I.

Demographic Data

Clients Name: Sex: Age: Birthdate: Birthpla!e: Stat$s: Nationality: &eligion: Address: 'd$!ational Ba!(gro$nd: *!!$pation: +ospital: -ate o. Admission: Final diagnosis:

manang Female 71 years old September 18, 19 7 "ili#, "ag$na %arried Filipino &oman Catholi! "ili#, "ag$na 'lementary )rad$ate None AF, %edi!al Center /an$ary 0, 1213 C4A, S$bara!hnoid +emorrhage

II. Sources and Reliability of Information 5pon inter6ie# and history ta(ing, data #ere gathered .rom the patients relati6es7 All the signi.i!ant in.ormation regarding laboratory res$lts, diagnosti! pro!ed$res, medi!ation orders, physi!al .indings, and other pertinent re!ords #ere a!8$ired .rom the patients !hart7 9he patient #as obser6ed and

assessed d$ring physi!al assessment to obtain rele6ant data that is 6ital in identi.ying a!t$al and potential problems7

III. Reason for Seeking Care %anang #as bro$ght to AF, %edi!al Center on /an$ary 0, 1213 at 8:22 pm7 She #as .o$nd $n!ons!io$s by her grandda$ghter at :: 2 pm7 She #as immediately r$shed to the hospital by her son and nephe#7 IV. History of Present Illness 9hree ho$rs prior to admission, %anang had been .eeling di;;y #hile she #as #at!hing tele6ision7 9his di;;iness e6ent$ally progressed to loss o. !ons!io$sness7 V. Past Medical History A!!ording to the relati6es, %anang has had hypertension sin!e she #as 32 years old7 She has been ta(ing her maintenan!e medi!ations religio$sly $ntil a month ago #hen they noti!ed that she #as p$rposely s(ipping ta(ing them7 9he relati6es !o$ld not re!all #hat her meds are7 9hey also said that it #as the se!ond time the patient experien!ed stro(e7 9he .irst time #as in 1221 #hile she #as in ballroom dan!ing7

VI. amily History

Patients Paternal Grandpa; unrecalleddeceased

Patients Paternal Grandma; unrecalleddeceased

Patients Maternal Grandpa; unrecalleddeceased

Patients Maternal Grandma; unrecalleddeceased

PatientsFather deceased

PatientsMother deceased

Patients hus"and 7# $%o

Patient Manang 71 y/o

Brother Deceased at age 67 (HPN DM renal disorder!

!egend"

Patient" CV# H$M%RRH#&IC 'Subarachnoid(

Female: -e!eased

%ale: -e!eased

%ale: +ypertensi6e

A!!ording to the .amily history, %anangs parents are both de!eased in!l$ding her grandparents .rom both sides d$e to reasons $nre!alled by her 3

relati6es7 She has one yo$nger brother #ho died at the age o. 07 a month be.ore her hospitali;ation be!a$se o. !ompli!ations bro$ght abo$t by diabetes7 %anangs h$sband is hypertensi6e also7 9he .amily history sho#s hypertension in the .amily sin!e she and her brother got it7

VII. unctional #ssessment #. Health Perception and Maintenance %anang reg$larly 6isited hospital .or !he!(<$ps7 As mentioned, she sti!(s to her pharma!ologi! regimen in order to ta(e good !are o. her health7 B$t #hen her brother passed a#ay a month ago, she started to s(ip her medi!ations and be!ame stressed7 ). #cti*ities+ $,ercise Pattern %anang does not engage into a reg$lar exer!ise7 B$t her relati6es mentioned that she does ho$sehold !hores be!a$se she !o$ld not stand dirty things7 9hese !hores made her b$sy at home and ser6e as her o#n exer!ise7 9hey said that she doesnt stop $ntil all the .$rnit$res and dishes are !lean7 C. Sleep+ Rest Period =hen as(ed abo$t her sleeping pattern, the relati6es said that shes not getting eno$gh sleep7 She only has abo$t three ho$rs o. sleep a day7 Be!a$se o. being a#a(e e6en late at the night, she tried to .ind time to rest at daytime7 She managed to ta(e a nap7

D. -utrition and $limination

%anang is .ond o. eating 6egetables, .r$its, and meat7 +er relati6es told $s that she lo6es !o..ee7 A!!ording to her relati6es, her bo#el mo6ement is not reg$lar7 She did it on!e in three days be.ore she #as hospitali;ed7 $. Interpersonal Relationship 9he li.e o. %anang !enters on her h$sband and six o.. springs >all o. them has their o#n .amily?7 +er relati6es mentioned they reg$larly 6isit %anang to (eep her !ompany be!a$se she !ompletely dotes on her grand!hildren7 9hey also shared #ith $s that %anang has a good relationship #ith the neighbors7 . Se,uality and Reproducti*e %anang is already on her menopa$sal years7 A!!ording to the relati6es, she and her h$sband get along pretty #ell7 A!!ording to 'ri( 'ri(sons theory, shes no# on her @Antegrity 6ers$s despairB stage7 &. Coping and Stress Management+ .olerance Pattern %anang has an $n#a6ering .aith in the "ord and she attended mass reg$larly #ith her h$sband7 =hene6er problems !ome their #ay, she C$st prayed and belie6ed e6erything #ill be o(ay .or as long as )od is #ith yo$7 She and her .amily stay together to sol6e #hate6er hardships arise7 B$t lately, things are not getting too smooth .or %anang7 +er relati6es stressed that %anang !onsidered the death o. her brother a blo# to her .or she is 6ery .ond and !lose to him7 '6en i. they tried to !heer her $p, the loneliness stayed #ith her7 H. Personal Habits

%anang stayed at home and spent her leis$re #at!hing tele6ision7 She $sed to engage in ballroom dan!ing b$t sin!e her .irst stro(e in 1221, she stopped doing this and C$st !on!entrated on ma(ing their home !lean7 =hen she gets bored, she sometimes goes to one o. her neighbors to !hat7 I. $n*ironmental Ha/ards 9he ho$se o. %anang is near the high#ay #here all .orms o. transportation pass7 +er relati6es say that the noise !oming .rom the 6ehi!les are lo$d b$t its bearable7 9hey mentioned that #hen it rains hea6ily, it does not .lood in their area7 VIII. Re*ie0 of Systems System )eneral Appearan!e 1st day 2uly 34 5663 'xpressi6e aphasia Cons!io$s A.ebrile =ith protr$ded tong$e Capillary re.ill o. 1 D se!onds ,oor eye !onta!t ,sy!homotor de!reased ,ale nail bed So.t palate .ails to rise in paralysis on !ranial ner6e E Ampaired and limited !oordination by #ea(ness -e!reased m$s!le strength 5ses in!omprehensible so$nds 5nd day 2uly 164 5663 'xpressi6e aphasia Cons!io$s A.ebrile =ith protr$ded tong$e ,oor eye !onta!t ,sy!homotor de!reased ,ale nail bed Ampaired and limited !oordination by #ea(ness -e!reased m$s!le strength 5ses in!omprehensible so$nds Noted drooling o. sali6a

 +''N9 Cardio6as!$lar )enito$rinary

Anteg$mentary

)astro intestinal tra!t

noted drooling o. sali6a Slight loss o. hearing =ith hair thinning =ith N)9 F the right nostril ,$pil 1mm,sl$ggishly rea!ti6e to light Ani!teri! s!lera ,in( palpebral !onC$n!ti6a B, 1 2G82 mmhg ,& 08 bpm =ith .$ll e8$al p$lses Slightly .la(y s(in ,ale in appearan!e Slightly dry lips ,ale nail bed Flabby abdomen No bo#el mo6ement =ith N)9 at right nostril

Slight loss o. hearing =ith hair thinning =ith N)9 F the right nostril Ani!teri! s!lera ,in( palpebral !onC$n!ti6a

B, 1 2G82 mmhg ,& 81 bpm

Slightly .la(y s(in ,ale in appearan!e Slightly dry lips ,ale nail bed Flabby abdomen No bo#el mo6ement =ith N)9 at right nostril

5rine o$tp$t 9:2 5rine o$tp$t 092 !! !! %enopa$se %enopa$se &espiratory &&H 19 !pm &&H 1 !pm #ith !ra!(les at #ith !ra!(les at both l$ng .ields both l$ng .ields Central ner6o$s system )"ASC*= C*%A )"ASC*= C*%A s!ale: s!ale: 'ye opening H to 'ye opening H to spee!h spee!h 4erbal response H 4erbal response H in!omprehensible in!omprehensible 1 1 motor response H motor response H .lexion .lexion >de!orti!ate? >de!orti!ate? 9otal )CS H 8 9otal )CS H 8 a#a(e and a#a(e and 7

Ne$rologi!

%$s!$los(eletal

disoriented disoriented =ith limitation on =ith limitation on mo6ement mo6ement )rading re.lexes: )rading re.lexes: ,lantar .lexor I 1 ,lantar .lexor I 1 diminished, lo# diminished, lo# normal normal Babins(i I1 Babins(i I1 diminished lo# diminished lo# Normal Normal Sensory: Sensory: Cranial ner6e 1 Cranial ner6e 1 able to smell b$t able to smell b$t $nable to $nable to 6erbali;ed #hat 6erbali;ed #hat she smell she smell %otor: %otor: Cranial ner6e Cranial ner6e p$pil 1 mm, p$pil 1 mm, sl$ggishly sl$ggishly rea!ti6e rea!ti6e to light to light Both: Both: Cranial ner6e : Cranial ner6e : respond to to$!h respond to to$!h b$t $nable to b$t $nable to s#allo# s#allo# !ranial ner6e 7 !ranial ner6e 7 !an ele6ate !an ele6ate eyebro#s eyebro#s %$s!le strength %$s!le strength &5 H 1G: "5 H 3G: &5 H 1G: "5 H 3G: &" H G: "" H 3G: &" H G: "" H 3G: =ith limitation on =ith limitation on mo6ement mo6ement ,sy!homotor ,sy!homotor de!reased de!reased -e!reased -e!reased m$s!le strength m$s!le strength

I7. #natomy and Physiology

#natomy and Physiology Human )rain 9he brain !onsists o. 12<12 ne$rons that are 6ery !losely inter!onne!ted 6ia axons and dendrites7 9he ne$rons themsel6es are 6astly o$tn$mbered by glial !ells7 *ne ne$ron may re!ei6e stim$li thro$gh synapses .rom as many as 12 to 12 other ne$rons >N$ne;, 1981?7 'mbryologi!ally the brain is .ormed #hen the .ront end o. the !entral ne$ral system has .olded7 9he brain !onsists o. .i6e main parts, as des!ribed in Fig$re :7:: 17 9he !erebr$m, in!l$ding the t#o !erebral hemispheres 17 9he interbrain >dien!ephalon? 7 9he midbrain 37 9he pons 4arolii and !erebell$m :7 9he med$lla oblongata

ig. 8.8. 9he anatomy o. the brain7 9he entire h$man brain #eighs abo$t 1:22 g >=illiams and =ar#i!(, 1989?7 An the brain the cerebrum is the largest part7 9he s$r.a!e o. the !erebr$m is strongly .olded7 9hese .olds are di6ided into t#o hemispheres #hi!h are separated by a deep fissure and !onne!ted by the corpus callosum7 'xisting #ithin the brain are three ventricles !ontaining cerebrospinal fluid7 9he hemispheres are di6ided into the .ollo#ing lobes: lobus frontalis, lobus parietalis, lobus occipitalis, and lobus temporalis7 9he s$r.a!e area o. the !erebr$m is abo$t 1022 !mJ, and its thi!(ness is mm7 Six layers, or laminae, ea!h !onsisting o. di..erent ne$ronal types and pop$lations, !an be obser6ed in this s$r.a!e layer7 9he higher !erebral .$n!tions, a!!$rate sensations, and the 6ol$ntary motor !ontrol o. m$s!les are lo!ated in this region7 9

9he interbrain or diencephalon is s$rro$nded by the !erebr$m and is lo!ated aro$nd the third 6entri!le7 At in!l$des the thalamus, #hi!h is a bridge !onne!ting the sensory paths7 9he hypothalamus, #hi!h is lo!ated in the lo#er part o. the interbrain, is important .or the reg$lation o. a$tonomi! >in6ol$ntary? .$n!tions7 9ogether #ith the hypophysis, it reg$lates hormonal se!retions7 9he midbrain is a small part o. the brain7 9he pons Varolii is an inter!onne!tion o. ne$ral tra!tsK the cerebellum !ontrols .ine mo6ement7 9he medulla oblongata resembles the spinal !ord to #hi!h it is immediately !onne!ted7 %any re.lex !enters, s$!h as the 6asomotor !enter and the breathing !enter, are lo!ated in the med$lla oblongata7 An the !erebral !ortex one may lo!ate many di..erent areas o. spe!iali;ed brain .$n!tion >,en.ield and &asm$ssen, 19:2K Liloh, %!Comas, and *sselton, 1981?7 9he higher brain .$n!tions o!!$r in the .rontal lobe, the 6is$al !enter is lo!ated in the o!!ipital lobe, and the sensory area and motor area are lo!ated on both sides o. the !entral .iss$re7 9here are spe!i.i! areas in the sensory and motor !ortex #hose elements !orrespond to !ertain parts o. the body7 9he si;e o. ea!h s$!h area is proportional to the re8$ired a!!$ra!y o. sensory or motor !ontrol7 9hese regions are des!ribed in Fig$re :707 9ypi!ally, the sensory areas represented by the lips and the hands are large, and the areas represented by the midbody and eyes are small7 9he 6is$al !enter is lo!ated in a di..erent part o. the brain7 9he motor area, the area represented by the hands and the spea(ing organs, is large7

ig. 8.9. 9he di6ision o. sensory >le.t? and motor >right? .$n!tions in the !erebral !ortex7 >From ,en.ield and &asm$ssen, 19:27? )rain unction %ost o. the in.ormation .rom the sensory organs is !omm$ni!ated thro$gh the spinal !ord to the brain7 9here are spe!ial tra!ts in both spinal !ord and brain .or 6ario$s modalities7 For example, to$!h re!eptors in the tr$n( synapse #ith 10

interne$rons in the dorsal horn o. the spinal !ord7 9hese interne$rons >sometimes re.erred to as se!ond sensory ne$rons? then $s$ally !ross to the other side o. the spinal !ord and as!end the #hite matter o. the !ord to the brain in the lateral spinothalami! tra!t7 An the brain they synapse again #ith a se!ond gro$p o. interne$rons >or third sensory ne$ron? in the thalam$s7 9he third sensory ne$rons !onne!t to higher !enters in the !erebral !ortex7 An the area o. 6ision, a..erent .ibers .rom the photore!eptors !arry signals to the brain stem thro$gh the opti! ner6e and opti! tra!t to synapse in the lateral geni!$late body >a part o. the thalam$s?7 From here axons pass to the o!!ipital lobe o. the !erebral !ortex7 An addition, bran!hes o. the axons o. the opti! tra!t synapse #ith ne$rons in the ;one bet#een thalam$s and midbrain #hi!h is the prete!tal n$!le$s and s$perior !olli!$l$s7 9hese, in t$rn, synapse #ith preganglioni! parasympatheti! ne$rons #hose axons .ollo# the o!$lomotor ner6e to the !iliary ganglion >lo!ated C$st behind the eyeball?7 9he re.lex loop is !losed by postganglioni! .ibers #hi!h pass along !iliary ner6es to the iris m$s!les >!ontrolling p$pil apert$re? and to m$s!les !ontrolling the lens !$r6at$re >adC$sting its re.ra!ti6e or .o!$sing 8$alities?7 *ther re.lexes !on!erned #ith head andGor eye mo6ements may also be initiated7 %otor signals to m$s!les o. the tr$n( and periphery .rom higher motor !enters o. the !erebral !ortex .irst tra6el along $pper motor ne$rons to the med$lla oblongata7 From here most o. the axons o. the $pper motor ne$rons !ross to the other side o. the !entral ner6o$s system and des!end the spinal !ord in the lateral !orti!ospinal tra!tK the remainder tra6el do#n the !ord in the anterior !orti!ospinal tra!t7 9he $pper motor ne$rons e6ent$ally synapse #ith lo#er motor ne$rons in the 6entral horn o. the spinal !ordK the lo#er motor ne$rons !omplete the path to the target m$s!les7 %ost re.lex motor mo6ements in6ol6e !omplex ne$ral integration and !oordinate signals to the m$s!les in6ol6ed in order to a!hie6e a smooth per.orman!e7 '..e!ti6e integration o. sensory in.ormation re8$ires that this in.ormation be !olle!ted at a single !enter7 An the !erebral !ortex, one !an indeed lo!ate spe!i.i! areas identi.ied #ith spe!i.i! sensory inp$ts >,en.ield and &asm$ssen, 19:2K Liloh, %!Comas, and *sselton, 1981?7 =hile the a..erent signals !on6ey in.ormation regarding stim$l$s strength, re!ognition o. the modality depends on pinpointing the anatomi!al !lassi.i!ation o. the a..erent path#ays7 >9his !an be demonstrated by inter!hanging the a..erent .ibers .rom, say, a$ditory and ta!tile re!eptors, in #hi!h !ase so$nd inp$ts are per!ei6ed as o. ta!tile origin and 6i!e 6ersa7? 9he higher brain .$n!tions ta(e pla!e in the .rontal lobe, the 6is$al !enter is in the o!!ipital lobe, the sensory area and motor area are lo!ated on both sides o. the !entral .iss$re7 As des!ribed abo6e, there is an area in the sensory !ortex #hose elements !orrespond to ea!h part o. the body7 An a similar #ay, a part o. the brain !ontains !enters .or generating !ommand >e..erent? signals .or !ontrol o. the bodyMs m$s!$lat$re7 +ere, too, one .inds proCe!tions .rom spe!i.i! !orti!al areas to spe!i.i! parts o. the body7 Ma:or )lood Vessels

11

Normal .$n!tion o. the brainMs !ontrol !enters is dependent $pon ade8$ate s$pply o. oxygen and n$trients thro$gh a dense net#or( o. blood 6essels7 Blood is s$pplied to the brain, .a!e, and s!alp 6ia t#o maCor sets o. 6essels: the right and le.t !ommon !arotid arteries and the right and le.t 6ertebral arteries7 9he !ommon !arotid arteries ha6e t#o di6isions7 9he external !arotid arteries s$pply the .a!e and s!alp #ith blood7 9he internal !arotid arteries s$pply blood to the anterior three<.i.ths o. !erebr$m, ex!ept .or parts o. the temporal and o!!ipital lobes7 9he 6ertebrobasilar arteries s$pply the posterior t#o<.i.ths o. the !erebr$m, part o. the !erebell$m, and the brain stem7 Any de!rease in the .lo# o. blood thro$gh one o. the internal !arotid arteries brings abo$t some impairment in the .$n!tion o. the .rontal lobes7 9his impairment may res$lt in n$mbness, #ea(ness, or paralysis on the side o. the body opposite to the obstr$!tion o. the artery7 *!!l$sion o. one o. the 6ertebral arteries !an !a$se many serio$s !onse8$en!es, ranging .rom blindness to paralysis7

#nterior Cerebral #rtery

12

9he anterior !erebral artery extends $p#ard and .or#ard .rom the internal !arotid artery7 At s$pplies the .rontal lobes, the parts o. the brain that !ontrol logi!al tho$ght, personality, and 6ol$ntary mo6ement, espe!ially the legs7 Stro(e in the anterior !erebral artery res$lts in opposite leg #ea(ness7 A. both anterior !erebral territories are a..e!ted, pro.o$nd mental symptoms may res$lt >a(ineti! m$tism?7 Middle Cerebral #rtery

9he middle !erebral artery is the largest bran!h o. the internal !arotid7 9he artery s$pplies a portion o. the .rontal lobe and the lateral s$r.a!e o. the temporal and parietal lobes, in!l$ding the primary motor and sensory areas o. the .a!e, throat, hand and arm and in the dominant hemisphere, the areas .or spee!h7 9he middle !erebral artery is the artery most o.ten o!!l$ded in stro(e7

Posterior Cerebral #rtery

13

9he posterior !erebral arteries stem in most indi6id$als .rom the basilar artery b$t sometimes originate .rom the ipsilateral internal !arotid artery N)ar!ia /+ et al7, An Barnett +/% at al >eds? Stro(e ,athophysiology, -iagnosis, and %anagement Ne# Oor( Ch$r!hill "i6ingstone 1991 11:P7 9he posterior arteries s$pply the temporal and o!!ipital lobes o. the le.t !erebral hemisphere and the right hemisphere7 =hen in.ar!tion o!!$rs in the territory o. the posterior !erebral artery, it is $s$ally se!ondary to embolism .rom lo#er segments o. the 6ertebral basilar system or heart7 Clini!al symptoms asso!iated #ith o!!l$sion o. the posterior !erebral artery, depend on the lo!ation o. the o!!l$sion and may in!l$de thalami! syndrome, thalami! per.orate syndrome, =eberMs syndrome, !ontralateral hemplegia, hemianopsia and a 6ariety o. other symptoms, in!l$ding in!l$ding !olor blindness, .ail$re to see to<and<.ro mo6ements, 6erbal dyslexia, and hall$!inations7 9he most !ommon .inding is o!!ipital lobe in.ar!tion leading to an opposite 6is$al .ield de.e!t7 9he posterior !erebral arteries stem in most indi6id$als .rom the basilar artery b$t sometimes originate .rom the ipsilateral internal !arotid artery N)ar!ia /+ et al7, An Barnett +/% at al >eds? Stro(e ,athophysiology, -iagnosis, and %anagement Ne# Oor( Ch$r!hill "i6ingstone 1991 11:P7 9he posterior arteries s$pply the temporal and o!!ipital lobes o. the le.t !erebral hemisphere and the right hemisphere7 =hen in.ar!tion o!!$rs in the territory o. the posterior !erebral artery, it is $s$ally se!ondary to embolism .rom lo#er segments o. the 6ertebral basilar system or heart7 Clini!al symptoms asso!iated #ith o!!l$sion o. the posterior !erebral artery, depend on the lo!ation o. the o!!l$sion and may in!l$de thalami! syndrome, thalami! per.orate syndrome, =eberMs syndrome, !ontralateral hemplegia, hemianopsia and a 6ariety o. other symptoms, in!l$ding in!l$ding !olor blindness, .ail$re to see to<and<.ro mo6ements, 6erbal dyslexia, and hall$!inations7 9he most !ommon .inding is o!!ipital lobe in.ar!tion leading to an opposite 6is$al .ield de.e!t7

14

9he posterior !erebral arteries stem in most indi6id$als .rom the basilar artery b$t sometimes originate .rom the ipsilateral internal !arotid artery N)ar!ia /+ et al7, An Barnett +/% at al >eds? Stro(e ,athophysiology, -iagnosis, and %anagement Ne# Oor( Ch$r!hill "i6ingstone 1991 11:P7 9he posterior arteries s$pply the temporal and o!!ipital lobes o. the le.t !erebral hemisphere and the right hemisphere7 =hen in.ar!tion o!!$rs in the territory o. the posterior !erebral artery, it is $s$ally se!ondary to embolism .rom lo#er segments o. the 6ertebral basilar system or heart7 Clini!al symptoms asso!iated #ith o!!l$sion o. the posterior !erebral artery, depend on the lo!ation o. the o!!l$sion and may in!l$de thalami! syndrome, thalami! per.orate syndrome, =eberMs syndrome, !ontralateral hemplegia, hemianopsia and a 6ariety o. other symptoms, in!l$ding in!l$ding !olor blindness, .ail$re to see to<and<.ro mo6ements, 6erbal dyslexia, and hall$!inations7 9he most !ommon .inding is o!!ipital lobe in.ar!tion leading to an opposite 6is$al .ield de.e!t7

X. Pathophysiology

Precipitating Factors: &H$pertension &Histor$ o' pre(ious )tro*e

Predisposing Factors: >+ge 15 &+cute )tress &,i'est$le

-(eracti(e o' the s$mpathetic ner(ous s$stem leading to increase stress response .asoconstriction Bloc*age o' the "lood (essel ,ac* o' -0$gen and Nutrients )uppl$ H$po0ia /m"olism

+ltered cere"ral meta"olism 1$toto0ic edema +neur$sm 2upture Blood suppl$ to the area supplied "$ arter$ reduced 3ncrease 31P

)udden entr$ o' "lood into )+ space

Brain 4issue Necrosis Paral$sis decreased muscle strength ps$chomotor decreased 3mpaired and limited coordination "$ 5ea*ness

7I. !aboratory Results Pathology '69;53;63( luid Creatinine Result 78 mgGdl -ormal Range 77<11 16 -ursing implication

Sodium Potassium

132 mmolG" 17 mmolG"

1 :<13: 7:

%ay indi!ate de.i!ient dietary inta(e, di$reti! administration

Pathology '69;<6;63( luid Cholesterol .riglycerides Direct HD!C Serum Result 193 mgGdl 71 mgGdl 8: mgGdl -ormal Range 97<121 2<1:2 32<02 -ursing implication Andi!ates that in!rease in +-"C ser6es as prote!ti6e role by mobili;ing !holesterol .rom tiss$es7 Ser6es as prote!tion against !ardio6as!$lar diseases7

in!rease

V!D! Potassium !D! CH%!+dHD!

13 mgGdl 372 mmolG" 93 mgGdl 1717 mgGdl

2< : 7:<:<1 2<102 2<22< 1222722

Pathology '6=;6>;63( luid Sodium Serum "o# Result 1 3 mmolG" -ormal Range 1 7<13: -ursing implication may indi!ate de.i!ient dietary inta(e, nasogastri! aspiration, di$reti! administration, may indi!ate de.i!ient dietary inta(e, di$reti!s, 17

Potassium

"o#

173 mmolG"

7:<:71

Hematology '6=;6>;63( .est Hemoglobin Hematocrit ?)C Result 1 0 2731 1:77 -ormal range 112<102 gG" 27 7<2737 3<12x12QgG" -ursing implication %ay indi!ate presen!e o. in.e!tion, se6ere emotional or physi!al stress

-eutrophils !ymphocyte $osinophils Platelets

770 711 721 ade8$ate

27:2<2772 2712<2732 2721<272 2722<2721

Chest 7;ray '69;53;63( 9here is note o. s$spi!io$s right api!al density: s$ggest api!o<lordoti! 6ie#7 +eart is enlarged #ith le.t 6entri!$lar prominen!e7 Aorta is prominent7 9orto$s and !al!i.ied there are lateral marginal osteophytes noted in the thora!i! spine7 No other signi.i!ant !hest x<ray .indings7 Impression" S$spi!io$s &ight Api!al -ensity Slight "e.t 4entri!$lar ,rominen!e Atheros!leroti! Aorta -egenerati6e 9hora!i! *steophytosis

Cranial C.;Scan '69;53;63( Clini!al history" "*CK +istory o. Stro(e in 1221 9e!hni8$e: Axial !ranial C9 sli!es are obtained #itho$t !ontrast7 9he s$baranoid spa!es are di..$sely hyperdense7 =ell !ir!$ms!ribed hypodense .o!i are seen in the normal !aps$le<ganglioni! region and le.t !opona radiate7 Small !al!i.i!ations are also noted in the bilateral basal ganglia the gray #hite matter inter.a!e is maintained7 9here is no midli.e shi.t7 +yperdensities seen in the o!!ipital horns o. the lateral 6entri!les7 9he basilar and 6ertebral arteries are !al!i.ied7 9he 6is$ali;ed posterior .ossa, penial region, orbits, 18

All petromatoins and body !al6ari$m are inta!t #ith no demonstrable .ra!t$re seen7

Impression" -i..$se s$bara!hnoid hemorrhage #ith intra6eno$s seepage and 1nd mild obstr$!ti6e hydro!ephal$s *ld in.ar!ts in the right !aps$le<ganglioni! region and le.t !orona radiate Atheros!leroti! basilar and 6ertebral arteries Age rGt bilateral ganglia !al!i.i!ation

@ltrasound of the #bdomen ,an!reas< 179 x 171 x 171 !m )all bladder< 070 x 173 &ight (idney< 877 x 78 x 73 C9< 17 !m "e.t (idney< 877 x 77 x 78 C9< 177 !m Spleen< :78 x 73 !m 9he li6er is normal, in si;e, smooth !onto$r and homogeno$s paren!hymal e!hopattern7 Both right and le.t intrahepati! and extrahepati! bile d$!ts are not dilated7 9here are no .o!al mass or !al!i.i!ations seen7 Common bile d$!t meas$res mm7 9he gallbladder is not dilated7 =all is not thi!(ened7 No intral$minal mass, e!hoes or bile sl$dge .ormation7 ,an!reas and spleen are both normal in si;e !on.ig$ration and e!hotext$re7 9here are no soiled nor .l$id .illed masses noted7 ,an!reati! d$!t is not dilated7 Spleni! 6ein is not dilated7 Both (idneys are in normal si;e and orientation #ith inta!t renal margin7 Both sho#ed normal and homogeno$s paren!hymal e!hogeni!ity7 9he !orti!al thi!(ness is #ithin normal sho#ing distin!t !orti!omed$llary di..erentiation7 9here is no e6iden!e o. lithiasis, renal !yst, mass or hydronephrosis bilaterally7 9he perirenal spa!es are !lear7 Both !entral e!ho< plexes are inta!t7 5reters are not dilated7 5rinary baldder is physiologi!ally distended7 No intral$minal !al!$l$s or extrinsi! mass !ompression7 9he $ter$s is atrophi!

19

Both o6aries are not seen, most li(ely atrophi!7 No adnexal mass seen7 No .l$id in the posterior !$l de sa!7 4is$ali;ed intestinal bo#el loops are normal7 Impression" Normal sonogram o. li6er, gallbladder, biliary tree, pan!reas and spleen Normal (idneys, $reters and $rinary bladder ><? .or .l$id or mass Normal bo#el loops Atrophi! $ter$s *6aries are not seen, most li(ely atrophi! Normal adnexae

20

XII. Drug Study

21

&$-$RIC

C!#SSI IC#.I%-

D%S#&$4 R%@.$4 R$A@$-CB 2 mg CA, 88

I-DIC#.I%-S+ C%-.R#I-DIC#.I%-S Andi!ations: 9o !ontrol toni!<!loni! and !omplex partial sei;$res7

SID$ $

$C.S

M%D$ % #C.I%%ay stabili;e ne$ral membranes and limit sei;$re a!ti6ity either by in!reasing e..l$x or de!reasing in.l$x o. sodi$m ions a!ross!ell membranes in the motor !ortex d$ring generation o. ner6e imp$lse

-@RSI-& R$SP%-SI)I!I.I$S Assess blood press$re7 #at!h .or ad6erse rea!tions 'xplain dr$g therapy, need .or .ollo#<$p tests and importan!e o. ta(ing the dr$g exa!tly as pres!ribed7 -i6ided doses gi6en a.ter meals or #ith meals may de!rease )A rea!tions7 -ont stop s$dden >-o!tors order? be!a$se this may #orsen sei;$res7 Call pres!riber immediately i. ad6erse rea!tion de6elop7

&-",henytoin

Central ner6o$s system dr$g

Anti!on6$lsant )-"-ilantin

Sto!( dose: 2 mg

Contraindi!ations: -ate started: /$ne 19 1229 Contraindi!ated in patients hypersensiti6e to dilantin and those #ith sin$s brady!ardia, SA blo!(, se!ond or third A4 blo!(, Adams stro(e syndrome

CNS: ataxia, de!reased !oordination, mental !on.$sion, sl$rred spee!h, di;;iness, heada!he, insomia, ner6o$sness

C4: periarteritis nodosa

5se !a$tio$sly in patients #ith hepati! dys.$n!tion, hypotension, myo!ardial ins$..i!ien!y or diabetes

''N9: diplopia, nystagm$s, bl$rred 6ision

)A: gingi6al hyperplasia,na$sea, 6omiting, !onstipation

SLAN: dis!oloration o. the s(in i. gi6en 6ia A4 p$sh in the ba!( o. hand, ex.oliati6e dermatitis *9+'&S: hirs$tism or lymphadenopathy

A. $sing to treat sei;$res, ta(e appropriate sa.ety pre!a$tions7

A. sei;$re !ontrol is established #ith di6ided doses on!e dailydosing may be !onsidered7

22

23

&$-$RIC

C!#SSI IC#.I%-

D%S#&$4 R%@.$4 R$A@$-CB

I-DIC#.I%-S+ C%-.R#I-DIC#.I%-S

SID$ $

$C.S

M%D$ % #C.I%-

-@RSI-& R$SP%-SI)I!I.I$S

&-"Nimodipine

Cal!i$m !hannel blo!(er

2mg, CA, RA- Indications" 9o remo6e ne$rologi! de.i!its a.ter a s$bara!hnoid hemorrhage .rom r$pt$red intra!ranial berry ane$rism

C-S: heada!he CV" hypotension, edema &I" na$sea, abdominal dis!om.ort M@SC@!%; SC$!$.#!" m$s!le !ramps R$SPIR#.%RB: dyspnea, #hee;ing

)-"Nimotop

Sto!( dose: 2 mg -ate started: /$ne 19 1229

Contraindications" AdC$st a dose and $se !a$tio$sly .or patients #ith hepati! .ail$re

Anhibits !al!i$m ion in.l$x a!ross !ardia! and smooth m$s!le !ells, de!reasing myo!ardial !ontra!tility and oxygen demandsK also dilates !oronary and !erebral arteries and arterioles

%onitor blood press$re and heart rate, espe!ially at start o. therapy

%onitor #eight and .l$id inta(e and o$tp$t7 Stay alert .or .l$id retention7 Ad6ise to ta(e dr$g on empty stoma!h 1 ho$r be.ore 1 ho$rs a.ter meal7 Anstr$!t him not to !ons$me grape.r$it or grape.r$it C$i!e #ithin 1 ho$r 2r 1 ho$rs a.ter ta(ing the dr$g7

24

&$-$RIC

C!#SSI IC#.I%-

D%S#&$4 R%@.$4 R$A@$-CB

I-DIC#.I%-S+ C%-.R#I-DIC#.I%-S $

SID$ $C.S

M%D$ % #C.I%-

-@RSI-& R$SP%-SI)I!I.I$S

&-"amlodipine besylate

Cardio6as!$lar system dr$g

12mg, 9AB, *-

Indications" +ypertension

Anti< hypertensi6e

Sto!( -ose: 12 mg

)-" Nor6as!

-ate Started: /$ne 19 1229

Chroni! stable angina, 6asospasti! angina >,rin;metals or 6ariant angina?

C-S" heada!he, .atig$e, di;;iness, light< headedness, paresthesia

CV" edema, .l$shing, palpitations &I" na$sea, abdominal pain &@: sex$al di..i!$lties M@SC@!%D SC$!$.#!" m$s!le pain R$SPI" dyspnea

Anhibits !al!i$m ion in.l$x a!ross !ardia! and smooth m$s!le !ells, de!reasing myo!ardial !ontra!tility and oxygen demandsK also dilates !oronary and !erebral arteries and arterioles

Alert: monitor patient !are.$lly7 Some patient, espe!ially those #ith se6ere obstr$!ti6e !oronary artery disease, ha6e de6eloped in!reased .re8$en!y, d$ration or se6erity o. angina or a!$te %A a.ter initiation o. !al!i$m !hannel blo!(er therapy or at time o. dosage in!rease7

%onitor blood press$re .re8$ently d$ring initiation o. therapy7 Noti.y pres!riber i. signs o. heart .ail$re o!!$r s$!h as s#elling o. hands and .eet or shortness o. breath7

25

SCI-" rash, pr$rit$s

-ont !on.$se amlodipine #ith amiloride7

26

&$-$RIC

C!#SSI IC#.I%-

D%S#&$4 R%@.$4 R$A@$-CB

I-DIC#.I%-S+ C%-.R#I-DIC#.I%-S

SID$ $

$C.S

M%D$ % #C.I%9#o me!hanisms

-@RSI-& R$SP%-SI)I!I.I$S 5se !a$tio$sly .or patients treated #ith la!t$lose syr$p

&-""a!t$lose

"axati6es

)-" "ila!

&elie. o. !onstipation Sto!( -ose: 112 in!l$ding !hroni! !onstipation7 ml ,ortal systemi! en!ephalopathy: +epati! -ate started: !oma or pre!oma stages /$ne 2 1229 #here hyperammonemia is present7

2 ml oral >syr$p? *-

Indications"

abdominal dis!om.ort asso!iated #ith .lat$len!e and intestinal !ramps7 Na$sea and

are belie6ed to be in6ol6ed in the laxati6e a!tion o. la!t$lose: First, metabolism o. la!t$lose by ba!teria res$lts in red$!ed !oloni! p+ #hi!h stim$lates peristalsis and de!reases stool transit time7 An t$rn, de!reased #ater reabsorption .rom the .e!es .$rther .a!ilitates the passage o. so.t #ell<.ormed stools7 Se!ond, in!reased osmoti! press$re o. .e!al material se!ondary to an in!rease in !oloni! organi! a!ids res$lts in

No laxati6e sho$ld be ta(en .or S1 #ee( #itho$t the ad6i!e o. a physi!ian7 No laxati6e sho$ld be $sed in the presen!e o. abdominal pain na$sea, .e6er or 6omiting, as s$!h symptoms may signal appendi!itis or an in.lamed bo#el7

Contraindications"

6omiting diarrhea #ith potential !ompli!ations eg, loss o. .l$ids, hypo(alemia and hyponatremia7

,atients #ho re8$ire a lo# la!tose dietK #ith gala!tosemia or disa!!haride de.i!ien!yK #ith intestinal obstr$!tion7

Care sho$ld be ta(en in patients #ho are la!tose< intolerant7

For elderly, debilitated patients #ho re!ei6e la!t$lose .or S0 months sho$ld ha6e ser$m ele!trolytes >potassi$m, !hloride, !arbon dioxide? meas$red periodi!ally7 27

&$-$RIC

C!#SSI IC#.I%-

D%S#&$4 R%@.$4 R$A@$-CB

I-DIC#.I%-S+ C%-.R#I-DIC#.I%-S $

SID$ $C.S

M%D$ % #C.I%-

-@RSI-& R$SP%-SI)I!I.I$S

&-" "osartan +ydro!hlorothia;ide

Angiotensin AA Antagonists -i$reti!s

122mg, 9AB, *-

Indications"

)-:Combi;ar

Sto!( -ose: 122 %anagement *. mg +ypertension7 -ate started: /$ne 19 1229 Contraindications"

Contraindi!ated 9o 9hose =ho Are +ypersensiti6e 9o S$l.onamides7 ,atients =G An$ria T -epleted Antra6as!$lar 4ol$me As #ell as pregnant #omen7

Abdominal pain, edema, asthenia, heada!he7 ,alpitation7 -iarrhea, na$sea7 Ba!( pain7 -i;;iness7 -ry !o$gh, sin$sitis, bron!hitis, pharyngitis, $pper resp in.e!tion7 &ash7

A sele!ti6e %ay be ta(en #ith or !ompetiti6e #itho$t .ood angiotensin 1 re!eptor antagonist simply inhibits indire!tly some s$bstan!e o!!$r in o$r body responsible .or #ater retention th$s by de!reasing body #ater 6ol$me lo#ers blood press$re

28

29

&$-$RIC

C!#SSI IC#.I%-

D%S#&$4 R%@.$4 R$A@$-CB 7

I-DIC#.I%-S+ C%-.R#I-DIC#.I%-S

SID$ $

$C.S

M%D$ % #C.I%-

-@RSI-& R$SP%-SI)I!I.I$S

&-"%annitol

-i$reti!,osmoti!

7: ml e6ery 0 ho$rs 9A4 Sto!( -ose: 1:2 ml

IndicationE ,re6ention and treatement o. the olig$ri! phase o. renal .ail$re &ed$!tion o. intra!ranial press$re and treatment o. !erebral edemaK o. ele6ated A*, #hen the press$re !annot be lo#ered by other means ,romotion o. the $rinary ex!retion o. toxi! s$bstan!es

C-S" -i;;iness, heada!he,bl$rred 6ision,sei;$res CV" +ypotension edema,thrombophebitis, ta!hy!ardia, !hest pain Dermatologic" $rti!aria, s(in ne!rosis #ith in.litration &@" di$resis, $rinary retention &I" Na$sea, anorexia, dry mo$th, thrist Hematologic: .l$id and ele!trolyte imbalan!es, hyponatremia Respiratory" p$lmonary !ongestion, rhinitis

)-" *smitol, rese!tisol

-ate started: /$ne 19 1229

Contraindication Contraindi!ated #ith an$ria d$e to se6ere renal disease7 5se !a$tio$sly #ith p$lmonary !ongestion, a!ti6e bleeding

'le6ates the osmolarity o. the glomer$lar .iltrate, thereby hindering the reabsorption o. #ater and leading to a loss o. #ater and sodi$m, !hloride !reate an osmoti! gradient in the eye bet#een plasma and o!$lar .l$ids, thereby red$!ing A*,, !reates an osmoti! e..e!ts, leading to de!reased s#elling in posttrans$rethral prostati! rese!tion

Assess .or STS o. ele!trolyte imbalan!e and dehydration %onitor 4S T AT* Oo$ may experien!e the side e..e!ts7 &eport di..i!$lty o. breathing, pain at the i6 site, !hest pain7

30

7III. Problem !ist

31

&ANL

AC95A" ,&*B"'%

-A9' A-'N9AFA'-

-A9' &'S*"4'-

1 1

Ampaired !ir!$lation %$s!le #ea(ness Anability to do sel.<!are

/$ly 9 1229 /$ly 9 1229 /$ly 9 1229

5nresol6ed 5nresol6ed 5nresol6ed

,rod$!ing in!omprehensible so$nds

/$ly 9 1229

5nresol6ed

&ANL

,*9'N9AA" ,&*B"'%

-A9' A-'N9AFA'-

-A9' &'S*"4'-

1 1 7IV. -ursing Care Plans

&is( .or AnC$ry &is( .or Aspiration

/$ly 9 1229 /$ly 9 1229

5N&'S*"4'5N&'S*"4'-

Impaired Circulation 32

#SS$SSM$-. SH

-@RSI-& DI#&-%SIS Ampaired !erebral tiss$e per.$sion rGt 6as!$lar o!!l$sion

P!#--I-& Short term ob:ecti*e" A.ter N$rsing inter6ention, the pt7 #ill demonstrate in!reased per.$sion as indi6id$ally appropriate

I-.$RV$-.I%-S S'stablish &apport

R#.I%-#!$ S 9o gain pts tr$st and !oordination

$7P$C.$D %@.C%M$ Short term ob:ecti*e" A.ter N$rsing inter6ention, the pt7 shall be able to demonstrate in!reased per.$sion as indi6id$ally appropriate

.he patient manifested the ff"

S%onitor 4ital signs

S 9o identi.y any other de6iations .rom normal7

*H 9< 077 ,<08 &<19 B,< 1 2G82 )"ASC*= C*%A s!ale: 'ye opening H to spee!h 4erbal response H in!omprehensible 1

!ong .erm %b:ecti*e" A.ter 1< days o. N$rsing Anter6ention, the pt7 #ill be able o demonstrate beha6iors #hi!h may impro6e proper !ir!$lation s$!h as !omplian!e to health management T therapies pro6ided7 SAdminister medi!ations as ordered s$!h as antihypertensi6e or di$reti!s7 SAssist pt7 in ass$ming semi.o#lers position #G head midline7 !ong .erm %b:ecti*e" S9o aid #ith proper per.$sion or .lo# o. blood >!ir!$lation or 6eno$s drainage?7 S9o probably de!rease !ardia! #or(load and in maximi;ing tiss$e per.$sion A.ter 1< days o. N$rsing Anter6ention, the pt7 shall be able to demonstrate beha6iors #hi!h may impro6e proper !ir!$lation s$!h as !omplian!e to health management T therapies pro6ided7

33

motor response H .lexion >de!orti!ate? 9otal )CS H 8 a#a(e and disoriented

S9o !onser6e energy S'n!o$rage 8$iet and rest.$l atmosphere7 #hi!h !o$ld aid in lo#ering the *1 tiss$e demand7

S'xer!ise !a$tion in $sing hot or !old pads7

S9he t iss$es may ha6e de!reased sensiti6ity d$e to is!hemia7

S'n!o$rage $se o. relaxation te!hni8$es or exer!ises7

S9o de!rease the tension le6el

S-is!$ss the importan!e o. pre6enting expos$re to

S9o retain heat or #armth e..i!iently

34

!old or extreme !old temp

S-is!$ss to the patients S* the importan!e o. !are o. dependent limbs, body hygiene, and .oot !are #hen !ir!$lation is impaired7

S9o promote #ellness

N5&SAN) AN9'&4'N9A*N ,&*)&'SS N*9' ,&*B"'%: A%,AA&'- CA&C5"A9A*N -A9': /5"O 29, 1229

ASS'SS%'N9: *N 9+' FA&S9 -AO =' +AN-"'- *5& C"A'N9, S+' +AS 9+' )"ASC*= C*%A SCA"', 'ye opening H to spee!h

35

4erbal response H in!omprehensible 1, motor response H .lexion AN-AS' 9+' &**%7 AN9'&4'N9A*N:

>de!orti!ate?, 9otal )CS H 8 a#a(e and disoriented7 S+' AS S"'',AN) =+'N =' CA%'

AF9'& 9+' ASS'SS%'N9, =' A-4AS'- 9+' &'"A9A4'S AN- 9'AC+ 9+' ,&*,'& ,*SA9A*NAN) *F 9+' ,A9A'N9, S'%A F*="'&S ,*SA9A*N =A9+ +'A- %A-"AN'7 '4A"5A9A*N: 9+' C"A'N9 S9A""S 9+' SA%' '4'N =' -A- *5& AN9'&4'N9A*NS7

Muscle 0eakness #SS$SSM$-. SH @ hindi sya gasinong ma(agala#B Ampaired physi!al mobility ne$rom$s!$lar *H and m$s!$los(eletal impairment as e6iden!e Short .erm %b:ecti*e" A.ter N$rsing Anter6ention, the pt7 #ill S'stablish &apport S 9o gain pts tr$st and !oordination Short .erm %b:ecti*e" A.ter N$rsing Anter6ention, the pt7 shall be able to -@RSI-& DI#&-%SIS P!#--I-& I-.$RV$-.I%-S R#.I%-#!$ $7P$C.$D %@.C%M$

36

Ampaired and limited !oordination by #ea(ness -e!reased m$s!le strength %$s!le strength &5H1G: &"H G: "5H3G: ""H3G:

by limited motor s(ills7

be able to maintain in!reased strength and .$n!tion o. a..e!ted or !ompensatory part7 SAssess patient !ondition !ong .erm %b:ecti*e" A.ter 1< days o. n$rsing inter6ention, the pt7 #ill be able to demonstrate beha6iors that enable res$mption o. a!ti6ities7 S9$rn pt7 slo#ly .rom side to side S,ro6ide ade8$ate rest periods as #ell as !om.ort T sa.ety meas$res S%onitor 4ital signs

S 9o identi.y any other de6iations .rom normal7

maintain in!reased strength and .$n!tion o. a..e!ted or !ompensatory part7

S9o determine any other $nderlying !a$se o. mani.estations !ong .erm %b:ecti*e" S 9o pre6ent .$rther stress T .atig$e A.ter 1< days o. n$rsing inter6ention, the pt7 shall be able to demonstrate beha6iors that enable res$mption o. a!ti6ities7 S 9o pro6ide proper !ir!$lation o. blood .lo# on both sides

37

S9o assess .$n!tional S-etermine pt7 le6el o. mobility S9o promote optimal SAssist pt7 in his a!ti6ities S,romotes #ell<being S'n!o$rage ade8$ate inta(e o. .l$ids T N$tritio$s .oods S9o assist in learning SAn6ol6e !lients S* in !are #ays o. managing problems o. immobility7 and maximi;es energy prod$!tion7 le6el o. .$n!tion ability

38

N5&SAN) AN9'&4'N9A*N ,&*)&'SS N*9' ,&*B"'%: %5SC"' ='ALN'SS -A9': /5"O 29, 1229

ASS'SS%'N9: *N 9+' FA&S9 -AO =' +AN-"'- *5& C"A'N9 +AS A%,AA&'- AN- "A%A9'- C**&-ANA9A*N BO ='ALN'SS AN- -'C&'AS'- %5SC"' S9&'N)9+7 AN9'&4'N9A*N: AF9'& 9+' ASS'SS%'N9, =' %*NA9*&'- 9+' 4A9A" SA)NS, ASS'SS'- 9+' C"A'N9S C*N-A9A*N7 =' A"S* ,&*4A'- +'& A-'R5A9' &'S9 ,'&A*-S AS ='"" AS C*%F*&9 AN- SAF'9O %'AS5&'S7 =' 95&N'- 9+' C"A'N9 S"*="O F*&% SA-' 9* SA-' '4'&O 1+*5&S7

39

'4A"5A9A*N: 9+' C"A'N9 S9A""S 9+' SA%' '4'N =' -A- *5& AN9'&4'N9A*NS7

Inability to do self;care #SS$SSM$-. SH -@RSI-& DI#&-%SIS Sel. Care de.i!it rGt ne$rom$s!$lar, m$s!$los(eletal 9he patient mani.ested the .ollo#ing: impairment P!#--I-& Short .erm %b:ecti*e" A.ter N$rsing Anter6ention, the pt7 #ill be able to identi.y personal reso$r!es #hi!h !an help in *H -e!reased m$s!le pro6iding assistan!e7 S%onitored 4ital signs S 9o identi.y any other de6iations .rom normal7 I-.$RV$-.I%-S S'stablished &apport R#.I%-#!$ S 9o gain tr$st o. the patient and S* in order to a!8$ire !omplian!e #ith appropriate treatments or tea!hings $7P$C.$D %@.C%M$ Short .erm %b:ecti*e" A.ter be !an able help to in N$rsing identi.y pro6iding

Anter6ention, the pt7 shall personal reso$r!es #hi!h assistan!e7

40

strength !ong .erm %b:ecti*e" A.ter 1< days o. n$rsing inter6ention, the pt7 #ill be able to demonstrate te!hni8$es or !hanges to meet sel. !are needs7 S,ro6ided ade8$ate rest periods as #ell as !om.ort T sa.ety meas$res S 9o pro6ide proper S9$rned pt7 slo#ly .rom side to side !ir!$lation o. blood .lo# on both sides o. he body S 9o pre6ent .$rther stress T .atig$e SAssessed patient !ondition S9o determine any other $nderlying !a$se o. mani.estations !ong .erm %b:ecti*e" A.ter 1< days o. n$rsing inter6ention, the pt7 shall be able to demonstrate te!hni8$es or !hanges to meet sel. !are needs7

S-etermined pt7 strengths and s(ills

S9o assess degree o. disability

41

SAssisted pt7 in his a!ti6ities

S9o promote optimal le6el o. .$n!tion

S'n!o$raged ade8$ate inta(e o. .l$ids T N$tritio$s .oods

S,romotes #ell<being and maximi;es energy prod$!tion7

S,ro6ided time .or listening to patient and S*, and pro6ided pri6a!y d$ring personal !are a!ti6ities7 SAn6ol6ed !lients S* in !are

S9o assist #ith the patients !$rrent disability or !ondition7

S9o assist in learning #ays o. managing problems o. immobility and .or pro6iding appropriate n$rsing

42

!are7

S ,ro6ided health tea!hings and s$pport o the S* .or !are options

S9o pro6ide !lari.i!ation &ein.or!ement and and periodi! &e6ie# by !lientG!aregi6ers7

43

N5&SAN) AN9'&4'N9A*N ,&*)&'SS N*9' ,&*B"'%: ANABA"A9O 9* -* S'"F<CA&' -A9': /5"O 29, 1229

ASS'SS%'N9: *N 9+' FA&S9 -AO =' +AN-"'- *5& C"A'N9 +AS -'C&'AS'- %5SC"' S9&'N)9+7 AN9'&4'N9A*N: AF9'& 9+' ASS'SS%'N9, =' %*NA9*&'- 9+' 4A9A" SA)NS, ASS'SS'- 9+' C"A'N9S C*N-A9A*N7 =' A"S* ,&*4A'- +'& A-'R5A9' &'S9 ,'&A*-S AS ='"" AS C*%F*&9 AN- SAF'9O %'AS5&'S7 =' 95&N'- 9+' C"A'N9 S"*="O F*&% SA-' 9* SA-' '4'&O 1+*5&S, =' A"S* -'9'&%AN'- C"A'N9S S9&'N)9+S AN- SLA""S7 '4A"5A9A*N: 9+' C"A'N9 S9A""S 9+' SA%' '4'N =' -A- *5& AN9'&4'N9A*NS7

44

Producing incomprehensible sounds #SS$SSM$-. -@RSI-& DI#&-%SIS impaired 6erbal andGor SH @ Na$ngol lang sya pag may (ailangan syaB #ritten !omm$ni!ation rGt impaired !erebral !ir!$lation, aphasia P!#--I-& Short .erm %b:ecti*e" A.ter n$rsing int7 the pt #ill be able to 6erbali;e or indi!ate $nderstanding o. the *H #G m$s!le #ea(ness 5ses in!omprehensible so$nds =ith drooling o. sali6a -i..i!$lty in expressing needs !ong .erm %b:ecti*e" A.ter days o. n$rsing SNote res$lts o. ne$rologi!al testing s$!h as '')GC9 s!an !omm$ni!ation di..i!$lty and plans .or #ays o. handling7 SAssess pts general !ondition S9o note .or the etiology or pre!ipitating .a!tors that !an lead to .e6er7 S9o assess !a$sati6eG!ontrib$ting .a!tors !ong .erm %b:ecti*e" A.ter the n$rsing S%onitor 6Gs S9o obtain baseline data I-.$RV$-.I%-S S'stablish rapport R#.I%-#!$ S9o gain pts tr$st and !oordination $7P$C.$D %@.C%M$ Short .erm %b:ecti*e" A.ter the n$rsing inter6ention the pt shall 6erbali;e or indi!ate $nderstanding o. !omm$ni!ation di..i!$lty and plans .or #ays o. handling

inter6ention the pt #ill establish method o.

45

!omm$ni!ation in #hi!h needs !an be expressed7

and the li(es S9o assess SAssess en6ironment .a!tors that may a..e!t ability to !omm$ni!ate S9o assist !lient to S'stablish relationship #ith the !lient , listening !are.$lly and attending to !lients 6erbalGnon6erbal expressions S%aintain a !alm, $nh$rried manner, pro6ide s$..i!ient time .or the !lient to responds SAnti!ipate needs $ntil S9o attend pts needs immediately SAndi6id$als may tal( more easily #hen they are rested and relaxed establish a means o. !omm$ni!ation to express needs, #ants, ideas and 8$estions !a$sati6eG!ontrib$ting .a!tors

inter6ention the pt shall be able to establish methods o. !omm$ni!ation in #hi!h !an be expressed7

46

e..e!ti6e !omm$ni!ation is reestablished SAdminister d$e meds SFor pts re!o6ery and to treat $nderlying !onditions

N5&SAN) AN9'&4'N9A*N ,&*)&'SS N*9'

47

,&*B"'%: %5SC"' ='ALN'SS -A9': /5"O 29, 1229

ASS'SS%'N9: *N 9+' FA&S9 -AO =' +AN-"'- *5& C"A'N9 +AS A%,AA&'- AN- "A%A9'- C**&-ANA9A*N BO ='ALN'SS AN- -'C&'AS'- %5SC"' S9&'N)9+7 AN9'&4'N9A*N: AF9'& 9+' ASS'SS%'N9, =' %*NA9*&'- 9+' 4A9A" SA)NS, ASS'SS'- 9+' C"A'N9S )'N'&A" C*N-A9A*N7 =' N*9'- 9+' &'S5"9S *F N'5&*"*)ACA" 9'S9AN) S5C+ AS '')GC9 SCAN, =' ASS'SS'- 'N4A&*N%'N9 FAC9*&S 9+A9 %'O AFF'C9 ABA"A9O 9* C*%%5NACA9'7 '4A"5A9A*N: 9+' C"A'N9 S9A""S 9+' SA%' '4'N =' -A- *5& AN9'&4'N9A*NS7

48

P%.$-.I#! PR%)!$M

Risk for In:ury -@RSI-& DI#&-%SIS &is( .or AnC$ry P!#--I-& Short .erm %b:ecti*e" A.ter n$rsing inter6ention the pt #ill demonstrate beha6iors, li.estyle !hanges to red$!e ris( .a!tors and prote!t sel. .rom inC$ry S%onitor 6Gs S9o obtain baseline data I-.$RV$-.I%-S R#.I%-#!$ $7P$C.$D %@.C%M$ Short .erm %b:ecti*e" 9he patient shall ha6e demonstrated beha6iors, li.estyle !hanges to red$!e ris( .a!tors and prote!t sel. .rom inC$ry !ong .erm %b:ecti*e" 9he patient shall ha6e been .ree o. inC$ry7

SAssess pts general !ondition !ong .erm %b:ecti*e"

S9o note .or the etiology or pre!ipitating .a!tors that !an lead to .e6er7

A.ter hospitali;ation, pt #ill be .ree o. SAssess mood, !oping abilities, Sthat may res$lt in inC$ry personality styles !arelessness and in!reased ris( ta(ing #itho$t !onsiderations o. !onse8$en!es

SAdenti.y inter6entions and sa.ety de6i!es

S9o promote sa.e physi!al en6ironment and indi6id$al sa.ety

49

S'n!o$rage parti!ipation in sel.<help programs, s$!h as asserti6eness training, positi6e sel. image

S9o enhan!e sel. esteem7 sense o. #orth

Sraise the side rails o. the bed

S9o promote sa.e physi!al en6ironment and indi6id$al sa.ety

SFre8$ent s(in inspe!tion

S 9o assess i. there is presen!e o. press$re $l!ers7

S5se e..e!ti6e lighting

S9o promote sa.ety and easy s!anning o. the en6ironment7

S&emind !lient to #al( slo#ly, amb$late

S9o pre6ent inC$ry d$e to slipping, and to promote sa.ety7

50

SLeep things into right premises and !lear the #ay going to the restroom

S9o pre6ent inC$ry and promote sa.ety7

Risk for #spiration

51

-@RSI-& DI#&-%SIS &is( .or Aspiration

P!#--I-& Short term ob:ecti*e" A.ter N$rsing inter6ention, the pt7 demonstrate te!hni8$es to pre6ent aspiration7

I-.$RV$-.I%-S

R#.I%-#!$

$7P$C.$D %@.C%M$ Short term ob:ecti*e"

S%onitored 4ital signs

S 9o identi.y any other de6iations .rom normal7

9he patient shall ha6e demonstrated te!hni8$es to pre6ent aspiration7

!ong .erm %b:ecti*e" A.ter hospitali;ation, the pt7 #ill experien!e no aspiration aeb noiseless respirations, and !lear breath so$nds7

SNote le6el o. !ons!io$sness o. s$rro$ndings, and !ogniti6e impairment7

S9o assess i. there is gag re.lex or di..i!$lty o. s#allo#ing7

!ong .erm %b:ecti*e" 9he patient shall ha6e experien!ed no aspiration aeb noiseless respirations, and !lear breath so$nds7

SS$!tion as needed

S9o !lear se!retions

SA$s!$ltate l$ng so$nds

Sto determine presen!e o. se!retions

S)i6e semisolid .oodsK a6oid S9o pre6ent aspiration and to p$reed that may in!rease ris( aide s#allo#ing e..ort7 o. aspiration7

S,ro6ide 6ery #arm or !old li8$ids

S9his a!ti6ates temperat$re re!eptors in the mo$th that help to stim$late s#allo#ing7

52

S&e.er to spee!h therapist

S9o strengthen m$s!les and te!hni8$es to enhan!e s#allo#ing7

7V. %*erall Progress -otes

53

*n the 1st day o. o$r d$ty, the patient #as !ons!io$s b$t in!oherent d$e to inability to spea( and she is C$st prod$!ing in!omprehensible so$nds #hene6er she #anted anything7 =e also noted that she has hemiphlagia on the right side o. the body7 She also had N)9 on her right nostril7 As part o. the n$rsing inter6entions, #e too( her 6ital signs #hi!h are as .ollo#s: 9emp7H A.ebrile, ,$lseH 08, &espiratoryH 19 and B, o. 1 2G82mm+g7 9he st$dents also pro6ided non pharma!ologi!al inter6entions s$!h as positioning et!7 9hey also pro6ided health tea!hings .or the .amily o. the !lient7 *n the se!ond day, the patient is still the same #ith #hat #e obser6e yesterday, For her 6ital signs: 9emp7H A.ebrile, ,$lseH81, &espiratoryH 1 and a B, o. 1 2G82mm+g7 9he st$dents per.ormed again those inter6entions they6e done #ith the !lient7 *6erall, the patients !ondition is still the same7

54