Post on 13-Nov-2014
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Liceo de Cagayan University
R.N Pelaez Blvd. Carmen, Cagayan de Oro City
College of Nursing
Submitted by:
Kenneth Joy S. Egona
NCM501204
Submitted to:
Mr. Leonard U. Solima
Clinical Instructor
August 2009
TABLE OF CONTENTS
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I. Introduction
a. Overview of the case
b. Objective of the study
c. Scope and Limitation of the study
II. Health History
a. Profile of patient
b. Family and Personal Health history
c. Chief Complaint & History of Present Illness
III. Developmental Data
IV. Medical Management
a. Medical Orders and Rationale
b. Laboratory Results
c. Drug Study
V. Pathophysiology with Anatomy and Physiology
VI. Nursing Assessment (System Review & Nursing Assessment II)
VII. Nursing Management
a. Ideal Nursing Management (NCP)
b. Actual Nursing Management (SOAPIE)
VIII. Referrals and Follow-up
IX. Evaluation and Implications
X. Bibliography
I. INTRODUCTION
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In our field of study it is very important for us to be exposed to different kinds of situations and
cases, which can help us gain more knowledge and is essential for us to be more effective in giving care
towards our patients.
A. Overview of the Case
B. Objective of the Study
The main reason and purpose why, I, as future nurse will conduct a study and exposure in the intensive
care unit is for me to be able to identify the problems encountered by my patient. As a health care provider,
it is indeed my vocation to adjoined hands with the health care team for the promotion of wellness of our
clients.
My main goals for this study are the following:
To establish rapport
To identify chief complaints of clients to give its specific interventions
To determine the family and personal history of the client that many affect clients present condition
To identify the cause and effect the main problem through the correct analysis of the
pathophysiology of the case
To determine the medical management given through identifying doctor’s order and its rationale
To make nursing care plans for the different health problems encountered by the client
To evaluate the effectiveness of the actual nursing care plan that was established
To give referrals and follow-up for the health promotion of the client
C. Scope and Limitation of the Study
Specifically this study is more concerned with the care of the patient in Northern Mindanao Medical
Center, Intensive Care Unit. I performed physical assessment to the patient to properly identify the nursing
problems, which requires necessary and direct interventions and medical regimen. I had 2 days duty or 16
hours care for the patient and some limited informants.
The preventive care and the anticipatory guidance are the integral practice to this practice. Thus
this care study focuses on the particular case of the patient. The study of the medications and doctor’s
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order are limited to our chosen patient, a case of Acute Gastroenteritis with severe Dehydration. Any
referrals and follow up, so as with the nursing management were fully granted and analyzed for the said
case.
II. HEALTH HISTORY
A. Profile of the Patient
Name: Mr. Panerio, Alijo Nacilla
Age: 74 years old
Sex: Male
Birth date: July 17, 1935
Religion: Roman Catholic
Civil Status: Married
Nationality: Filipino
Address: Zone-6 Baluarte, Tagoloan, Misamis Oriental
Occupation: Former Farmer
Date of Admission: October 19, 2009
Time of Admission: 10:00 pm
Admitting Diagnosis: AGE, with Severe Dehydration
A P: Dr. Karen G. Gonzales MD
Vital Signs Assessment
Temperature: 36.7c
Heart Rate: 68 bpm
Respiratory Rate: 18 cpm
Blood Pressure: 60/40 mmhg
Height: 5 ft. and 4 inches
Weight: 45 kgs.
Allergy: No known food and drug allergy
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B. Family History and Personal Health History
The Panerio family resides at Zone-6 Baluarte, Tagoloan, Misamis Oriental. Patient was a former
farmer and his spouse is a house wide. Both of their mother and father side had no history of hypotension.
C. History of Present Illness
A case of Panerio a 73 years old, male, married, a former farmer was admitted for the first time at
Northern Mindanao Medical Center. 5 days prior to admission onset of LBM, watery, mucoid, nonblood
stealed, amounting 1cup/episode x 10 episode. Associated with vomiting x 5 episode AUD, abdominal
pain.
3 days onset of dysuria associated with moderate fever due to LBM thus consult, hence admitted.
D. Chief Complaint
Patient was admitted to the said hospital last October 19, 2009 at 10:0 pm, his chief complaint prior
to admission was LBM associated with moderate fever.
III. DEVELOPMENTAL TASK
A. Erik Erikson’s Stages of Psychosocial Development Theory
Erikson describes eight developmental stages through which a healthily developing human should
pass from infancy to late adulthood. In each stage the person confronts, and hopefully masters, new
challenges. Each stage builds on the successful completion of earlier stages. The challenges of stages not
successfully completed may be expected to reappear as problems in the future. Each of Erikson's stages of
psychosocial development are marked by a conflict, for which successful resolution will result in a favorable
outcome and by an important event that this conflict resolves itself around.
In the Eriksons 8th stage of psychosocial Development theory which is Senior: Integrity vs. Despair
(65 years onwards). Integrity means moral soundness, whole or completeness of a person, Despair means
being hopeless. When it comes to my patient he was loosing hope that his illness will be cure, it is because
he feels that he was really old and he don’t have the capabilities of living the way it should be. But still,
because of the support of the family little by little he was trying to understand his situation tried to think on
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positive side and for himr to live longer for his family that still need him as a father, as a grandfather and as
a husband.
B. Sigmund Freud’s Psychosexual Development Theory
According to Freud, people enter the world as unbridled pleasure seekers. Specifically, people
seek pleasure through from a series of erogenous zones. These erogenous zones are only part of the
story, as the social relations learned when focused on each of the zones are also important. Freud's theory
of development has 2 primary ideas: One, everything you become is determined by your first few years -
indeed, the adult is exclusively determined by the child's experiences, because whatever actions occur in
adulthood are based on a blueprint laid down in the earliest years of life (childhood solutions to problems
are perpetuated) Two, the story of development is the story of how to handle anti-social impulses in socially
acceptable ways.
My patient belongs to the genital stage which begins at puberty involves the development of the
genitals, and libido begins to be used in its sexual role. However, those feelings for the opposite sex are a
source of anxiety, because they are reminders of the feelings for the parents and the trauma that resulted
from all that.
C. Robert J. Havighurst’s Developmental Task Theory
Havighurst categorized the tasks, in first category are the tasks, which has to be completed in
certain period, and the second are the tasks that continue for a long, sometimes for a lifetime.
So what happens if the task is not completed in that stage or completed in a later date? Havighurst
reply to that it is critical that the tasks should be completed during the appropriate stage, otherwise result
will be the failure to achieve success in future tasks.
D. Jean Piaget’s Theory of Development
According to Piaget, development is driven by the process of equilibration. Equilibration
encompasses assimilation (i.e., people transform incoming information so that it fits within their existing
schemes or thought patterns) and accommodation (i.e., people adapt their schemes to include incoming
information).
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My patient belongs to the formal operational stage. In this stage, individuals move beyond concrete
experiences and begin to think abstractly, reason logically and draw conclusions from the information
available, as well as apply all these processes to hypothetical situations. The abstract quality of the
adolescent's thought at the formal operational level is evident in the adolescent's verbal problem solving
ability. The logical quality of the adolescent's thought is when children are more likely to solve problems in a
trial-and-error fashion. Adolescents begin to think more as a scientist thinks, devising plans to solve
problems and systematically testing solutions. They use hypothetical-deductive reasoning, which means
that they develop hypotheses or best guesses, and systematically deduce, or conclude, which is the best
path to follow in solving the problem.
IV. MEDICAL MANAGEMENT
Doctor’s Order
DATE DOCTOR’S ORDER RATIONALEOctober 19, 2009 4:10pm
BP: 80/60HR:86\RR:20T:38C
Please admit to P1F2/A3T2 (ICCU) Please secure conset to care\ DWI-AGE with severe dehydration DAT\ V/S Q4 reffer the FF:
-BP >140/90 or 90/60mmHg-HR >110 OR < 60BPM-RR >30 OR < 12
Intake and output every shift
Labs: CBC with creatinine, K,BUN, U/A, Chest xray, ECG 12 leads + LII
Start colysis PLR 1L Fd now\ IVF to follow PNSS 1L @ 60gtts/min MEDICATIONS:
-Metronidazole, 500mg IVTT q 8hours-Ciprofloxacin 200mg every 12hours\-Paracertamol 500mg 1TAB Q4-Omeprazole 40mg cap OD
Please chart frequency, character, color, volume of stool and please record in separate sheet.
For proper admission and treatment
To closely monitor patients’ vital signs
To know avoid complications and to observe any problems
To hydrate the patient and to replace the fluid and electrolyte imbalances
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4:10pmAwake, coherent, BM X 4BP 70/60
August 20,2009
1:45pm
Refer if with sign of SOB, chest pain, change of and unsualities.
IVF PLR 1L @ 30GTTS/MIN To 80 gtts/min\
Increase IVF
LABS: o CBCo HGT nowo attach CT scan o (brain) result o to charto Na, K, SGPT, o creatinine, BUNo 12L ECG now
Meds:o coversyl 5mg/80 I tab
OD/ngto Dilantin 100g/cap
iii caps q8h x 3doses/NGTo Omeprazole 40mg IVTT
OD
FBC attached to urobag in placed – bloody urine
I&O q shift Maintain head part @30-40 degree Standby intubation set Monitor neurovitalsigns q2h Pls inform AP once admitted Discussed plan w/ pt.
o transport to cebuo cerebral angio- graphyo Possible coiling/o clipping of
To know any complications and for and for examination purposes
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July 10, 2009 8:00am
10:00am
11:32am
2:40pm
July 11, 2009 10:00am
o aneurysm
Pt seen and examined-(+) HPN > 5yrs. w/ good compliance of medication to atenolol- (-DM), (-) BA
Oral care w/ bactidol IVF TF PNSS rate 20gtts/min Turn side to side q2h chest physiotherapy
Nimodipine drip @ 5cc/hr (Nimodipine 4 vials via infusion pump)
For chest x-ray
For UA
Paracetamol I amp IVTT now
Start nicardipine drip 10mg in 100ml D5W solution in solution set start at 20gtts/min
Give captopril 50mg q6h for SBp ≥ 140mmhg
Please do chest tapping q after nebulization
To consume nicardipine drip
Same IVF to follow; PNSS @ 15gtts/min
May resume nicardipine drip @ 10cc/hr, titrate q 15mins to keep SBp @ 130-140mmhg
Hold vasalat
Resume Amlodipine(Vasalat), 10 mg, OD
IVF TF PNSS reg.@15gtts/min
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1:20pm
5:50 pm
9:40pm
July 12, 2009 9:10am
Besacodyl 10mg/supp; 2 rectal suppository now
Laboratory Results
Date Ordered Diagnostic Exam Result Normal Values Interpretation
Complete Blood Count
7/8/09 WBC 8,100 5,000-10,000/mm³ Normal
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RBC 4.80 4.20-5.40mil Normal
Hemoglobin 14.4 12.0-16.0 g/dl Normal
Hematocrit 43.8 37.0-47.0% Normal
Platelet 233,000 174,000 – 340,000 Normal
Differential Blood Count
Neutrophils 44 43.4-76.7% Normal
Lymphocytes 43 17.4-46.2% Normal
Monocytes 08 4.5-10.5% Normal
Eosinophils 05 0-2% %
Urinalysis
7/8/09 Color: Bloody
ph 6.5
Transparency: Hazy
Sugar Negative
Albumin Negative
Pus: +(0-21hpf)
RBC To numerous to count
Epithelial Cells; Rare
Mucous Threads: Rare
Drug study
Generic Name of
ordered drug
Dexamethasone
Brand Name
Date Ordered
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Classification CorticosteroidGlucocorticoidHormone
Dose/Frequency/Route
Mechanism of Action Enters target cells and binds to specific receptors, initiating many complex reactions that are responsible for its anti-inflammatory and immunosuppressive effects.
Specific Indication Trichinosis with neurologic or myocardial involvement
Contraindication Contraindications and cautions Contraindicated with infections, especially tuberculosis, fungal
infections, amebiasis, vaccinia and varicella, and antibiotic-resistant infections, allergy to any component of the preparation used.
Use cautiously with renal or hepatic disease; hypothyroidism, ulcerative colitis with impending perforation; diverticulitis; active or latent peptic ulcer; inflammatory bowel disease; CHF, hypertension, thromboembolic disorders; osteoporosis; seizure disorders; diabetes mellitus; lactation.
Side Effects/Toxic
Effects
CNS: Seizures, vertigo, headaches, pseudotumor cerebri, euphoria, insomnia, mood swings, depression, psychosis, intracerebral hemorrhage, reversible cerebral atrophy in infants, cataracts, increased IOP, glaucoma
CV: Hypertension, CHF, necrotizing angiitis Endocrine: Growth retardation, decreased carbohydrate
tolerance, diabetes mellitus, cushingoid state, secondary adrenocortical and pituitary unresponsiveness
GI: Peptic or esophageal ulcer, pancreatitis, abdominal distention
GU: Amenorrhea, irregular menses Hematologic: Fluid and electrolyte disturbances, negative
nitrogen balance, increased blood sugar, glycosuria, increased serum cholesterol, decreased serum T3 and T4 levels
Hypersensitivity: Anaphylactoid or hypersensitivity reactions Musculoskeletal: Muscle weakness, steroid myopathy, loss of
muscle mass, osteoporosis, spontaneous fractures Other: Impaired wound healing; petechiae; ecchymoses;
increased sweating; thin and fragile skin; acne; immunosuppression and masking of signs of infection; activation of latent infections, including TB, fungal, and viral eye infections; pneumonia; abscess; septic infection; GI and GU infections
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Intra-articular Musculoskeletal: Osteonecrosis, tendon rupture, infection
Intralesional therapy CNS: Blindness (when used on face and head—rare)
Respiratory inhalant Endocrine: Suppression of HPA function due to systemic
absorption Respiratory: Oral, laryngeal, pharyngeal irritation Other: Fungal infections
Nursing Precaution History for systemic administration: Active infections; renal or hepatic disease; hypothyroidism, ulcerative colitis; diverticulitis; active or latent peptic ulcer; inflammatory bowel disease; CHF, hypertension, thromboembolic disorders; osteoporosis; seizure disorders; diabetes mellitus; lactation
History for ophthalmic preparations: Acute superficial herpes simplex keratitis, fungal infections of ocular structures; vaccinia, varicella, and other viral diseases of the cornea and conjunctiva; ocular TB
Physical for systemic administration: Baseline body weight, T; reflexes, and grip strength, affect, and orientation; P, BP, peripheral perfusion, prominence of superficial veins; R and adventitious sounds; serum electrolytes, blood glucose
Physical for topical dermatologic preparations: Affected area for infections, skin injury
Generic Name of ordered
drug
Chlonidine Hydrchloride
Brand Name Catapres
Date Ordered
Classification AntihypertensiveSympatholytic (centrally acting)Central analgesic
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Dose/Frequency/Route
Mechanism of Action Stimulates CNS alpha2-adrenergic receptors, inhibits sympathetic cardioaccelerator and vasoconstrictor centers, and decreases sympathetic outflow from the CNS.
Specific Indication Hypertension, used alone or as part of combination therapy Treatment of severe pain in cancer patients in combination
with opiates; epidural more effective with neuropathic pain (Duraclon)
Contraindication Contraindicated with hypersensitivity to clonidine or any adhesive layer components of the transdermal system.
Use cautiously with severe coronary insufficiency, recent MI, cerebrovascular disease; chronic renal failure; pregnancy, lactation.
Side Effects/Toxic Effects Adverse effectsOral therapy
CNS: Drowsiness, sedation, dizziness, headache, fatigue that tend to diminish within 4–6 wk, dreams, nightmares, insomnia, hallucinations, delirium, nervousness, restlessness, anxiety, depression, retinal degeneration
CV: CHF, orthostatic hypotension, palpitations, tachycardia, bradycardia, Raynaud's phenomenon, ECG abnormalities manifested as Wenckebach period or ventricular trigeminy
Dermatologic: Rash, angioneurotic edema, hives, urticaria, hair thinning and alopecia, pruritus, dryness, itching or burning of the eyes, pallor
GI: Dry mouth, constipation, anorexia, malaise, nausea, vomiting, parotid pain, parotitis, mild transient abnormalities in LFTs
GU: Impotence, decreased sexual activity, diminished libido, nocturia, difficulty in micturition, urinary retention
Other: Weight gain, transient elevation of blood glucose or serum creatine phosphokinase, gynecomastia, weakness, muscle or joint pain, cramps of the lower limbs, dryness of the nasal mucosa, fever
Nursing Precaution Name confusion has been reported between clonidine and Klonopin (clonazepam); use caution.Assessment
History: Hypersensitivity to clonidine or adhesive layer components of the transdermal system; severe coronary insufficiency, recent MI, cerebrovascular disease; chronic
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renal failure; lactation, pregnancy Physical: Body weight; T; skin color, lesions, T; mucous
membranes—color, lesion; breast examination; orientation, affect, reflexes; ophthalmologic examination; P, BP, orthostatic BP, perfusion, edema, auscultation; bowel sounds, normal output, liver evaluation, palpation of salivary glands; normal urinary output, voiding pattern; LFTs, ECG
Generic Name of ordered
drug
amlodipine besylate
Brand Name Norvasc
Date Ordered
Classification Calcium channel-blockerAntianginal drugAntihypertensive
Dose/Frequency/Route
Mechanism of Action Inhibits the movement of calcium ions across the membranes of cardiac and arterial muscle cells; inhibits transmembrane calcium flow, which results in the depression of impulse formation in specialized cardiac pacemaker cells, slowing of the velocity of conduction of the cardiac impulse, depression of myocardial contractility, and dilation of coronary arteries and arterioles and peripheral arterioles; these effects lead to decreased cardiac work, decreased cardiac oxygen consumption, and in patients with vasospastic (Prinzmetal's) angina, increased delivery of oxygen to cardiac cells.
Specific Indication Angina pectoris due to coronary artery spasm (Prinzmetal's variant angina)
Chronic stable angina, alone or in combination with other drugs
Essential hypertension, alone or in combination with other antihypertensives
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Contraindication Contraindicated with allergy to amlodipine, impaired hepatic or renal function, sick sinus syndrome, heart block (second or third degree), lactation.
Use cautiously with CHF, pregnancy.
Side Effects/Toxic Effects
Nursing Precaution
Generic Name of ordered
drug phenytoin (diphenylhydantoin, phenytoin sodium)
Brand Name Dilantin
Date Ordered
Classification AntiepilepticAntiarrhythmic, group 1bHydantoin
Dose/Frequency/Route
Mechanism of Action Has antiepileptic activity without causing general CNS depression; stabilizes neuronal membranes and prevents hyperexcitability caused by excessive stimulation; limits the spread of seizure activity from an active focus; also effective in treating cardiac arrhythmias, especially those induced by digitalis; antiarrhythmic properties are very similar to those of lidocaine; both are class IB antiarrhythmics.
Specific Indication Control of grand mal (tonic-clonic) and psychomotor seizures
Prevention and treatment of seizures occurring during or following neurosurgery
Parenteral administration: Control of status epilepticus of the grand mal type
Unlabeled uses: Antiarrhythmic, particularly in digitalis-induced arrhythmias (IV preparations); treatment of trigeminal neuralgia (tic douloureux)
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Contraindication Contraindicated with hypersensitivity to hydantoins, sinus bradycardia, sinoatrial block, Stokes-Adams syndrome, pregnancy (data suggest an association between antiepileptic use and an elevated incidence of birth defects; however, do not discontinue antiepileptic therapy in pregnant women who are receiving such therapy to prevent major seizures; this is likely to precipitate status epilepticus, with attendant hypoxia and risk to both mother and fetus), lactation.
Use cautiously with acute intermittent porphyria, hypotension, severe myocardial insufficiency, diabetes mellitus, hyperglycemia.
Side Effects/Toxic Effects CNS: Nystagmus, ataxia, dysarthria, slurred speech, mental confusion, dizziness, drowsiness, insomnia, transient nervousness, motor twitchings, fatigue, irritability, depression, numbness, tremor, headache, photophobia, diplopia, conjunctivitis
CV: CV collapse, hypotension (when administered rapidly IV; not to exceed 50 mg/min)
Dermatologic: Dermatologic reactions, scarlatiniform, morbilliform, maculopapular, urticarial and nonspecific rashes; serious and sometimes fatal dermatologic reactions—bullous, exfoliative, or purpuric dermatitis, lupus erythematosus, and Stevens-Johnson syndrome, toxic epidermal necrolysis, hirsutism, alopecia, coarsening of the facial features, enlargement of the lips, Peyronie's disease
GI: Nausea, vomiting, diarrhea, constipation, gingival hyperplasia, toxic hepatitis, liver damage, sometimes fatal; hypersensitivity reactions with hepatic involvement, including hepatocellular degeneration and fatal hepatocellular necrosis
GU: Nephrosis Hematologic: Hematopoietic complications, sometimes
fatal: thrombocytopenia, leukopenia, granulocytopenia, agranulocytosis, pancytopenia; macrocytosis and megaloblastic anemia that usually respond to folic acid therapy; eosinophilia, monocytosis, leukocytosis, simple anemia, hemolytic anemia, aplastic anemia, hyperglycemia
IV use complications: Hypotension, transient hyperkinesia, drowsiness, nystagmus, circumoral tingling, vertigo, nausea, CV collapse, CNS depression
Respiratory: Pulmonary fibrosis, acute pneumonitis Other: Lymph node hyperplasia, sometimes progressing to
frank malignant lymphoma, monoclonal gammopathy and
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multiple myeloma (prolonged therapy), polyarthropathy, osteomalacia, weight gain, chest pain, periarteritis nodosa, hirsutism, alopecia
Nursing Precaution History: Hypersensitivity to hydantoins; sinus bradycardia, AV heart block, Stokes-Adams syndrome, acute intermittent porphyria, hypotension, severe myocardial insufficiency, diabetes mellitus, hyperglycemia, pregnancy, lactation
Physical: T; skin color, lesions; lymph node palpation; orientation, affect, reflexes, vision examination; P, BP; R, adventitious sounds; bowel sounds, normal output, liver evaluation; periodontal examination; LFTs, urinalysis, CBC and differential, blood proteins, blood and urine glucose, EEG and ECG
Generic Name of ordered
drug
Brand Name
Date Ordered
Classification
Dose/Frequency/Route
Mechanism of Action
Specific Indication
Contraindication
Side Effects/Toxic Effects
Nursing Precaution
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V. Anatomy and Physiology
The Brain
Three cavities, called the primary brain vesicles, form during the early embryonic development of the
brain. These are the forebrain (prosencephalon), the midbrain (mesencephalon), and the hindbrain
(rhombencephalon).
During subsequent development, the three primary brain vesicles develop into five secondary brain
vesicles.
The telencephalon generates the cerebrum (which contains the cerebral cortex, white matter,
and basal ganglia).
The diencephalon generates the thalamus, hypothalamus, and pineal gland.
The mesencephalon generates the midbrain portion of the brain stem.
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The metencephalon generates the pons portion of the brain stem and the cerebellum.
The myelencephalon generates the medulla oblongata portion of the brain stem
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The cerebrum consists of two cerebral hemispheres connected by a bundle of nerve fibers,
the corpus callosum. The largest and most visible part of the brain, the cerebrum, appears as
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folded ridges and grooves, called convolutions. The following terms are used to describe the
convolutions:
A gyrus (plural, gyri) is an elevated ridge among the convolutions.
A sulcus (plural, sulci) is a shallow groove among the convolutions.
A fissure is a deep groove among the convolutions.
The deeper fissures divide the cerebrum into five lobes (most named after bordering skull
bones)—the frontal lobe, the parietal love, the temporal lobe, the occipital lobe, and the insula.
All but the insula are visible from the outside surface of the brain.
A cross section of the cerebrum shows three distinct layers of nervous tissue:
The cerebral cortex is a thin outer layer of gray matter. Such activities as speech,
evaluation of stimuli, conscious thinking, and control of skeletal muscles occur here.
These activities are grouped into motor areas, sensory areas, and association areas.
The cerebral white matter underlies the cerebral cortex. It contains mostly myelinated
axons that connect cerebral hemispheres (association fibers), connect gyri within
hemispheres (commissural fibers), or connect the cerebrum to the spinal cord (projection
fibers). The corpus callosum is a major assemblage of association fibers that forms a
nerve tract that connects the two cerebral hemispheres.
Basal ganglia (basal nuclei) are several pockets of gray matter located deep inside the
cerebral white matter. The major regions in the basal ganglia—the caudate nuclei, the
putamen, and the globus pallidus—are involved in relaying and modifying nerve
impulses passing from the cerebral cortex to the spinal cord. Arm swinging while
walking, for example, is controlled here.
The diencephalon connects the cerebrum to the brain stem. It consists of the following major
regions:
The thalamus is a relay station for sensory nerve impulses traveling from the spinal cord
to the cerebrum. Some nerve impulses are sorted and grouped here before being
transmitted to the cerebrum. Certain sensations, such as pain, pressure, and
temperature, are evaluated here also.
The epithalamus contains the pineal gland. The pineal gland secretes melatonin, a
hormone that helps regulate the biological clock (sleep-wake cycles).
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The hypothalamus regulates numerous important body activities. It controls the
autonomic nervous system and regulates emotion, behavior, hunger, thirst, body
temperature, and the biological clock. It also produces two hormones (ADH and
oxytocin) and various releasing hormones that control hormone production in the
anterior pituitary gland.
The following structures are either included or associated with the hypothalamus.
The mammillary bodies relay sensations of smell.
The infundibulum connects the pituitary gland to the hypothalamus.
The optic chiasma passes between the hypothalamus and the pituitary gland. Here,
portions of the optic nerve from each eye cross over to the cerebral hemisphere on the
opposite side of the brain.
The brain stem connects the diencephalon to the spinal cord. The brain stem resembles the
spinal cord in that both consist of white matter fiber tracts surrounding a core of gray matter.
The brain stem consists of the following four regions, all of which provide connections between
various parts of the brain and between the brain and the spinal cord. (Some prominent
structures are illustrated in Figure 2 ).
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Figure 2 Prominent structures of the brain stem.
The midbrain is the uppermost part of the brain stem.
The pons is the bulging region in the middle of the brain stem.
The medulla oblongata (medulla) is the lower portion of the brain stem that merges with
the spinal cord at the foramen magnum.
The reticular formation consists of small clusters of gray matter interspersed within the
white matter of the brain stem and certain regions of the spinal cord, diencephalon, and
cerebellum. The reticular activation system (RAS), one component of the reticular
formation, is responsible for maintaining wakefulness and alertness and for filtering out
unimportant sensory information. Other components of the reticular formation are
responsible for maintaining muscle tone and regulating visceral motor muscles.
The cerebellum consists of a central region, the vermis, and two winglike lobes, the cerebellar
hemispheres. Like that of the cerebrum, the surface of the cerebellum is convoluted, but the
gyri, called folia, are parallel and give a pleated appearance. The cerebellum evaluates and
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coordinates motor movements by comparing actual skeletal movements to the movement that
was intended.
The limbic system is a network of neurons that extends over a wide range of areas of the brain. The
limbic system imposes an emotional aspect to behaviors, experiences, and memories. Emotions such
as pleasure, fear, anger, sorrow, and affection are imparted to events and experiences. The limbic
system accomplishes this by a system of fiber tracts (white matter) and gray matter that pervades the
diencephalon and encircles the inside border of the cerebrum. The following components are
included:
The hippocampus (located in the cerebral hemisphere)
The denate gyrus (located in cerebral hemisphere)
The amygdala (amygdaloid body) (an almond-shaped body associated with the caudate
nucleus of the basal ganglia)
The mammillary bodies (in the hypothalamus)
The anterior thalamic nuclei (in the thalamus)
The fornix (a bundle of fiber tracts that links components of the limbic system)
Pathophysiology
Definition:
Cerebrovascular accident or stroke (also called brain attack) results from sudden interruption of
blood supply to the brain, which precipitates neurological dysfunction lasting longer than 24 hrs.
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Hemorrhagic stroke is the leakage of blood vessel causes compression of brain tissue and spasm of
adjacent vessels.
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Predisposing Factor - Family History
PrecipitatingFactor - High fat diet
Fatty Dispostion in tunica Intimae sp. Low density lipoprotein
Macropages will treat them as foreign bodies
Will engulf fatty deposits in the tunica Intima
Macrophage will become heavier because of fatty deposits
Macrophages will be deposited together with fats (foam cells)
Acumulate, becomes atherosclerotic plaque
Hyperperfusion of vital organs specially kidney
Juxtaglumerular cells of kidney will secrete renin angiotensin 1
Angiotensin 1 converted to angiotensin 2 by ACE
Increase peripheral assistance
VI. NURSING ASSESSMENTNURSING SYSTEM REVIEW CHART
Name:: Mrs. LML Date: July Pulse: 94bpm Temp.: 36.7 c RR: 22 cpm BP: 160/100 mmhg Weight: 55 kgs. Height: 5’4
EENT:× impaired vision □ blind □ Pain □ reddened □ drainage□ gums □ hard of hearing □ deaf□ burning □ edema □ lesion □ teeth __Diplopia ____________ Assess eyes, ears, nose ___Eyepatch __________ Throat for abnormality □ no problem _____________________RESP: _____________________ □ Asymmetric □ tachypnea _____________________□ apnea □ rales □ cough □ barrel chest _BP- 160/100mmhg_____□ bradypnea □ shallow □ brochi _____________________□ sputum □ diminished □ dyspnea _____________________□ orthopnea □ labored □ wheezing _Dry skin_____________
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Increase Blood Pressure
Hypertension
Blood vessels become weak
Outpouching of brain arteries(aneurysm)
Rupture of Blood vessels
CVA, Hemorrhagic
Increase Intracranial Pressure
s/sx:- diplopia - nausea- nape pain- dizziness
Accumulation of blood in the brain
Compression of brain organs De-creased Brain Perfu -sion
□ pain □ cyanotic _____________________Assess resp, rate, rhythm, depth, pattern, _____________________ breath sounds, comfort × no problem __IVF _site____________CARDIO VASCULAR _____________________□ arrhythmia □ tachycardia □ numbness _____________________□ diminished pulses □ edema □ fatigue ___FBC to Urobag ______ □ irregular □ bradycardia □ murmur _____________________□ tingling □ absent pulses □ pain _____________________ Asses heart sounds, rate rhythm, pulse, blood _____________________ pressure, clrc., fluid retention, comfort _____________________ □ no problem _____________________GASTRO INTESTINAL TRACT _____________________□ obese □ distention □ mass _____________________□dysphagia □ rigidly □ pain ____mild headache _____ Asses abdomen, bowel habits, swallowing, _____________________bowel sounds, comfort × no problem _____________________GENITO-URINARY and GYNE _____________________□ pain □ urine color □ vaginal bleeding _____________________□ hermaturia □ discharge □ noctoria _____________________Asses urine freq., color, control, odor, comfort/ nape pain _ _________ Gyn-bleeding, discharge × no problem _____________________NEURO _____________________□ paralysis □ stuporous □ unsteady □ seizures _____________________□ lethartic □ comatose □ vertigo □ tremors□ confused □ vision □ grip _____________________Asses motor function, sensation, LOC, strength, _____________________ Grip, gait, coordination, orientation, speech, Poor Skin turgor ________ × no problem _____________________MUSCULOSKELETAL and SKIN _____________________□ appliance □ stiffness □itching □ petechiae _____________________ hot □ drainage □ prosthesis □ swelling _____________________□ lesion × poor turgor □ cool □ deformity _____________________□ wound □ rash □ skin color □ flushed _____________________□ atrophy □ pain □ ecchymosis _____________________□ diaphoretic □ moist _____________________Asses mobility, motion. Galt, alignment, joint function _____________________ /skin color, texture, turgor, integrity □ no problem _____________________
__________________________________________
NURSING ASSESSMENT II
SUBJECTIVE OBJECTIVE
COMMUNICATION:
Hearing Loss× Visual Changes Denied
comment: “duha man ang ako panan-aw mao gani gi butangan ko ani tanon sa ako mata. ”
Glasses Contact Lens Pupils size: 3 mmReaction: Pupils Equally round and react to light and accommodation
Languages Hearing Loss Speech Difficulties
OXYGENATION: COMMENT: _”maayo raman pud akong pag-ginhawa, wala man pud ko naglisod, usahay lang kay mutukar ako ubo”
Resp. × Regular Irregular Dyspnea Smoking History× Cough Sputum Denied
Describe: Breathing pattern is regular.
R right lung is symmetrical to the left lung. L left lung is symmetrical to the right lung.
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CIRCULATION: Heart Rhythm × Regular Irregular
Chest Pain Leg Pain Numbness of Extremities×Denied
COMMENT: “,wala man nuon sakit sa ako tiil ug dughan, kani raman ako liog”
Ankle edema: Presence of ankle edemaPulse Car. Rad. DP Femoral*R ___+_______+______+______+____L ___+______ +______+____ _+_____COMMENT: all pulses are present and palpable
NUTRITION:* If applicable
Diet: Low salt, low fat Diet × Dentures None
Full Partial W/ patientUpper ×
Lower
N □V Character:
COMMENT: “katong miaging adlaw ga suka ko, pero karon wala naman, pero wala lng ko gana mukaon.”
×Recent change in weight, appetite Swallowing Diff.Denied
ELIMINATION: COMMENT:Patient has a normal bowel movement. Her urine color is yellowish and aromatic in odor.
Bowel sounds:Normo active bowel sounds
Abdominal Distention: Present Yes × NoUrine* Urine is yellowish in color* If Foley is in placePatients FBC to Urobag is in place.
Usual bowel pattern:1-2x daily_________
Urinary Frequency: Dysuria Hematuria Incontinence Polyuria × Foley in place Denied
Constipation remedies: ___Date of last BM: July 6, 2009Diarrhea Character:None_____________
MGT. OF HEALTH AND ILLNESS: Briefly describe patient’s ability to follow treatments for chronic health problems (if present):
Patient follows treatment regimen properly.
Alcohol × Denied (Amount, Frequency): SBE: Last Pap Smear:__N/A____LMP: ____N/A ________
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SUBJECTIVE OBJECTIVE
SKIN INTEGRITY: ×DryItching OtherDenied
COMMENT: “gamala akong panit karon kay dili man gud ko galigo, tigulang napud gud”
×Dry Cold Pale Flushed Warm Moist Cyanoticrashes, ulcers, decubitus ulcers (describe size, location, drainage): none
ACTIVITY / SAFETY: LOC and Orientation: Patient is oriented to time and space. Gait: Walker Cane Others × Steady Unsteady
Sensory and motor losses in face or extremities: There is having diplopia.
ROM Limitations: The patient cannot bath by itself appropriately and needs guidance when doing it.
Convulsion×Dizziness Limited motion of joints
Limitations in ability to: Ambulate× Bathe self Others Denied
COMMENT: “dili man nako pa kaya magkatindog kay gakalipong ko”
COMFORT / SLEEP / AWAKE: Pain (Location, Freq., Remedies) Nocturia Sleep DifficultiesDenied
COMMENT: “Maaayo man hinuon ang ako pagkatulog”
Facial Grimaces Guarding Other signs of pain: none_ side rail release from signed(60+years) None
COPING: Observed nonverbal behavior:
Patient follows instructions, cooperative, but sometimes she easily get depressedof her situation and she likes to talk things about her life and family.
Occupation: Retired TeacherMumbers of household: _3__Most supportive person:_husband __ ____
VII. NURSING MANAGEMENT A.IDEAL NURSING INTERVENTIONS
30
Nursing Diagnosis: Ineffective cerebral tissue perfusion related to hemorrhage
Interventions Rationale
Independent:
1. Determine factors related to individual
situation/ cause for coma/ cerebral
tissue perfusion and potential
increased in ICP.
2. Monitor or document neurolohgical
status frequently and compare with
baseline.
3. Monitor vital signs
4. Position with head slightly elevated
and in neutral position and maintain
bedrest.
Influences choice of interventions.
Assesses trends in level of consciousness
and potential increase in ICP and is useful
in determining location, extent and
progression of the CNS damage.
Fluctuations in pressure may occur
because of cerebral pressure/ injury in
vasomotor area of the brain. Change in rate
of heart rhythm can occur because of the
brain damage.
Reduces arterial pressure by promoting
venous drainage and may improve cerebral
circulation or perfusion.
Dependent:
5. Administer prescribed medications,
supplemental oxygen,anticoagulants,
antihypertensive drugs as ordered.
Reduces hypoxemia, increase of
ICP and may use to improve
cerebral blood flow.
Nursing Diagnosis: Impaired physical mobility related to neuromuscular involvement
Interventions Rationale
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Independent:
1. Assess functional ability/ extent of
impairment initially and on a regular
basis.
2. Change position at least every 2hrs.
and possibly more often on the
affected side.
3. Inspect skin regularly, particularly over
bony prominences. Gently massage
any reddened areas and provide aids
such as sheepskin pads as necessary.
4. Encourage patient to assist with the
movement and exercisse using the
unaffected extremity to support or
move weaker side.
Identifies strengths/ deficiencies and may
provide information regarding recovery.
Reduces risk of tissue ischemia/injury.
Affected side has poorer circulation and
reduced sensation and is more predisposed
to skin breakdown/ decubitus.
Pressure points over bony priminences are
most at risk for decreased perfusion/
ischemia. Circulatory stimulstion
and ,padding help prevent ski breakdown
and decubitus development.
May respond as if the affected side is no
linger part of the body a nd needs
encouragement and active training to
reincorporate it as a part of its own body.
Dependent:
5. Consult with the physical therapist
regarding active resistive exercises
and patient ambulation.
Individualized program can develop to meet
particular needs/ deal with deficits in
balance, coordination and strength.
Nursing Diagnosis: Disturbed Sensory perception related to altered sensory receptor
Interventions Rationale
32
Independent:
1. Observe behavioral responses
2. Eliminate extrenous noise/ stimuli as
necessary.
3. Speak in calm, quiet voice, using short
sentences. Maintain eye contact.
4. Ascertain/ validate patient’
perceptions. Reorient patient
frequently to environment , staff,
procedures.
5. Evaluate visual deficits. Note loss of
visual field, changes in depth
perception , presence of
diplopia(double vision)
Individual responses are variable, but
commonalities such as emotional ability,
lowered frustration threshold, apathy, and
impulsiveness may complicate care.
Reduces anxiety and exaggerated
emotional responses/ confusion associated
with sensory overload.
Patient may have limited attention span or
problems with comprehension. These
measures can help the patient to attend to
communication.
Assists patient to identify inconsistencies in
reception and integration of stimuli and may
reduce perceptual distortion of reality.
Presence of visual disorders can negatively
affect patient’s ability to perceive
environment and relearn motor skills and
increases risk of accident/ injury.
B. ACTUAL NURSING INTERVENTION
S
o
A
33
P
I
E
B.
S
“ Kani man ang ako liog ang nag sakit ug pag – ayo, unya ga doble na ang ako panan-
aw”
o BP – 160/100 mmhg
34
Appeared weak
Diplopia
Presence of eyepatch
A
Ineffective cerebral tissue perfusion related to hemorrhage.
P Long term: At the end of 2 days duty I will be able to
I
Independent
1. Positioned with head slightly elevated.
Reduces arterial pressure by promoting venous drainage and may improve
cerebral circulation or perfusion.
2. Maintained bed rest.
Continual stimulation or activity ma increase intracranial pressure.
3. Provided quiet environment.
Absolute rest and quiet environment may be needed to prevent rebleeding.
4. Prevented straining at stool, holding breath.
Valsava manuever increase ICP and potential risk of rebleeding.
Dependent
5. Administer and stool softeners per doctor’s order.
Prevent straining during bowel movement and corresponds to increase ICP.
35
E
S
“ Gakalipong paman ko, mao pud gain ga hungitan pako sa ako anak or asawa, ka
para dili ko maglisod. Unya duha pa gyod ako panan-aw.”
o
Eye patch placed alternately q2h
A
Risk for injury related to visual disturbance.
P Long term:
At the end of 8 hours the patient with the help of relatives and health care
provider will be able to modify environment as indicated to enhance safety and use
resources appropriately.
Short term:
At the end of 1 hour the patient will be able to identify individual risk factors.
I Independent
1. Assessed patient for dizziness or diplopia.
To know the extent of disturbance and further interventions to be done.
2. Oriented patient on possible risk factors and on the environment.
To familiarize patient on her environment and identify and avoid where danger
is at its peak.
3. Adjust bed and keep side rails raised up, especially if patient is at
36
rest.
To prevent further injury from falls.
4. Placed unnecessary objects away from clients’ sight.
To enhance safety appropriate use of necessary resources.
5. Administer medication as prescribe by the physician.
E
At the end of 8 hours shift the patiently with the help of relatives and health care
provider was able to modify environment a indicated to enhance safety and use of
resources appropriately.
VIII. Referrals and Follow-up
Patient was transferred to Cebu as what was planned by the family and together
with Dr. Surdilla for proper treatment of the patients condition. Patient, together with the family was
advised to follow medications and treatment regimen. Emotional and spiritual support towards the
patient should be given attention, because the patient easily gets depressed and is sometimes
loose hope on her situation.
Follow – up check ups should also be follow according to the schedule. This is very important so
that the patient and the family may be aware if there are any problems found from the patients of
how the patients responds on the treatment process.
37
IX. Evaluation and Implication
After conducting this care study, I was able to appreciate more the essence of utilizing the
nursing process in the care and management of my patient. It was indeed a tough job on
conducting this study yet, it gave me a big impact regarding how useful it is in my chosen
profession. Nursing really demands a tender loving care attitude. It demands patience and it is
calling that cannot be merely taken for granted.
This study will serve as a reference material in rendering competent care to my client
especially those with similar situation. Through this, I will be able to develop my knowledge as well
as my skills and attitudes in applying the prescribed procedure to improve the health status of the
patient.
Moreover, this care study taught us to stand on our own by not depending on others just to
make this. This provides us, the students, a big learning regarding on how well we take care of or
38
patients in the real clinical setting. Most of all, this study teaches the students to provide clients
care more efficiently and competently to achieve an effective and quality nursing care.
X. BIBLIOGRAPHY
BOOKS
Suzzanne C. Smeltzer, EdD, RN,FAAN,et.al
Medical Surgical Nursing
11th Edition, page 1118
Lippincott Williams and Wilkins
Manual of Nursing Practice
7th Edition page 570-571
© 2001 by Lippincott Williams and Wilkins
Robert Berhow M.D, et al
39
Home Edition, page 562
©1997 by Merck Co. Inc
Microsoft ® Encarta ® Reference Library 2004
©1993-2003 Microsoft Corporation
WEB
www.nursingcrib.com
http://www.wisegeek.com/what-is-cva.htm
http://en.wikipedia.org/wiki/cerebrovascularacciddent
http://www.Emedicinehealth.com/cerebrovascularaccident/pages.em.htm
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