
Risk Factors:
Hypertension
Diabetes
Smoking
Age over 65 years
High cholesterol
SmokingEtiology: Thrombosis
Embolism
Systemic hypoperfusion
Venous thrombosis
Molecular or cellular
changes:
Ischemic cascade
Gross/Anatomical Physical
Changes:
Motor loss
Communication loss
Perceptual disturbances
Sensory loss
Cognitive impairment
Psychological effects
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

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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.

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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

of 38
DATE NURSING
PROBLEM
IDENTIFIED
CUES JUSTIFICATION
August
7,2008
Self Care-
feeding deficit
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
According to Maslow’s
Hierarchy of Needs, in
order to become a self-
actualized 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.
Ineffective
Cerebral Tissue
Perfusion
Subjective:
Objective:
Extremity
weakness,
paralysis
Difficulty in
swallowing
Weak pulses
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.
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

of 38
XIV. Nursing Care Plan

of 38
Nursing Problem Analysis Goal/Objectives Nursing Interventions Rationale Evaluation
Self-care deficit
(feeding)
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
Scientific :
Muscle
Weakness on
face, arms and
legs
Immediate
cause:
Stroke
Intermediate
cause:
High blood
pressure and
High
cholesterol
Root cause:
Unhealthy
lifestyle
After 2 weeks of
nursing intervention,
client will be able to:
1. Utilize maximum
level of
functional
abilities
2. Maximize use of
available
resources for a
more effective
rehabilitation
process
3. Minimize risk
factors such as
smoking and
intake of salty
and fatty food
4. Gain full support
from family
members and
the rest of the
health team
5. Demonstrate
behavioral/lifest
yle changes to
improve health
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
client’s efforts
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
After nursing
intervention, the
client was able
to respond to
interventions and
was able to
demonstrate
positive behavior
changes.

of 38
XV. 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.

of 38
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.
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

of 38
body) to tilt forward. Don't try to hold your head up; instead, let it relax to
the side.
Legs
• Rock and roll: Sit straight in your chair with your hands on your hips.
Gently rock your hips from side to side.
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

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After 1 week.
Diet
Advise client to eat:
Healthy Fats (raw nuts, olive oil, fish oils, flax seeds, avocados)
Colorful, nutrient-loaded fruits and vegetables
Fiber rich foods (whole grains and legumes)It binds with the
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

of 38
High glycemic refined carbs. It causes the body to overproduce
cholesterol and raises the body’s insulin level. High insulin levels are a big
risk in heart disease.
Sex
Advise client not to engage or refrain from sexual activity.
XVI. Bibliography
Books
Doenges, M, Moorhouse, MF, Murr, A: Nurse’s 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 &Suddarth’s 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
AGE/SEX = 70/F *******ABNORMAL ECG
H. /W. = inch/ lb. 701: POOR R PROGRESSION
B.P. = /mmhg 210: MILD LEFT AXIS
DEVIATION
H.R = 73/MIN (O.818S) 142: CLOCKWISE ROTATION
P.R = * S 832: ATRIAL FIBRILATION
QRS = 0.092S

of 38
AXIS = -25DEG
QT/QTc = 0.392S/0.432
Rv5 = 0.47Sv
SVI = 0.60Sv
MEDICATION = unconfirmed
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