Liceo de Cagayan University

College of Nursing
NCM501204

A Case Presentation of

‘Cerebrovascular
accident’
Submitted to:
Mr. Rey Solde; RN MAN

Submitted by:
Mellitante, Jandale
Mendoza, Lucky Dawn
Miranda Neil
Namocatcat, Meriam Dominice
Oliveros, Melvin
Pearson, Almathea

February 4, 2010
TABLE OF CONTENTS
Page
 I. Introduction……………………………………………………………………………..
a. Overview of the Case………………………………………………………
b. Objective of the Study……………………………………………………..
c. Scope and Limitation………………………………………………………

II. Health History……………………………………………………………………………

a. Profile of the Patient…………………………………………………………
b. Family and Health History………………………………………………….
c. History of Present Illness……………………………………………….....

III. Developmental Data…………………………………………………………………….

IV. Medical Management……………………………………………………………………

a. Medical Orders……………………………………………………………..
b. Significant Laboratory Exam………………………………………………
c. Drugs Study…………………….…………………………………

V. Anatomy, Physiology and Pathophysiology…

VI. Nursing Assessment ………………………………………………………………….

(System Review Chart and Nursing Assessment II)

VII. Nursing Management…………………………………………………………………..

a. Ideal Nursing Management (NCP)……………………………………….
b. Actual Nursing Management (SOAPIE)……………………………….

VIII. Evaluation ……………………………………………………………………………….

IX. Referrals and Follow-up …………………...……………………………………….…

X. Bibliography……………………………………………………………………………..

XI. Documentation……………………………………………………………………….....

I. Introduction:
 a. Overview of the Case

A stroke (sometimes called an acute Cerebrovascular attack) is the rapidly developing loss of brain
function(s) due to disturbance in the blood supply to the brain. This can be due to ischemia (lack of
glucose and oxygen supply caused by thrombosis or embolism or due to a hemorrhage. As a
result, the affected area of the brain is unable to function, leading to inability to move one or more
limbs on one side of the body, inability to understand or formulate speech, or inability to see one
side of the visual field.

A stroke is a medical emergency and can cause permanent neurological damage, complications,
and death. It is the leading cause of adult disability in the United States and Europe. It is the
number two cause of death worldwide and may soon become the leading cause of death
worldwide. Risk factors for stroke include advanced age, hypertension (high blood pressure),
previous stroke or transient ischemic attack (TIA), diabetes, high cholesterol, cigarette smoking
and atrial fibrillation.[4] High blood pressure is the most important modifiable risk factor of stroke.

The traditional definition of stroke, devised by the World Health Organization in the 1970s,] is a
"neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by
death within 24 hours". This definition was supposed to reflect the reversibility of tissue damage
and was devised for the purpose, with the time frame of 24 hours being chosen arbitrarily. The 24-
hour limit divides stroke from transient ischemic attack, which is a related syndrome of stroke
symptoms that resolve completely within 24 hours. With the availability of treatments that, when
given early, can reduce stroke severity, many now prefer alternative concepts, such as brain attack
and acute ischemic Cerebrovascular syndrome (modeled after heart attack and acute coronary
syndrome respectively), that reflect the urgency of stroke symptoms and the need to act swiftly. [6]

A stroke is occasionally treated with thrombolysis ("clot buster"), but usually with supportive care
(speech and language therapy, physiotherapy and occupational therapy) in a "stroke unit" and
secondary prevention with antiplatelet drugs (aspirin and often dipyridamole), blood pressure
control, statins, and in selected patients with carotid endarterectomy and anticoagulation.

Ischemic stroke
In an ischemic stroke, blood supply to part of the brain is decreased, leading to dysfunction of the
brain tissue in that area. There are four reasons why this might happen:

1. Thrombosis (obstruction of a blood vessel by a blood clot forming locally)

2. Embolism (obstruction due to an embolus from elsewhere in the body, see below),

3. Systemic hypoperfusion (general decrease in blood supply, e.g. in shock)

4. Venous thrombosis.

Stroke without an obvious explanation is termed "cryptogenic" (of unknown origin); this constitutes
30-40% of all ischemic strokes.

There are various classification systems for acute ischemic stroke. The Oxford Community Stroke
Project classification (OCSP, also known as the Bamford or Oxford classification) relies primarily
on the initial symptoms; based on the extent of the symptoms, the stroke episode is classified as
total anterior circulation infarct (TACI), partial anterior circulation infarct (PACI), lacunar infarct
(LACI) or posterior circulation infarct (POCI). These four entities predict the extent of the stroke, the
area of the brain affected, the underlying cause, and the prognosis. [11][12] The TOAST (Trial of Org
10172 in Acute Stroke Treatment) classification is based on clinical symptoms as well as results of
further investigations; on this basis, a stroke is classified as being due to (1) thrombosis or
embolism due to atherosclerosis of a large artery, (2) embolism of cardiac origin, (3) occlusion of a
small blood vessel, (4) other determined cause, (5) undetermined cause (two possible causes, no
cause identified, or incomplete investigation).

b. Objective of the Study

 After 1 hour of Presentation of the case (Cerebrovascular Accident), we, students and
audience, will be able to:

1. Acquire knowledge about the disease process.

2. Discuss thoroughly the disease process.
3. Formulate realistic and appropriate nursing care plans.
4. Identify and learn more about the treatment and modalities of the said disease
5. Apply the nursing process and appreciate its significance in nursing practice.

c. Scope and Limitation

This study covers about facts related to patient’s condition. It includes the nature, causes,
signs and symptoms, Pathophysiology, prognosis, treatment and the nursing interventions
appropriate for his condition. A nursing care plan is also provided which serves as a guide for the
interventions to be applied to the patient to aid in recovery and it will also serve as basis for the
evaluation of client care outcomes. Health teachings including referrals were also imparted to the
patient and the watcher to ensure his recovery during hospital stay and after discharge.
It is limited only to the case of our client. For the completion of this study, some information
was taken from significant others. The assessment and so with the interventions rendered to the
patient were also limited due to time constraint, with a total of 2 days, dated December 9 and 10 of
2009. Thus, we’ve supplemented our study with facts from various references.
II. Health History

a. Patient’s Profile

Name: S.R.
Address: Elzalvador, Misamis Oriental
Sex: Male
Age: 59 years old
Birth date: April 20, 1951
Place of Birth: Cebu City
Educational Attainment: College Graduate
Occupation: Pensioner
Height: 5’4” inches tall
Weight: 84 kg
Civil status: Married
Name of Spouse: N.S.
Income: Base only on every month received from pension (5,000
pesos
Citizenship: Filipino
Religion: Roman Catholic
Date of Admission: December 07, 2009
Time of Admission: 7:54 pm
Chief Complaints: Dizziness and Headache, later fall down hitting his
forehead and loss of consciousness
Admitting Diagnosis: Cerebrovascular Accident
Attending Physician: Dr. Surdilla
III. Health History

A. History of Present Illness

This is the case of R.S; who was admitted in Cagayan de Oro Medical Center at
their Intensive Care Unit area last December. She was already known for being hypertensive for
almost 20 years from this present day. She was maintaining anti hypertensive drugs like vascor
and Metropolol.
One day prior to admission he was apparently well and went to the city at late in the
afternoon to buy some herbal medicines from certain company called ‘DXN’ where his friends
advise him to buy which they believe that it can treat hypertension and other diseases. When he
was bout to leave the building suddenly he felt dizzy and headache, inspite of what he felt he still
try to wall in the hall way until he reached the outside the building. Until he suddenly felt more dizzy
and fell down on the ground.
He was brought to the hospital by the people who had seen the accident and they call one
of his friends when they try to look some information from his wallet. His friend was the one who’s
with him when he was at the emergency area.
Upon her arrival at the hospital at the emergency department he was cater under the care
of Dr. Surdilla. They just found out after checking his vital signs and signs and symptoms that he
just had a stroke (Cerebrovascular accident).

B. Family History and Health History

Upon assessment, client and the significant others h he was 20 years old and used to
consume about 1pack of cigarette stick in a day. He was also heavy drinker of alcohol in which he
can consume about 1 case of ‘’ jumbo red horse ‘’ in every week.
He was admitted last June, 2008 at one hospital in the city and diagnose with
hypertension. Since then he was already maintaining anti hypertension drugs as mentioned earlier.
On the first month he was cooperative and used to take the medication seriously but on the later
months when he felt that he don’t have the symptoms of hypertension he had an on and off taking
compliance of medication. And occasionally continue smoking and still drinks alcohol until the
present day.

III. Developmental Data

Developmental theories of learning have to do with the additional learning tasks individuals
can accomplish as they mature mentally, emotionally, and physically. Although this maturation
actually progresses in slow, continuous fashion, it is often described as proceeding in stages.
Many names are associated with developmental research. The following people and their
stages of development are important in the field of development theory

FREUD’S PSYCHOSEXUAL THEORY

Genital Stage: 13 yrs and above
Freud’s advanced a theory of personality development that centered on the effects of the
sexual pleasure drive on the individual psyche. At particular points in the developmental process,
he claimed, a single body part is particularly sensitive to sexual, erotic stimulation.
Based on Sigmund Freud’s Psychosexual Stages of development our client belongs to the
genital Stage. Characteristics of this stage are that energy of a person is directed toward full sexual
maturity and function and development of skills needed to cope with environment as well as its
demands. The patient is able to achieve independence and able to practice decision-making. But
this condition the patient needs support from family in activities of daily living as well as decision
making to his present condition.

ERIKSON’S THEORY OF PSYCHOSOCIAL DEVELOPMENT THEORY

ROBERT J. HAVIGHURST’S DEVELOPMENTAL THEORY

PIAGET’S COGNITIVE DEVELOPMENT THEORY

Formal Operations Phase: 11- 15 and above

In this developmental theory, our patient belongs to FORMAL-OPERATIONAL wherein

logical reasoning processes are applied to abstract ideas as well as concrete objects. This is the
time when people are most capable of forming new concepts and shifting their thinking in order to
solve problems and general concepts are related to specific situations and alternatives are
considered.

IV. Medical Management:

A.Doctor’s Order:
B.Significant Laboratory exam :
 CT scans (without contrast enhancements)

Sensitivity= 16%
Specificity= 96%
 MRI scan

Sensitivity= 83%
Specificity= 98%

C. Drug Study:
Name of Drug: Citicoline 100mg TID
Date Ordered: Dec.07, 2009

Classification: Central Nervous System Drugs (CNS stimulants /Neurotonics)

Mechanism of Action: increase dopamine receptor densities, and suggest that CDP-choline
supplementation can ameliorate memory impairment caused by
environmental conditions.
Specific Indication: CVA in acute and recovery phase.w/ symptoms and signs of
cerebral insuffiency; dizziness, headache and recent crania
trauma.
Contraindication: Hypersensitivity; Contraindicated in hypertonia of the
parasympathetic meclofenoxate (clophexonate).
Side Effects/Toxic Effects: It stimulates parasympathetic action and fleeting and discreet hypotensor
effect.
Nursing Precaution: Use cautiously in patients& observe proper dosage, take vital signs
Before Giving the medication can cause sudden drop of vital signs.

Name of Drug: Metropolol 25mg q8h

Date Ordered:
Classification:
Mechanism of Action:
Specific Indication:
Dec. 07, 2009
antihypertensive, anti- anginas
Bocks stimulation of beta adrenergic receptor; doest not usually affect
beta2- adrenergic receptor sites.
Hypertension, prevention of M.I. and decreased mortality in
patients with recent M.I. management of stable angina,

Contraindication:
Side Effects/Toxic Effects: Dizziness, fatigue, anxiety, drowsiness, nervousness, erectile
Nursing Precaution:
Name of Drug:
Date Ordered:
Classification:
Mechanism of Action:
Specific Indication:
Contraindication:
Side Effects/Toxic Effects:
Nursing Precaution:
Name of Drug:
Date Ordered:
Classification:
Mechanism of Action:
Symptomatic heart failure due to ischemic hypertensive or
cardiomyopathic origin
Hypersensitivity
Dysfunction, hyperglycemia, back pain, dry mouth
. Monitor for possible drug induced adverse reactions
Captopril 80mg q8h
Dec 07, 2009
Angiotensin- converting enzyme ace inhibitors
It blocks the conversion of angiotensin1 to the vasoconstrictor
angiotensin2. It also prevents degradation of bradykinin and other
vasodilatory prostaglandins.
alone or with other agents in the management of hypertension.
hypersensitivity; history of angioedema with previous use of ace
Inhibitors
dizziness, drowsiness, fatigue, headache, weakness, cough, dyspnea
Monitor for possible drug induced adverse reactions
Valsartan 20mg BID
Dec. 07, 2009
Angiotensin 2 receptor antagonist; Antihypertensives
blocks vasoconstrictor and aldosterone producing effects of angiotensin
2 at receptor sites including vascular smooth muscles and adrenal
glands.
Specific Indication:
Contraindication:
Side Effects/Toxic Effects: Headache, dizziness, anxiety, depression, fatigue, weakness
Nursing Precaution:
Name of Drug:
Date Ordered:
Classification:
Mechanism of Action:
Specific Indication:
Contraindication:
Side Effects/Toxic Effects:
Nursing Precaution:
Name of Drug:
Date Ordered:
Classification:
Mechanism of Action:
Specific Indication:
Contraindication:
alone or with other agent in the management of hypertension
Hypersensitivity
use cautiously in CHF patients may result oliguria, acute renal
Failure.
tranexamic acid / Hemostan 800 mg q6h
Dec.07, 2009
cardiovascular drugs/ hemostatics
Tranexamic acid is a competitive inhibitor of plasminogen activation,
and at much higher concentrations, a noncompetitive inhibitor of
plasmin.
control of hemorrhage in surgical and clinical cases, hemostatics for
traumatic injuries.
severe renal insufficiency, patients with microscopic hematuria
GI disturbances, giddiness, hypotension, color vision disturbances.
Use with caution in patients with thromboembolic disease.
Mannitol 100cc q4h
Dec.09, 2009
Diuretics
increase the osmotic pressure of the glumerular filtrate, thereby
inhibiting Reabsorption of water and electrolytes cause of
excretion of water, sodium, potassium, sodium chloride calcium,
Uric acid, urea, magnesium
adjunct treatment of acute oliguric renal failure, edema, increase
Intracranial or intraocular pressure, toxic overdose
Hypersensitivity; anuria dehydration
Side Effects/Toxic Effects: transient volume expansion, confusion, pulmonary edema, urinary
retention, nausea and vomiting, thirst
Nursing Precaution: Used cautiously to patient with drug –drug interactions increase the risk
of digoxin toxicity.

VII. Anatomy and Physiology, Pathophysiology

The nervous system is an organ system containing a network of specialized cells called neurons
that coordinate the actions of an animal and transmit signals between different parts of its body. In
most animals the nervous system consists of two parts, central and peripheral. The central nervous
system contains the brain and spinal cord. The peripheral nervous system consists of sensory
neurons, clusters of neurons called ganglia, and nerves connecting them to each other and to the
central nervous system. These regions are all interconnected by means of complex neural
pathways. The enteric nervous system, a subsystem of the peripheral nervous system, has the
capacity, even when severed from the rest of the nervous system through its primary connection by
the vagus nerve, to function independently in controlling the gastrointestinal system.

Neurons send signals to other cells as electrochemical waves travelling along thin fibres called
axons, which cause chemicals called neurotransmitters to be released at junctions called
synapses. A cell that receives a synaptic signal may be excited, inhibited, or otherwise modulated.
Sensory neurons are activated by physical stimuli impinging on them, and send signals that inform
the central nervous system of the state of the body and the external environment. Motor neurons,
situated either in the central nervous system or in peripheral ganglia, connect the nervous system
to muscles or other effector organs. Central neurons, which in vertebrates greatly outnumber the
other types, make all of their input and output connections with other neurons. The interactions of
all these types of neurons form neural circuits that generate an organism's perception of the world
and determine its behavior. Along with neurons, the nervous system contains other specialized
cells called glial cells (or simply glia), which provide structural and metabolic support.

Nervous systems are found in most multicellular animals, but vary greatly in complexity. [1] Sponges
have no nervous system, although they have homologs of many genes that play crucial roles in
nervous system function, and are capable of several whole-body responses, including a primitive
form of locomotion. Placozoans and mesozoans—other simple animals that are not classified as
part of the subkingdom Eumetazoa—also have no nervous system. In Radiata (radially symmetric
animals such as jellyfish) the nervous system consists of a simple nerve net. Bilateria, which
include the great majority of vertebrates and invertebrates, all have a nervous system containing a
brain, spinal cord, and peripheral nerves.
Structure

The nervous system derives its name from nerves, which are cylindrical bundles of tissue that
emanate from the brain and spinal cord and branch repeatedly to innervate every part of the body.
Nerves are large enough to have been recognized by the ancient Egyptians, Greeks, and Romans,
but their internal structure was not understood until it became possible to examine them using a
microscope. A microscopic examination shows that nerves consist primarily of the axons of
neurons, along with a variety of membranes that wrap around them and segregate them into
fascicles. The neurons that give rise to nerves do not lie within them—their cell bodies reside within
the brain, spinal cord, or peripheral ganglia.

All animals more advanced than sponges have a nervous system. However, even sponges,
unicellular animals, and non-animals such as slime molds have cell-to-cell signalling mechanisms
that are precursors to those of neurons. In radially symmetric animals such as the jellyfish and
hydra, the nervous system consists of a diffuse network of isolated cells. In bilaterian animals,
which make up the great majority of existing species, the nervous system has a common structure
that originated early in the Cambrian period, over 500 million years ago.
Cells

The nervous system is primarily made up of two categories of cells: neurons and glial cells

Neurons

The nervous system is defined by the presence of a special type of cell, the neuron (sometimes
called "neurone" or "nerve cell"). Neurons can be distinguished from other cells in a number of
ways, but their most fundamental property is that they communicate with other cells via synapses,
which are membrane-to-membrane junctions containing molecular machinery that allows rapid
transmission of signals, either electrical or chemical. Many types of neuron possess an axon, a
protoplasmic protrusion that can extend to distant parts of the body and make thousands of
synaptic contacts. Axons frequently travel through the body in bundles called nerves.

Even in the nervous system of a single species such as humans, hundreds of different types of
neurons exist, with a wide variety of morphologies and functions.These include sensory neurons
that transmute physical stimuli such as light and sound into neural signals, and motor neurons that
transmute neural signals into activation of mucles or glands; however in many species the great
majority of neurons receive all of their input from other neurons and send their output to other
neurons.

Glial cells

Glial cells are non-neuronal cells that provide support and nutrition, maintain homeostasis, form
myelin, and participate in signal transmission in the nervous system.In the human brain, it is
estimated that the total number of glia roughly equals the number of neurons, although the
proportions vary in different brain areas.Among the most important functions of glial cells are to
support neurons and hold them in place; to supply nutrients to neurons; to insulate neurons
electrically; to destroy pathogens and remove dead neurons; and to provide guidance cues
directing the axons of neurons to their targets.One very important type of glial cell generates layers
of a fatty substance called myelin that wraps around axons and provides electrical insulation which
allows them to transmit action potentials much more rapidly and efficiently.
The central nervous system (CNS) is the largest part, and includes the brain and spinal cord. The
spinal cavity contains the spinal cord, while the head contains the brain. The CNS is enclosed and
protected by meninges, a three-layered system of membranes, including a tough, leathery outer
layer called the dura mater. The brain is also protected by the skull, and the spinal cord by the
vertebrae.

The peripheral nervous system (PNS) is a collective term for the nervous system structures that do
not lie within the CNS.The large majority of the axon bundles called nerves are considered to
belong to the PNS, even when the cell bodies of the neurons to which they belong reside within the
brain or spinal cord. The PNS is divided into somatic and visceral parts. The somatic part consists
of the nerves that innervate the skin, joints, and muscles. The cell bodies of somatic sensory
neurons lie in dorsal root ganglia of the spinal cord. The visceral part, also known as the autonomic
nervous system, contains neurons that innervate the internal organs, blood vessels, and glands.
The autonomic nervous system itself consists of two parts: the sympathetic nervous system and
the parasympathetic nervous system. Some authors also include sensory neurons whose cell
bodies lie in the periphery (for senses such as hearing) as part of the PNS; others, however, omit
them.

Horizontal bisection of the head of an adult man, showing skin, skull, and brain with grey matter
(brown in this image) and underlying white matter

The vertebrate nervous system can also be divided into areas called grey matter ("gray matter" in
American spelling) and white matter.[14] Grey matter (which is only grey in preserved tissue, and is
better described as pink or light brown in living tissue) contains a high proportion of cell bodies of
neurons. White matter is composed mainly of myelinated axons, and takes its color from the
myelin. White matter includes all of the peripheral nerves, and much of the interior of the brain and
spinal cord. Grey matter is found in clusters of neurons in the brain and spinal cord, and in cortical
layers that line their surfaces. There is an anatomical convention that a cluster of neurons in the
brain or spinal cord is called a nucleus, whereas a cluster of neurons in the periphery is called a
ganglion There are, however, a few exceptions to this rule, notably including the part of the
forebrain called the basal ganglia.

Pathophysiology
NURSING ASSESSMENT
 Nursing System Review Chart:

Name: S.R. Age: 59 Sex: Male BP: 130 /80 mmHg

Status: Married Temp: 36.5’C Height: 5’4
Pulse Rate: 80 bpm Resp. Rate: 16 cpm Weight: 72 kg head injury due
to fall
[x] Impaired vision [ ] blind
[ ] pain redden [ ] drainage With nasogastric
[ ] gums [ ] hard of hearing [ ] deaf tubing at the right Oxygen supply
[ ] burning [ ] edema [ ] lesion teeth nostril Via nasal
Assess eyes ears nose cannula
[ ] throat for abnormality [ ] no problem
RESP:
[ ] asymmetric [ ] tachypnea [ ] barrel chest paralysis at the altered
[ ] apnea [ ] rales [ ] cough lower right swallowing
[x] Bradypnea [ ] shallow [ ] rhonchi extremeties
[ ] sputum [ ] diminished [ ] dyspnea
[ ] orthopnea [ ] labored [ ] wheezing
Dry mouth
[ ] pain [ ] cyanotic
Assess Resp. rate, rhythm, pulse blood
[ ] breath sounds, comfort [ ] no problem
CARDIOVASCULAR:
[ ] arrhythmia [ ] tachycardia [ ] numbness Catherization
[ ] diminished pulses [ ] edema [ ] fatigue site (uro bag
[ ] irregular [ ] bradycardia [ ] mur mur attached at
[ ] tingling [ ] absent pulses [x] pain the bed side)
Assess heart sounds, rate rhythm, pulse, blood
Pressure, circ., fluid retention, comfort
[ ] No problem
GASTROINTESTINAL TRACT:
[ ] obese [ ] distention [ ] mass
[x] Dysphagia [ ] rigidity [ ] pain
Assess abdomen, bowel habits, swallowing
Bowel sounds, comfort [ ] no problem
GENITO – URINARY AND GYNE
[ ] pain [ ] urine [ ] color [ ] vaginal bleeding
[ ] hematuria [ ] discharge [ ] nocturia
[ ] gyne bleeding [ ] discharge [x] no problem
Assess urine frequency, control, color, odor, comfort
NEURO:
[x] Paralysis [x] stuporus [ ] unsteady [ ] seizure
[ ] lethargic [ ] assess motor, function, sensation, LOC, strength [ ] grip,
gait, coordination, (x) speech
[ ] no problem Generalized
MUSCULOSKELETAL and SKIN: body weakness
Untrimmed
[ ] appliance [ ] stiffness [ ] itching [ ] petechie finger nails
[ ] hot [ ] drainage [ ] prosthesis [ ] swelling
[ ] lesion [ ] poor turgor [ ] cool [ ] flushed IV
[ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic insertion
Assess(x) mobility, motion gait, alignment, joint function site
Skin color, texture, turgor, integrity
[ ] no problem
IV. Nursing Assessment Pulse
SUBJECTIVE OBJECTIVE oxymeter
COMMUNICATION: Comments: the patient [ ] glasses [ ] languages
[ ] hearing loss was stuporous and his [ ] contact lenses [ ] hearing aide
[ ] visual changes speech was affected Pupil size: anisocoria /Unequal size of pupil
[ x] denied also due to the present L:3mm R:4mm
disease condition. but [x ] speech difficulties
the patient was able to Reaction: sluggish reaction
used alternative
communication in
communicating us like
nodding and sign
language.
OXYGENATION: Resp. [√] regular [ ] irregular
[ ] dyspnea Comments: the Describe: ( respiration are both symmetrical in left
[x] smoking history patient’s daughter and right area
[ ] cough states that his father R: 16 cpm symmetrical
[ ]sputum was a smoker. L: 16 cpm symmetrical
[ ] denied
CIRCULATION: Heart Rhythm [ ] regular [/ ] irregular
[ x] chest pain Comments: The patient Ankle Edema none seen
[ ] leg pain shows a nod when he Pulse Car Rad. DP Fem*
[ ] numbness of was ask if he was R + 80bpm +___ + _
extremities experiencing pain. And L + 80bpm +___ +_
[ ] denied he pointed his chest. Comments: The pulse are palpable and is
irregularly fast
NUTRITION:
Low salt diet Comments: [ ]dentures [x]none
[]N[]V None
Character >the patient was Full Partial
[ ]recent change in unresponsive
weight and appetite Upper [] []
[ x] swallowing
 Difficulty Note: presence of Lower [] []
[ ] denied nasogastric tube for Note: the patient have no presence of dentures
feeding due to impaired
function of swallowing
of the cranial nerve
affected.
ELIMINATION: None Bowel sound:
Usual bowel pattern normoactive bowel
Once a day [ ] urgency Note: the patient was sound.
[ ] constipation [ ] dysuria unresponsive Abdominal Distention
remedy [ ] hematuria Present [] yes [ ] no
NONE [ ] incontinence Urine* (color,
Date of last BM [ ] Polyuria consistency, odor)
Dec. 7, 2008 [ x] foley in place Urine color is dark
[ ] diarrhea [ ] denied yellow with aromatic
character odor.

MGT. OF HEALTH & ILLNESS: Briefly describe the patient’s ability to follow
[√] alcohol [ ] denied treatments (diet, meds, etc.) for chronic health
(amount & frequency) problems (if present):
The patient is a heavy drinker with no known limits The patient was very cooperative during the
[ ] SBE Last Pap Smear: N/A LMP: N/A treatment.
Skin Integrity
[x ] dry Comments: the [x] dry [ ] cold [ ] pale
[ ] itching patient’s skin shows [ ] flushed [ ] warm
[ ] denied dryness. [ ] moist [ ] cyanotic
[ ]moist Rashes,ulcers,decubitus (describe size,
location,drainage)
>the patient’s skin is dry and it has no rashes, and
ulcers that can be found
Activity Safety Comments: [ ]LOC and orientation:
[ ] convulsion The patient was The patient was having an altered speech due to
[ ]dizziness experiencing paralysis the accident and he has altered level of
[x ] limited motion of joints at lower right consciousness
Limitation in extremities and have Gait: [ ] walker [ ] cane [ ] other
ability to limited range of motion >the patient has limited range of motion and in
[x ] ambulate due to the accident Complete Bed Rest.
[ x]bathe self [x] steady [ ]unsteady___________
[ ] denied [x] sensory and motor losses in face or extremities:
the patient was experiencing lower extremities
paralysis

] ROM limitations: the patient has limited range of

motion
Comfort/Sleep/Awake
[ ] pain Comments: none [ x] facial grimaces
(location frequency Note: [ ] guarding
remedies) >The patient was [ ] other signs of pain:
[ ] nocturia unresponsive patient is weak in appearance and shows no other
[ ] sleep difficulties signs of pain except for facial grimace
[x ] denied
[ ] side rail release formed signed
Side rails: the patient was placed in bed with side
rails to prevent from falling from the bed specially
that his lower right extremities are paralyze.

VII. NURSING MANAGEMENT

A. IDEAL NURSING MANAGEMENT

 Nursing Diagnosis Desired Outcome Interventions Rationale
INDEPENDENT:
Altered Cerebral The patient will be able > Monitor patient’s vital -This is to check the
Tissue Perfusion to demonstrate signs and changes in patient’s condition and
related to behaviors, and mentation. mental status for
interruption of blood verbalizes knowledge further treatment to be
flow as evidenced condition, therapy >Observe a close rendered.
by altered level of regimen. monitoring for any signs
consciousness and of sudden chest pain, -This is to ensure that
changes of motor respiratory distress and he patient is safe from
responses restlessness. getting worse of the
condition and to be
>Assess visual given management in
personality, sensory / early time
motor changes such as
headaches, dizziness, -This is to ensure that
and altered mental the patient’s condition
status. is monitor and to check
for any progress in the
>Elevate the bed about status.
30 degrees and
maintain head /neck in - This is to promote
midline or neutral circulation and venous
position. drainage.

DEPENDENT:

>Administer -This is for the

medications as treatment of the
prescribed by the present disease
attending physician. condition.
 Nursing Diagnosis Desired Outcome Interventions Rationale
INDEPENDENT:
Impaired Physical The patient will be able >Assess degree of -This is to check the
Mobility related to to verbalize and immobility in relation patient’s behavioral
neuromuscular demonstrate behavioral responses. responses and its
involvement , willingness to degree of mobility for
weakness, limited participate activities. > Position the patient further treatment.
range of motion and for optimum comfort or
impaired side turnings in every - This is to promote
coordination 2hours ventilation and to
prevent any bed sores
>Monitor circulation / of the patient’s back.
nerve function in the
affected body parts -This is to know the
noting the temperatures present condition at the
color, sensation and affected body parts for
movement. treatment.

>Place a side rails each - This is to protect the

side of the bed of the patient from falling from
patient and encourages the bed to the floor and
the patient to do range ROM exercise
of motion exercises. promotes blood
circulation of the body.
DEPENDENT: - for the treatment of
> Give medications as the present illness
prescribed by the
attending physician

Nursing Diagnosis Desired Outcome Interventions Rationale

INDEPENDENT:
Impaired Verbal The patient will be able > Observe the degree of -Helps evaluate degree
Communication to established method Impairment and of the impairment of
related to motor of communication in Assess the style of the patient and to
deficits and which needs can be speech that the patient identify its type of
generalized expressed shows speech for further
weakness as treatment to be given.
evidenced by > Establish relationship > To have the best way
inability to speak with the patient listening in communicating the
words. carefully to patients patient and have
verbal / nonverbal his/her cooperation and
expressions. also to know the
patients needs.
>Anticipate needs until
effective > this is to make sure
communication is that if earlier methods
reestablished are not very effective
make more of the best
>Provide environmental of it until it will be met.
stimuli as needed to > this to reduce or
maintain contact with lessen the patients’
reality or reduce stimuli anxiety.
to lessen anxiety
DEPENDENT: > This is for therapeutic
>Administer medication treatment of the patient
as order by the for the present illness
attending physician that she/ he have.

B. ACTUAL NURSING MANAGEMENT

S . No subject cues the patient cant able to speak due to the head injury where speech is
affected.
O Restless, facial grimace, chest pain
A Acute Pain related to Head Injury as evidence by facial grimace when head is touch
 specifically the forehead area
P Short term: At the end of 30 minutes the patient will be relieve from pain.
Long term: At the end of 8 hours the patient will be shows less stressful and relieved from
pain that he was experiencing.
I 1. Monitored the patient closely by taking vital signs
- This is to check the patient’s status to prevent any complication and to know if there
progress of the status of the patient.
2. Provided comfort measures such as back rub
- Massage and backrubs helps to relieved pain that he was experiencing
3. provided a quite and comfortable place to relieved the patient from getting irritated
4. Provide diversional activities, like encouraging expressing the feeling in other form of
communication through actions to lessen the feeling of having the pain.
5. Administered medication as ordered by the attending physician
- This is for the treatment of the present illness of the patient
E At the end of 30 minutes the patient shows gestures and facial expressions that indicates no
pain.

S . No subject cues the patient cant able to speak due to the head injury where speech is
affected.
O Respiratory difficulties, dry mouth , weakness
A Anxiety related to the situational crisis, change in physical and emotional condition.
P Short term: At the end of 30 minutes the patient will be have lesser feeling of anxiety.
Long term: At the end of 8 hours the patient will be shows less stress and anxiety.
I 1. Monitored the patient closely by taking vital signs
- This is to check the patient’s status to prevent any complication and to know if there
progress of the status of the patient.
2. Provided comfort measures such as back rub
- Massage and backrubs decreases anxiety and tension
3. provided a quite and comfortable place to prevent the patient from getting irritation
4.Given oral care/ mouth care to the patient especially that its dry
- This is to prevent halitosis and make sure to prevent cracks of the lips which are very
painful.
5. Administered medication as ordered by the attending physician
- This is for the treatment of the present illness of the patient
E At the end of 30 minutes the patient shows gestures and facial expressions that reflects
decrease distress.

S . No subject cues the patient cant able to speak due to the head injury where speech is
affected.
O Nasogastric tubing attached in the left nostrils for feeding and per orem medications
Altered facial muscle function
A Impaired swallowing related to neuromuscular dysfunction as evidenced by traumatic head
injury
P Short term: At the end of 72 hours the patient will be able to pass food from the mouth to the
stomach instead of using feedings through Nasogastric tubing.
Long term: At the end of 5 days the patient will be able to demonstrate feeding methods
appropriate to the individual situation.
I 1. Checked the oral mucosa for any abnormalities.
- this is to identify the abnormalities that can be found and basis for the care to be given
2.Positioned the bed about 30 degrees in the head part especially when giving feedings
- this is to prevent aspiration
3.Turned the patient in every 2 hours in the sides and monitored neurovital signs hourly
- This is to prevent bed sores and pressure ulcers and to check the neurological status of
the patient
4.Applied baby powder to patient’s back and give back tapping
- This is to maintain the patient’s back dry and prevent aspiration in the lungs
5. Administer medication as ordered by the attending physician
To treat the present illness
E At the end of 5 days the patient was able to maintain adequate hydration and achieve the
desired body weight and good skin turgor.

S . . No subject cues the patient cant able to speak due to the head injury where speech is
affected.
O Difficulty in forming words/ verbalizes with difficulty
A Impaired Verbal communication patterns and motor coordination related to central
nervous system alteration as evidenced by traumatic head injury
P Short term: at the end of 30 minutes the patient will be able to use alternative methods of
communication effectively
Long term: at the end of 8 hours the patient will be able to use effective communication
techniques.
I 1. Assessed the patients’ condition that involves the communication status
- This is to check the patients communication status to be given
2.Used simple communication ; speak in a well modulated voice that shows concern
- This will encourage the client to have active participation and to prevent confusion
3. Encouraged to have a ROM exercises
- This will promote blood circulation to the body
4. Established rapport with the patient by listening carefully through nonverbal cues
- This will help you identify what the patient needs and feels
5. Administer medication as ordered
- This is for the treatment of the present illness
E At the end of 30 minutes the patient was able to establish effective methods of
communication needs can be expressed.
XI. Health Teachings
MEDICATIONS  Instructed complete procurement of stocks of medicine and take it on
right time, dosage, route as prescribed. Emphasized the importance
of following proper protocol and consideration upon taking the
medicine.

EXERCISE  Encouraged to have range of motion exercises to promote blood

circulation throughout the body.
 Encouraged also to have adequate balance between sleep and daily
exercise to prevent further stress that can more complicate the
situation.
TREATMENT  Instructed to follow what has been ordered by the doctor and
stressed the importance of strict compliance of all the medications
and treatment prescribed by the physician.
OUT-PATIENT  With patient’s critical case. He should see the doctor regularly for
(Check-up) check-up. Doing so will help foresee probable readmission and
management. Proper compliance to every instruction given before
discharge will help prevent untoward complications, and help patient
live a normal life again.
DIET  Eat well-balanced diet for proper nutrition; nutritious foods like fruits
and green leafy vegetables (eg. pechay, Malunggay, and oranges,
apple, banana, etc.)
 Instructed to avoid foods that are high in cholesterol, fats, and
sodium.

Evaluation:
 At the end of 3 days of hospital duty at Cagayan de Oro Medical center at their Intensive care
unit area. The completion of this care study enabled the proponent to do the following:

a. assessed client’s profile, historical data and chief complaints;

b. carried out medical orders and relate this interventions to the alleviation of the client’s
health;

c. described the anatomy, physiology and Pathophysiology of the disease;

d. identified clinical manifestations as basis for nursing care plans (NCP);

e. established rapport and harmonious dealings during the whole course of the study;

f. used the nursing process as framework for client care through NCP’s;

g. intervened with each identified problem through action- based nursing care;

h. Promoted patient self-care through health education.

Prognosis:
CRITERIA GOOD PROGNOSIS POOR PROGNOSIS
A.) Onset of Illness /
B.) Duration of Illness /
C.)Precipitating Factor /
D.)Attitude and Willingness
toward taking medication and
/
treatment
E.) Family Support /

On the criteria listed above it shows only 2 out of 5 criteria falls under poor prognosis
therefore the clients prognosis is good..

Referrals and Follow- up:

Mr. R.S. will be referred to a doctor (internist) after discharge persistence of chief
complaints reoccurs and complicates. Schedules for follow-up visits should not be over look to
evaluate progress of the patient’s health condition after termed medical and nursing management
he should have check up at the nearest hospital a week after discharge as scheduled by her
physician. The physician also ordered to continue on using all the medications prescribed.

XIII. Bibliography

 Brunner and Suddarth Textbook of Medical-Surgical Nursing, 11 th Edition by Johnson

pages, 1000; 1500; 2013; 2089

 Pocket Guide Nursing Diagnosis with Interventions, 3 rd Edition by M. Doenges,

pages,123; 423; 543; 589; 1002; 1570

 Nursing 2010 Drug Handbook, 20th Anniversary Edition by Davis drug guide, pages,
23; 58; 348; 479; 996; 998

 Medical Surgical Nursing, 7th Edition by Black and Hawks ,pages,1589; 5090

 Manual of Nursing Practice, 7th edition, Volume 1, Lippincott, pages 899; 900

Documentation: we weren’t able to have any pictures with the patient due to their request that they
don’t want any pictures taken from them for confidentiality purposes.