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CHAPTER I INTRODUCTION

We as student nurses and future nurses for tomorrow of this institution was given a privilege to take care of a patient who was admitted at OSMUN because of obstructive jaundice secondary to Choledocholithiasis. At first we were so excited because we will have a case finally, but as days goes of hardship and sleepless nights to prepare for the big day .Seeing the things ,events ,people. We realized that maybe in a way nursing is not just taking care of patients or classes of theory. But it was a profession that we should be proud because it was a profession thats puts us not by our parents, relatives, or who so ever pays our tuition. Its god who puts us in this position not just to be a nurse but to be a nurse that delivers his unconditional love to mankind. Post-hepatic jaundice, also called obstructive jaundice, is one of the types of jaundice which are pre-hepatic jaundice is caused by anything which causes an increased rate of hemolysis (breakdown of red blood cells).Then last is Hepatocellular (hepatic) jaundice can be caused by acute hepatitis, hepatotoxicity, and alcoholic liver disease. Cell necrosis reduces the liver's ability to metabolize and excrete bilirubin leading to a buildup of unconjugated bilirubin in the blood. Other causes include primary biliary cirrhosis leading to an increase in plasma conjugated bilirubin. Obstructive jaundice is a condition in which there is blockage of the flow of bile out of the liver. This results in an overflow of bile and its by-products into the blood, and bile excretion from the body is incomplete. Bile contains many by-products, one of which is bilirubin, a

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pigment derived from dead red blood cells. Bilirubin is yellow, and this gives the characteristic yellow appearance of jaundice in the skin, eyes, and mucous membranes. Symptoms of obstructive jaundice include yellow eyes and skin, abdominal pain, and fever.Any type of obstruction that blocks the flow of bile from the liver can cause obstructive jaundice. Most commonly, gallstones create the blockage. Other causes of obstruction include inflammation, tumors, trauma, pancreatic cancer, pancreatic pseudocysts, narrowing of the bile ducts, biliary atresia, ductal carcinoma, and structural abnormalities present at birth. Also, a group of parasites known as "liver flukes" can live in the common bile duct, causing obstructive jaundice. A rare cause of obstructive jaundice is Mirizzi's syndrome. The signs and symptoms of obstructive jaundice differ depending on the completeness of the blockage, and the disease course varies among individuals. Some people with obstructive jaundice may have no symptoms initially, but if the condition persists, they may have severe abdominal pain, fever, nausea, and vomiting. In complete obstruction of the bile duct, no urobilinogen is found in the urine,since bilirubin has no access to the intestine and its in the intestine that bilirubin gets converted to urobilinogen to be later released into the general circulation. In this case, presence of bilirubin(conjugated) in the urine without urine-urobilinogen suggests obstructive jaundice, either intra-hepatic or post-hepatic. The presence of pale stools and dark urine suggests an obstructive or post-hepatic cause as normal feces get their color from bile pigments. However, although pale stools and dark urine are a feature of biliary obstruction, they can occur in many intra-hepatic illnesses and are therefore not a reliable clinical feature to distinguish obstruction from hepatic causes of jaundice.

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Patients also can present with elevated serum cholesterol, and often complain of severe itching or "pruritus" because of the deposition of bile salts. Fortunately, in most cases, obstructive jaundice can be treated with intravenous fluids, antibiotics, and surgical removal of the obstruction.

A. Significance of the study The main goal for choosing this case is to educate not only the readers, but as well the student nurses. Regarding the above mentioned disease conditions. This study will give them ample information regarding how the disease can be acquired and some measures for prevention and treatment, it also aims to provide cues for the immediate identification of signs,symptoms,predisposing,precipitating and risk factors

associated with the clients condition and will thereby serve as the basis in determining the appropriate type of care and interventions to be rendered. And this study serve as a comprehensive tool for better understanding of nurses role. B. Objectives of the Study At the end of the case presentation the student will be able to: Define what is. Obstructive Jaundice 2O to Choledocholithiasis. Identify the Risk Factors in developing Obstructive Jaundice 2O to Choledocholithiasis. Describe the signs and symptoms of To ex Obstructive Jaundice 2O to Choledocholithiasis. Explain the Pathophysiology of Obstructive Jaundice 2O to Choledocholithiasis.

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To be able to use critical thinking skills and knowledge in interpreting assessment data that would be necessary in identifying actual and potential problems on how to manage a Patient with Obstructive Jaundice 2O to Choledocholithiasis.

To educate the readers about the prevention of Obstructive Jaundice 2O to Choledocholithiasis.

Choose suitable Nursing Diagnosis and interventions to be done.

CHAPTER II PATIENT DATABASE A. Demographic Data Our patient is Mrs. Kc she is a 41 year old woman, born on October 03, 1969 in Pampanga. She was 7th among the 10 children of Daddy Echo and Mommy Kristine ,at present she is happily married to Mr. Piolo 45 years old. They are blessed with three wonderful children their eldest daughter is Maja 8 years old ,Next is Luis 6 years old then their youngest son is Billy 4 years old. Mrs. Kc is unemployed and is supported by her husband; they are currently residing in Blk. 10 Bayanan Muntilupa City. 2 weeks prior to admission Mrs. Kc experience colicky pain on epigastric area , accompanied by nausea and vomiting . 1 week prior to admission patient was noted to have icteric sclera patient consulted a physician ultrasound was done and she was transferred for admission in Ospital ng muntinlupa.

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B. Nursing History 1. Gordons Functional Health Patterns Health Perception Health management pattern Mrs. Kc is a a non smoker, she does not drink alcohol. Mrs. Kc does not have any allergies to food or medications, she is taking vitamins specifically Revicon but not continuously.

Nutrition Metabolic pattern Before admission, Mrs. Kc is in atherogenic diet mostly made up of meat chicken,pork or beef every day. He sometimes eats , vegetables but he prefers meat above all. She is fun of eating food rich in seasoning ,during his stay in the hospital she had low fat diet, she does not take any supplement, but he still has a normal appetite. Their are 7 molars missing.

Elimination pattern Mrs. Kc has normal bowel movement (borborygmi) before and during admission when 15 sounds per minute in all quadrants. He defecates 1 per day gray in color , the color of the urine is dark orange.

Activity and Exercise Pattern According to her, the only exercise that he does is to walk around their house and do his chores around the house: sweep the floor and wipe the windows

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every day and take care of her children. She sometimes goes out of their house and walks to his friends house and chat with them.

Sleep Rest Pattern Prior to hospitalization Mrs. Kc has irregular sleep pattern she sleeps for 6 hours a day, he sleeps at 10pm and wakes up around 3am in the morning because of episodes of nausea and vomiting with colicky pain on epigastric area. During the whole duration of his hospitalization Mrs. Kc she only sleeps 6 hours because of generalized itching and discomfort on RUQ and according to her she feels inadequately rested after sleep .

Cognitive Perpetual Pattern According to Mrs. Kc she had no hearing or eye problems, she was alert and coherent she was able to answer all questions, she had no difficulty in speech. Self Perception and Self Concept She is satisfied with her physical appearance according to her she gets easily angry to those people who are liars and do not know how to return depth of gratitude. But during hospitalization she experience inferiority complex upon having jaundice because of her physical appearance. Yet at the same time, he is concerned about how he can get well.

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Role Relationship pattern She has a close relationship with his family, she is already married with 3 children they are 5 in a family , she is unemployed she takes care of the children and do household chores. her spouse is her support system. Their is no family problem encountered lately, and if their is a problem it is easily resolved by having open forums. Their is community interaction problems and she feel of isolation from others.

Sexuality Reproductive Pattern She is sexually active, they are using family planning method Coping Stress Tolerance Pattern According to her if she has problem her way of relieving stress is by

means of sharing it to others, her major concern is on how his family would take care of her and the expenses after he goes out of the hospital. Value Belief Patter She and her husband are both members of the Roman Catholic, the both of them are faithful to the church. They dont have any restrictions on their religion that forbids them to eat any forbidden food. For her religion is very important although she seldom go to church.

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2. Developmental Tasks Sigmund Freud: Psychosexual Development Genital Stage (Ages 12 20 years above) energy is directed toward full sexual maturity and function and development skills needed to cope with the environment. (Kozier 2008:352). Mrs. Kc is in this stage because his interest and energy is focused on the development of interest in the opposite sex. Not like in the earlier stages where the focus was solely on his individual needs. In this stage interest of others develops. she has a healthy and active sex life and does not suffering from any sexual problem she has completed the other stages successfully .

Erik Erikson: Psychosocial Development theory Generativity vs. Stagnation (Middle Adulthood 40-65 years ) Generativity is the concern of establishing and guiding the next generation. Sociallyvalued work and disciplines are expressions of generativity. Simply having or wanting children does not in and of itself achieve generativity. (Kozier 2008: 353). Mrs. Kc is in this stage because she was able to raise a family and Achieve mature, civic and social responsibility. Health History History of Present Illness 2 weeks prior to admission Mrs. Kc experience colicky pain on epigastric area , accompanied by nausea and vomiting . 1 week prior to

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admission patient was noted to have icteric sclera patient consulted a physician, ultrasound was done and she was transferred for admission in Ospital ng muntinlupa.

Past Medical History The patient is a non smoker and non alcohol drinker. The patient stated that she was never been hospitalized before.

3. Family Medical History Her family has a history of hypertension and diabetes in paternal side while heart attack in maternal side. 4. Nursing Assessment INTEGUMENTARY RESULT Has jaundice. Generalized itching or pruritis Dry skin Icteric sclera generalized NORMAL - Evenly colored skin tones without unusual or prominent discoloration. - No itchness - Skin is smooth and even. - No yellowing of the Eyes. SIGNIFICANCE Jaundice results from an abnormally high

accumulation of bilirubin in the

blood as a result of which there is a

With lesions in - the knees abdomen,legs, -

yellowish discoloration to the skin and deep

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arm

tissues.

Jaundice

becomes evident when the serum bilirubin

level rises above 2.0 to 2.5 mg/dL. Pruritus is the primary symptom of cholestasis and is thought to be due to interactions of serum bile acids with opioidergic nerves. Rough,flaky,dry skin is seen hypothyroidism. in

GASTROINTESTINAL RESULT Abdomen yellow in color . 1 BM/day Bowel sounds heard 15 times in a minute in NORMAL Abdominal skin may be paler than the SIGNIFICANCE The bile gives the stool its brown to black color. Obstruction in the bile flow lessens and may hinder the

general skin tone. Normal bowel sound: 5 - 30/min

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four quadrants Stools grayish in color Tenderness in RUQ

Brown in color

absorption of bile in the intestines making the stool pale in color. Tenderness elicited

over the liver may be associated inflammation infection (hepatitis,cholecystitis) with or

URINARY RESULT Urine output of 1,500 cc/shift Dark orange color NORMAL Normal urine output is 30 cc/hr or 1500SIGNIFICANCE Normally urine are not dark in color, excess bilirubin are excreted by the kidneys as a compensatory mechanism to balance the bile level in the body.

1600ml/day

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CHAPTER III THE DISEASE ENTITY

A. Medical Diagnosis with Chief complaints Mrs. Kc was admitted on August 22, 2011 at 4:00 pm in the out patient

department with a chief complaint of yellowing of the sclera and skin. The admitting diagnosis/impression was cholelithiasis.

B. Theoretical Background The gallbladder is a hollow, pear-shaped sac from 7 to 10 cm (3-4 inches) long and 3 cm broad at its widest point. It consists of a fundus, body and neck. It can hold 30 to 50 ml of bile. It lies on the undersurface of the livers right lobe and is attached there by areolar connective tissue. Serous, muscular, and mucous layers compose the wall of the gallbladder. The mucosal lining is arranged in folds called rugae, similar in structure to those of the stomach. The gallbladder stores bile that enters it by way of the hepatic and cystic ducts. During this time the gallbladder concentrates bile fivefold to tenfold. Then later, when digestion occurs in the stomach and intestines, the gallbladder contracts, ejecting the concentrated bile into the

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duodenum. Jaundice a yellow discoloration of the skin and mucosa, results when obstruction of bile flow into the duodenum occurs. Bile is thereby denied its normal exit from the body in the feces. Instead, it is absorbed into the blood, and an excess of bile pigments with a yellow hue enters the blood and is deposited in the tissues.The gallbladder stores about 50 mL (1.7 US fluid ounces / 1.8 Imperial fluid ounces) of bile, which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats and neutralizes acids in partly digested food. After being stored in the gallbladder the bile becomes more concentrated than when it left the liver, increasing its potency and intensifying its effect on fats. Most digestion occurs in the duodenum. C. Pathophysiology of the disease entity

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Pathophysiology of Cerebrovascular Disease

Non-modifiable factors: o o o o Age:69 yrs.old Gender: male Heredity:mother (+) HPN, (+)stroke, (+)MI Race

Modifiable factors: o o o o o o o o HPN: 10 years Sedentary Lifestyle Smoking: 52 pack/yr. (4 years emphysema) Alcohol use: 1 bottle/day Fat, Na diet Atherogenic diet Obesity Hyperlipidemia DM

Thinning and tearing of internal Elastic Lamina

Narrowed arteries

Increased resistance to blood in arteries Adherence of platelets to rough surfaces

Decrease blood flow to body tissues Adenosine diphosphate is released Body compensates by increasing heart rate Initiation of clotting sequence Increase blood flow to narrow arteries Formation of Thrombus Increased Pressure in the arteries

Thrombus remains in place and continue to enlarge Completely occlusion of the lumen

Rupture of Ganglionic arteries

Blood enters the brain tissue

Breaks off of Thrombus

Increased ICP

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Carried to the brain

Lodge in a vessel too narrow to permit further movement Ischemia to area of brain supplied by blocked vessel Cerebral Infarction

s/sx: Behavior changes Decreased consciousness Headache Lethargy Neurological problems Seizures Vomiting

Compression of adjacent brain tissue

Further increase in Intracranial Pressure

Possible Complications:

Clinical Manifestations

Death Permanent neurological problems Reversible neurological problems Seizures Stroke

Frontal Lobe Paralysis of contralateral foot or leg Impaired gait Contralateral sensory loss over toes, foot, and leg Easily distracted Slowness of thought Aphasia depends on the hemisphere involved Urinary incontinence

Deeper structures of the frontal, parietal, and temporal lobes Contralateral hemiplegia Contralateral sensory impairment Aphasia Homonymous hemianoopsia altered consciousness Inability to turn eyes toward paralyzed side, denial of paralyzed side or limb Possible acalculia Alexia Finger anopsia Loft-right confusion Vasomotor paresis

P a g e | 17 Occipital Lobe Contralateral hemiplegia Memory deficits Visual hallucinations Loss of central vision Homonymous hemianopia Thalamus Loss of all sensory modalities Spontaneous pain Intention tremor Mild hemiparesis aphasia

Cerebellum and Brain stem Diplopia Dystaxia Vertigo Dysphagia dysphonia

Cerebral peduncle involvement Oculomotor nerve palsy with contralateral hemiplegia

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CHAPTER IV THE MANAGEMENT

A. Diagnostic Test results & Significance NAME OF TEST Ultrasound (Abdomen) (August 18, 2011) Purpose: The test helps Differentiate between Obstructive and non ob structive jaundice and diagnose cholelithiasis, cholecystitis ,and certain metastases and hematomas. Hct: 0.37 0.47 Hgb: 110 160 gm/L WBC: 5 10 x 10^9/L Lymphocytes: 0.25 0.35 Segmenters: .50 - .65 Platelet: 140 450 x 10^9/L Protein: (-) negative Blood: (-) negative Glucose: (-) negative WBC: 0 5 RBC: 0 2 NORMAL VALUES RESULTS Hyper dense focus at the left putamen with an approximate volume of 20 mL SIGNIFICANCE Hemorrhagic stroke is a rupture of blood vessel in the brain. as a result of the rupture, blood enters the brain, the cerebral ventricles or subarachnoid space. An elevated white blood cell count indicates an infection in the body, a drug reaction, a bone marrow disease or an immune system disorder. Blood in the urine is a sure sign of hematuria.

Complete Blood Count (July 23, 2011) Purpose: CBC is ordered to help in the detection and treatment of anemia; hydration status; and as a part of the routine hospital admission tests. Urinalysis (July 23, 2011) Purpose: is ordered to detect renal and metabolic diseases, diagnosis of disorders of the kidneys or urinary tract; monitoring of patients with diabetes.

.40 131 10.30 .14 .8 N

Negative Positive Negative 12 20 25

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B. Physician initiated interventions 1. Surgery or other medical procedures N/A

2. Drugs

GENERIC/TRADE CLASSIFICATION INDICATION NAME Mannitol Osmotic diuretic To reduce intracranial pressure and brain mass; and intraocular pressure

DOSAGE Adults: 0.5 to 2 g/kg IV infusion as 15 25% solution given over 30 to 60 minutes

ACTION Increases osmotic pressure of plasma in

glomerular filtrate, inhibiting tubular reabsorption of water and electrolytes. These actions enhance water flow from the

NURSING CONSIDERATION - Monitor IV site carefully to avoid extravasatio n and tissue necrosis - In comatose patient, insert indwelling urinary catheter as ordered to monitor urine output. - Monitor renal function tests, urinary output, fluid balance, central venous pressure, and electrolyte levels - Watch for excessive fluid loss

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various tissues and ultimately decrease intracranial and intraocular pressures; serum sodium level while potassium and blood rises -

and sign and symptoms of hypovolemi a and dehydration. Assess for evidence of circulatory overload, including pulmonary edema, water intoxication, and heart failure.

urea levels falls. Also

protects kidneys by preventing toxins from forming and blocking tubules.

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C. Nurse Initiated NURSING CARE PLAN Problem # 1: Difficulty of breathing

Subjective

Objective: (07-25-11)

Use of accessory muscles RR of 33 bpm Productive cough with whitish sputum Sonorous wheeze on both upper lung field History of emphysema NGT ABG: pO2: 324 mmHg HCO3: 26 mmol/L (07-26-11)

Mechanical ventilator: Mode: S/MV TV: 500 PF: 70 BUR: 24

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FiO2:100% PEEP: 5 Nursing Diagnosis: Ineffective airway clearance related to accumulation of secretions secondary to emphysema. Ineffective breathing pattern related to tracheobronchial obstruction Alveolar wall destruction causes alveoli and air spaces to enlarge with loss of corresponding portions of the capillary bed Presence of secretions decreases the gas exchange in the lungs. Work of breathing increases greatly as lung compliance decreases. As moving air in and out of the lungs becomes more and more difficult, the breathing pattern alters to include use of accessory muscles to increase chest excursion to facilitate effective breathing. Right sided weakness decreases the coughing reflex. NIC: airway management; airway suctioning NOC: respiratory status; airway clearance

Expected Outcomes: Short term Goal: After 30 minutes of nursing intervention, the patient will be able to maintain airway patency as evidenced by improvement in respiratory rate from 33 to 20 brpm.

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Long term Goal: After 2 days of nursing intervention, the patient will be able to demonstrate decrease of congestion and improved oxygen exchange as evidenced by absence of nasal flaring, not using accessory muscles for breathing and decrease sonorous wheeze upon auscultation. Nursing Intervention: Dependent: Assessed changes in vital signs and temperature. Tachycardia and hypertension may be related to increase work of breathing or hypoxia. Fever may develop in response to retained secretions or atelectasis or may be a manifestation of an infectious or inflammatory process (Gulanick;Myers,2007). Assessed changes in mental status. Increasing confusion, restless and irritability can be early signs of cerebral hypoxia. Lethargy and somnolence are late signs (Gulanick;Myers,2007). Monitored respiratory patterns, including rate, depth, and effort. A normal respiratory rate for an adult without dyspnea is 12-16 bprm. With secretions in the airway, the respiratory rate will increase (Ackley,2004). Auscultated breath sounds q4; breath sounds are normally clear or scattered fine crackles at bases, which clear with deep breathing. The presence of coarse crackles during late inspiration indicates fluid in the airway; wheezing indicates an airway obstruction (Ackley,2004). Positioned the patient to optimize respiration (e.g. semi-fowlers position and repositioned at least every two hours). An upright position allows for maximal lung

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expansion; lying flat causes abdominal organs to shift toward the chest, which crowds the lungs and makes it more difficult to breathe (Collard et al,2004); to take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of or ventilation to different lung segments (Doenges,2004). Positioned head midline. To open or maintain open airway (Doenges,2004). Suctioned patient to clear the secretions. Needed to clear secretions (Doenges,2004). Performed back rubbing. Mobilize secretions (Doenges,2004).

Independent:

Ensured that O2 delivery system is applied to the patient. So that the appropriate amount of oxygen is continuously delivered and the patient does not desaturate, O2 has been shown to correct hypoxemia, which can be caused by retained respiratory secretions (Ackley,2004).

Used humidity (humidified oxygen). This loosens secretions and facilitates their removal (Gulanick;Myers,2007).

Gave bronchodilators as ordered Combivent neb to q6. This promotes clearance of airway secretions, and bronchodilation decreases airway resistance

(Gulanick;Myers,2007).

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Evaluation:

Short term Goal met: After 30 minutes of nursing intervention, the patient was able to maintain airway patency as evidenced by improvement in respiratory rate from 33 to 20 brpm. Long term Goal partially met: After 2 days of nursing intervention, the patient will be able to demonstrate decrease of congestion and improved oxygen exchange as evidenced by absence of nasal flaring, not using accessory muscles for breathing and decrease sonorous wheeze upon auscultation.

Problem # 2: Decreased Level of Consciousness Subjective: Drowsy but oriented when asked Objective: Lethargic Decreased concentration Vital signs: RR: 33 bpm HR: 108 bpm BP: 140/70 mmHg Glasgow coma scale: 12

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*eye opening response *most appropriate verbal response *most integral motor response

= 4, spontaneous opening = 5, oriented = 3, flexion (decorticate rigidity)

Nursing Diagnosis: Ineffective cerebral tissue perfusion r/t decreased cerebral blood flow. In stroke there is disruption of the cerebral blood flow. This occurrence leads to decreased cerebral tissue oxygenation. Immediate manifestation of decreased oxygen supply to the brain includes lethargy (Smeltzer and Bare, 2004). NIC: Cerebral perfusion promotion NOC: Tissue perfusion: Cerebral

Expected Outcomes: Short term Goal: After 2 hours of nursing intervention, the patient will be free from injury and fall. Long term Goal: After 2 days of nursing intervention, the patient will be able to demonstrate absence of signs of increased ICP such as decrease consciousness, lethargy and behavior changes.

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Nursing Intervention: Assessed LOC using Glasgow coma scale. Glasgow coma scale is widely used objective scale for assessment of neurological patient in the areas of consciousness (best verbal response), best motor response (muscle strength and movement), and papillary reactions (Rogers, 2008). Assessed for nuchal rigidity, twitching, increased restlessness, irritability, onset of seizure activity. Indicative of meningeal irritations (Doenges 2007). Monitored/documented neurological status frequently and compare with baseline. Assesses trends in level of consciousness (LOC) (Doenges, 2007). Monitored vital signs every hour. Changes in rate, especially bradycardia, can occur because of the brain damage. Hypotension may occur because of circulatory collapse (Doenges 2007). Performed a respiratory assessment- rate, rhythm, depth and effort. Changes in respiratory pattern assist in identifying the level of brainstem dysfunction or injury. Evaluation of respiratory pattern must also include of the effectiveness of gas exchange in maintaining adequate oxygen and carbon dioxide level. Alteration in oxygenation or carbon dioxide levels can result in further neurologic dysfunction (Urden and Stacy, 2006). Avoided neck flexion by positioning the patients head properly. Placed the patients head midline, slightly elevated and place pillow at each side of the patients head. This avoid obstruction of the arterial venous blood flow (Lewis, et al,2007).

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Assisted the patient in semi-fowlers position with head midline. Maintains airway, improves airway clearance, maximizes venous return from head; assists in decreasing intracranial pressure and blood pressure (Rogers,2008).

Administered oxygen via endotracheal tube as ordered by the physician. Maximize cerebral oxygenation (due to increased CO2) (Rogers,2008).

Administered Mannitol 150 cc via IV. The active metabolite alpha-norepinephrine stimulates central alpha2-adrenergic receptors in the CNS, resulting in decreased sympathetic outflow from the brain to the heart, kidneys and peripheral vasculature. Antidiuretics decreases intracranial pressure.

Evaluation: Short term Goal met. After 2 hours of nursing intervention, the patient was free from injury and fall. Long term Goal partially met. After 2 days of nursing intervention, the patient was able to demonstrate absence of signs of increased ICP such as decrease consciousness, lethargy and behavior changes.

Problem # 3: Partially impaired swallowing (07-25-11)

Subjective

Objective:

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Depressed gag reflex Right sided weakness o RUE: + o RLE:+

Lethargic NGT (07-26-11)

Nursing Diagnosis: Risk for aspiration related to depressed gag reflex secondary to decrease LOC. The gag reflex prevents foreign objects such as food or fluids from entering the lungs. The reduced level of consciousness causes the gag reflex to be altered predisposing foods or fluids to be aspirated to the lungs (Hauser, 2004).

Expected Outcomes: Short term Goal: After 8 hours of nursing intervention, patients airway patency is maintained as evidenced by no shortness of breath and normal breath sound. Long term Goal: After 2 days of nursing intervention, the patient is free from aspiration. NIC: Aspiration precaution NOC: Risk control

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Nursing Intervention: Dependent: Monitored level of consciousness. A decreased level of consciousness is a prime risk factor for aspiration (Doenges 2007). Assessed cough and gag reflexes. A depressed cough or gag reflex increases the risk of aspiration (Doenges 2007). Maintained the patient in High-fowlers position with head flexed slightly forward during meals. Upright position facilitates gravity flow of food or fluid of food through alimentary tract. Aspiration is less likely to occur with head tilted slightly forward (position narrows airway) (Doenges 2007). Maintained upright position for 45-60 minutes after eating. Helps patient manage oral secretions and reduces risk of regurgitation (Doenges 2007). Placed suction equipment at bedside, and suctioned as possible. With impaired swallowing reflexes, secretions can rapidly accumulate in the posterior pharynx and upper trachea, increasing risk for aspiration (Doenges 2007). Instructed caregiver on signs and symptoms of aspiration. This aids in appropriately assessing high-risk situations and determining when to call for further evaluation (Doenges 2007). Demonstrate to the patient, caregiver, or family what should be done if patient aspirates (e.g. chokes, coughs, becomes short of breath). For example, use of suction, if available. If liquid aspiration, turn the patient three-fourths prone with head

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slightly lower than the chest. Being prepared for an emergency helps prevent further complications. (Doenges 2007).

Collaborative: Collaborate with dietician. Patient needs appropriate diet for CVA and to supply his need.

Evaluation: Short term Goal met: After 8 hours of nursing intervention, patients airway patency is maintained as evidenced by no shortness of breath and normal breath sound. Long term Goal met: After 2 days of nursing intervention, the patient is free from aspiration.

Problem #4: Inability to move Assessment Subjective: As verbalized by the wife, Nahihirapan po siyang gumalaw, mahina po kasi yung kanang parte ng katawan niya. Objective:

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Right sided weakness Decrease ROM on right side of the body Inability to move purposefully within physical environment Decrease muscle strength and control Nursing diagnosis: Impaired physical mobility r/t decrease level of motor function secondary to compression of Basal ganglia Risk for fall related to decrease physical mobility. Impaired coordination due to decrease level of motor function compromises ability to move purposefully within the environment thus causing mobility to be decreased and easily exhausted. (Smeltzer 2004). Decreased physical mobility increases risk for fall that may lead to fracture (LeMone 2005). NIC: Activity tolerance NOC: energy management

Expected Outcomes: Short term goal: After 8 hours of nursing intervention, the client will maintain maximum physical mobility within limitations imposed by the disease or injury and treatment plan.

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Long term goal: After 2 days of nursing intervention patient will maintain to be free from unnecessary injury.

Nursing Intervention: Assessed patients level of mobility. This aids in defining what the patient is capable of, which is necessary before setting of realistic goal (Gulanick; Myers 2007). Assessed patient or caregivers knowledge of immobility and its implications. Even patients who are temporarily immobile are at risk for some of the effects of immobility, muscle weakness, thrombophlebitis, constipation, pneumonia, and depression (Gulanick 2007). Assisted with ADLs as indicated, however avoid doing for patients what they can do for themselves. Assisting the patient with ADLs allows for conservation of energy. Caregivers need to balance providing assistance with facilitating progressive endurance that will ultimately enhance the patients activity tolerance and self-esteem (Gulanick; Myers,2007). Provided positive reinforcement during activity. Patients may be reluctant to move or initiate new activity from a fear of falling or tripping (Gulanick 2007). Allowed patient to perform tasks at his or her own rate. Do not rush the patient. Encourage independent activity as able and safe. Hospital workers and family caregivers are often hurried and do more for patients that needed, thereby slowing patients recovery and reducing his or her self esteem (Gulanick 2007).

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Performed/Assisted in ROM exercises. The longer the patient remains immobile the greater the level of debilitation that will occur, and minimizes muscle atrophy and muscle contractures (Doenges, 2007).

Taught energy saving techniques. To optimize patients limited services (Gulanick 2007).

Referred to multidisciplinary health team as appropriate. Physical therapists can provide specialized services (Gulanick 2007).

Evaluation: Short term goal met: After 8 hours of nursing intervention, the client was able to maintain maximum physical mobility within limitations imposed by the disease Long term goal met: After 2 days of nursing intervention patient will maintain to be free from unnecessary injury.

Problem #5: Slurred speech Subjective Objective Difficulty producing speech Difficulty vocalizing words Poor eye contact

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Nursing diagnosis: Impaired verbal communication related to compression of left putamen. Putamen is the covering of basal ganglia which is responsible for motor, thus compression of this affects one motor function. The vertebral arteries and branches provide blood to the back half of the brain. Damage to this artery can cause difficulty in talking (Sessler, 2004.) NIC: communication enhancement: speech deficit NOC: information processing

Expected Outcome: Short term Goal: After 1 hour of nursing intervention, patient will be able to choose a comfortable or preferred way of communication. Long term Goal: After an hour of nursing intervention, patient will be able to use a form of communication to get needs met and to relate effectively with persons and his environment. Nursing Interventions: Assessed the patients primary and preferred means of communication (e.g. verbal, written or gestures. Patients may have skill with many forms of communication, yet they will prefer one method for important communication (Gulanick;Myers,2007).

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Assessed patients energy level. Fatigue and/or shortness of breath can make communication difficult or impossible (Gulanick 2007).

Assessed knowledge of patients familys, or caregivers understanding of sign language, as appropriate. Individuals who have no formal training in sign language usually develop mechanisms for communication, but because communication is such a critical aspect of everyones life, consider formal training for patients and caregivers to enhance communication (Gulanick;Myers,2007).

Placed important objects within reach. This maximizes patients sense of independence (Gulanick 2007).

Encouraged patients attempts to communicate; praise attempts and achievements. Positive feedback enhances the patients efforts to overcome communication barriers (Gulanick;Myers,2007).

Listened attentively when the patient attempted to communicate and clarified understanding of the patients communication with the patient or watcher. Patients need feedback about the success of their communication attempts. Feedback promotes effective communication by allowing the sender of the message to verify that the message sent was the message received (Gulanick;Myers,2007).

Demonstrated communication techniques, such as gestures, sign language, and eye blinking to patient. To develop alternative communication skills (Doenges 2007).

Used short sentences and asked only one question at a time. This allows the patient to stay focused on one thought. Sudden shifts from one subject to another does not allow time for the brain to keep pace with the messages (Gulanick;Myers,2007).

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Never talk in front of patient as though he or she comprehends nothing. This will prevent increasing the patients sense of frustration and feelings of helplessness (Gulanick 2007).

Gave the patient ample time to respond. It may be difficult for patients to respond under pressure; they may need extra time to organize responses, find the correct word, or make necessary language translations (Gulanick 2007).

Evaluation: Short term Goal met: After 5 minutes of nursing intervention, patient was able to choose a comfortable or preferred way of communication. Long term Goal met: After an hour of nursing intervention, patient was able to use a form of communication to get needs met and to relate effectively with persons and his environment.

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CHAPTER V GENERAL IMPLICATION OF THE STUDY A. General Implication of the Study Nursing Education One of the factors in improving therapeutic care for the client is nursing education. The research study implies that nurses must have more knowledge about the disease, called Cerebrovascular Disease. In acquiring this knowledge these will help them to identify the manifestations, treatment and how to take care of the patient. Nursing Practice Nursing practice is a vital part of nursing management of a patient, if researches study the appropriate care and interventions regarding CVD patients, they could manage the patient well, and the knowledge that they must possess must include, right medicines, treatments and proper diagnostic procedures. Nursing Research Within the research it contains the information that one must know about the disease process of CVD. The research was done thoroughly to give right information and data, in the making of the research it was formulated that the reader may enhance their learning and knowledge.

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B. Summary and Conclusion Cerebrovascular Disease is one of the leading causes of death, which is manifested by persisting neurologic symptoms, such as numbness and paralysis. Nowadays, stroke is a manageable and treatable problem if it is diagnosed earlier. However, because of the minute knowledge of the population about the early signs and symptoms many of the clients still suffer from the consequence of stroke. The aim of the treatment of people with stroke is to maximize the function and preventing disability. And the greatest factor in a persons life in developing CVD is lifestyle. For a person to be cautious he must first know the disease process. In caring for a CVD patient, they need you full understanding, nurses should always extend to them their caring personality, not only to the patient/client but also to the family of the client.

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BIBLIOGRAPHY

A. Books 1. Ackley, B. & Ladwig, G. (2006). Nursing Diagnosis Handbook (7th edition) Singapore: Mosby Inc. 2. Chernecky, C. & Barbara B, (2008).Laboratory Tests and Diagnostic Procedures (5th edition) Missouri: Saunders Elsevier. 3. Doenges, M. Et. al.,(2006).Nursing Care Plans (7th edition) Pennsylvania: Davis Company Philadelphia. 4. Gulanick, M. (2005). Nursing Care Plans: Nursing Diagnosis and Interventions (5thedition). USA Mosby 5. Kozier, B. et. al. (2008). Fundamentals of Nursing Concepts, Process and Practice (8th edition) Singapore: Pearson Education South Asia Pte. Ltd. 6. LeMone, Priscilla. Et al. (2005). Fundamental of Nursing the Art and Science of Nursing Care (5th edition) USA: Lippincott Williams and Wilkins. 7. Schull, P.(2008) Nursing Spectrum Drug Handbook. McGrow Hill 8. Smeltzer, S. C. & Bare, B. G., (2005).Brunner & Suddarths Testxbook of Medical Surgical Nursing, Vol. 1&2 (11th edition). Lippincott Williams & Wilkins. 9. Tortora, G. J & Grabowski, S. R.,(2006). Principles of Anatomy and Physiology(11th edition) New Jersey: Jphn Wiley and Sons, Inc. 10. Udan, Josie Quiambao. (2002). Medical Surgical Nursing: Concepts and Clinical Application. (1st edition). Philippines: Educational Publishing House.

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B. Internet http://www.medicinenet.com/script/main/hp.asp