I



…………………………………………………………………………

…………..TABLE OF CONTENTS

TITLE PAGE NO.

I. Introduction 1-2

II. Objectives 2-3

III. Nursing Assessment

1. Personal History

1. Patient’s Profile 3-4

2. Family and Individual Information 4

3. Level of Growth and Development

1.3.1. Normal Development at Particular Stage 5-7

2. Ill Person at Particular Stage of Patient 8

2. Diagnostic Results 8-11

3. Present Profile of Functional Health Pattern 11-14

4. Pathophysiology and Rationale 14-22

IV. Nursing Intervention

1. Care Guide of Patient 22-25

2. Actual Patient Care

1. Nursing Assessment 26-27

2. Nursing Care Plan 27-32

3. Drug Study 33-34

4. Health Teaching Plan 35-36

V. Evaluation and Recommendation 36

VI. Evaluation and Implication 36-37

VII. Referral and Follow –up 37-38

VIII. Bibliography 38-39

I. Introduction

“Cerebrovascular disorders” is an umbrella term that refers to any functional abnormality of the central nervous system (CNS) that occurs when the normal blood supply to the brain is disrupted. It also refers to any functional or structural abnormality of the brain caused by a pathological condition of the cerebral vessels or of the entire cerebrovascular system. This pathology either causes hemorrhage from a tear in the vessel wall or impairs the cerebral circulation by a partial or complete occlusion of the vessel lumen with transient or permanent effects. Stroke is the primary cerebrovascular disorder and it is the third leading cause of death after heart disease and cancer and is the leading cause of disability among nations.

Stroke is a term used to describe neurologic changes caused by an interruption in the blood supply to a part of the brain. The most common vessels involved are the carotid arteries and those of the vertebrobasilar system at the base of the brain. The two major types of stroke are ischemic and hemorrhagic. Ischemic stroke is caused by a thrombotic or embolic blockage of blood flow to the brain, with thrombosis being the main cause of both CVA’s and transient ischemic attacks (TIAs). A thrombotic CVA causes a slow evolution of symptoms, usually over several hours, and is “completed” when the condition stabilizes. An embolic CVA occurs when a clot is carried into cerebral circulation and causes a localized cerebral infarct. Ischemia may be transient and resolve within 24 hours, reversible with resolution of symptoms over a period of 1 week (reversible ischemic neurologic deficit [RINDI]), or progress to cerebral infaction with variable effects and degrees of recovery.

Bleeding into the brain tissue or the subarachnoid space causes a hemorrhagic stroke. It is caused by other conditions such as a ruptured aneurysm, hypertension, arteriovenous (AV) malformations, or other bleeding disorders. Symptoms depend on distribution of the cerebral vessels involved. Ischemic strokes account for approximately 83% of all strokes. The remaining 17% of strokes are hemorrhagic.

Cerebrovascular disorder are the third leading cause of death in the United State. And in the Philippine setting, it ranked as the second leading causes of mortality with a 62.3 rate per 100,000 population in both sexes and with a percentage of 12.5 by the year 2002. Therefore, giving emphasis in the study of this disease condition is very relevant. Breakthroughs could happen and may help in the welfare of not just to Filipinos but to all people at risk in this condition.

The advent of thrombolytic therapy for the treatment of acute ischemic stroke has revolutionized the care of the client following a stroke. Before, health care professionals could offer only supportive measures and rehabilitation to stroke survivors. New therapies can now prevent or limit the extent of brain tissue damage caused by acute ischemic stroke. Thrombolytic therapy must be administered as soon as possible after the onset of the stroke; a treatment window of 3 hours from the onset of manifestations has been established. To convey this sense of urgency regarding the evaluation and treatment of stroke, health care professionals now refer to stroke as brain attack. Public education is focused on prevention, recognition of manifestations, and early treatment of brain attack.

II. Objectives

Student Nurse

General Objectives

After 2 days of giving holistic nursing care to the patient who have viral meningitis, the nurse will be able to gain adequate knowledge, attitude and skills in taking care of a patient who is suffering from this disease condition.

Specific Objectives

After 8 hours of giving holistic nursing care, the nurse will be able to:

1. relate the patients history and level of growth and development

2. explain the significance of the diagnostic results

3. review the anatomy and physiology of the brain

4. explain the disease process and organ involved

5. compare the chart in classical and clinical symptoms of the disease process

6. formulated appropriate nursing care plan based on identified problem of patient

7. impart health teachings to the patient and significant others on viral meningitis

Patient and Family

General Objective

After 2 days of nurse- client interaction the client and family will be able to acquire adequate knowledge, attitude and skills in the promotion of health and prevention of injuries and disease as well as rehabilitation from the condition.

Specific Objective

After 8 hours of giving holistic nursing care, the patient and significant others will be able to:

1. establish a trusting relationship with the nurse

2. verbalize feelings and thoughts to the nurse

3. share information about self and the family and life experiences to the nurse

4. explain the disease process in their own level of understanding

5. show willingness in the implementation of planned nursing care

III. Nursing Assessment

1. Personal History

1.1Patient’s Profile

Name: Lee, George Ang

Age: 54 years Old

Sex: Male

Civil Status: Married

Religion: Buddhist

Date of Admission: January 2, 2006

Room number: 221

Complaints: Right sided weakness and slurred speech

Impression/Diagnosis: Cerebrovascular Accident (Bleed- left basal ganglia)

Physician: Dr. M. Lim, Dr. W. Briones, Dr. G. Lim, Dr. E. Hernandez

Hospital Number: 782349

1.2 Family and Individual Information, Social and Health History

A case of Mr. George Ang Lee, 54 year old, male, Filipino and Buddhist. He is a businessman living at 515 MJ Cuenco Avenue, Cebu City.

Patient is a known hypertensive for many years already with a usual blood pressure of 140/90. He has a maintenance medication when systolic blood pressure reaches to 170. He is non-diabetic and non-asthmatic. Inspite, his condition, he has no previous hospitalization until January 2, 2006 when he experienced a sudden onset of weakness at the right side of his body. Patient was later noted to be on the floor with slurred speech and drowsiness, then was rushed immediately to Chong Hua Hospital- Emergency Room and later transferred to Cebu Doctor’s University Hospital after basic diagnostic procedures were taken. CT Scan taken revealed 25 cc bleed at left basal ganglia with medial shift to the right. BP was noted to be elevated with highest BP at 190/110 and captopril was given.

The patient doesn’t smoke and drink alcoholic beverages. His usual diet consist of vegetable and no meat. He also has a regular exercise schedule everyday but he has a strong heredofamilial disease of hypertension. His wife shared that lately his husband was under stress due to increase sales in their business on the month of December and missed to have his regular exercise and only sleeps a lesser hour per night compared to his usual sleep.

1.3 Level of Growth and Development

1.3.1 Normal Development at Particular Stage

Physical

Appearance Changes

Hair begins to thin, and gray hair appears. Skin turgor and moisture decreases, subcutaneous fat decreases and wrinkling occurs. Fatty tissue is redistributed, resulting in fat deposits in the abdominal area.

Cardiovascular Changes

Blood vessels lose elasticity and become thicker.

Gastrointestinal Changes

Gradual decrease in tone of large intestine may predispose the individual to constipation.

Sensory Perception Changes

Visual acuity declines, often by the late forties, especially for near vision (presbyopia). Auditory acuity for high-frequency sounds (presbycusis) also decreases, particularly in men. Taste sensation also diminish.

Metabolism Changes

Metabolism slows, resulting in weight gain.

Urinary changes

Nephron units are lost during this time, and glomerular filtration rate decreases.

Sexuality Changes

Hormonal changes takes place.

Musculoskeletal Changes

Skeletal muscle bulk decreases at about age 60. Thinning of the intervertebral disks causes a decrease in height of about 1 inch. Calcium loss from bone tissue may occur. Muscle growth continues in proportion to use.

Psychosocial

Erickson viewed the development tasks of middle-aged adult as generativity versus stagnation. Generativity is defined as the concern for establishing and guiding the nest generation. In other words, there is concern about providing for the welfare of humankind that is equal to the concern of providing for self. In middle age, the self seems more altruistic, and concepts of service to others and love and compassion gain prominence. These concepts motivate charitable and altruistic actions, such as church work, social work, political work, community fund-raising drives, and cultural endeavors. Marriage partners have more time for companionship and recreation; thus, marriage can be more satisfying in the middle years of life. Generative middle-aged persons are able to feel a sense of comfort in their life-style and receive gratification form charitable endeavors.

Erickson believes that persons who are unable to expand their interests at this time and who do not assume the responsibility of middle age suffer a sense of boredom and impoverishment, that is, stagnation. These persons have difficulty accepting their aging bodies and become withdrawn and isolated. They are preoccupied with self and unable to give to others. Some may regress to younger patterns of behavior.

Cognitive

The middle-aged adult’s cognitive and intellectual abilities change very little. Cognitive processes include reaction time that stays much the same or diminishes during the later part of the middle years, perception, learning that continues and can be enhanced by increased motivation oat the time in life, memory and problem solving that are maintained through middle adulthood, and creativity.

Middle-aged adults are able to carry out all the strategies described in Piaget’s phase of formal operations. Some may use post-formal operations strategies to assist them in understanding the contraindications that exist in both personal and physical aspects of reality. The experiences of the professional, social and personal life of middle-aged persons will be reflected in their cognitive performance. Thus, approaches to problem solving and task completion will vary considerably in a middle-aged group. The middle-aged adult can “reflect on the past and current experiences and can imagine, anticipate, plan and hope”

Moral

According to Kohlberg, the adult can move beyond the conventional level to the postconventional level. Kohlberg believes that extensive experience of personal moral choice and responsibility is required before people can reach to postconventional level. Kohlberg found that few of his subjects achieved that highest level of moral reasoning. To move from stage 4, a law and order orientation, to stage 5, a social contract orientation, requires that the individual move to a stage in which rights of others take precedence. People in stage 5 take steps to support another’s right.

Spiritual

Not all adults progress through Fowler’s stages to the fifth, called the paradoxical-consolidative stage. At this stage, the individual can view the “truth” from a number of viewpoints. Fowler’s fifth stage corresponds to Kohlberg’s fifth stage of moral development. Fowler believes that only some individuals after the age of 30 years reach this stage.

In middle age, people tend to be less dogmatic about religious beliefs, and religion often offers more comfort to the middle-aged person than it did previously. People in this age group often rely on spiritual beliefs to help them deal with illness, death and tragedy.

1.3.2 The Ill Person at a Particular Stage of Patient

The three most common causes of death in older adults are heart disease, cancer and stroke. Other frequently reported causes of death are lung disease, accidents/falls, diabetes, kidney disease, and liver disease. Heart disease is the leading cause of death in older adults. Common cardiovascular disorders are hypertension and coronary artery disease. Cancer or malignant neoplasms are the second most common cause of death among older adults. Cerebrovascular accidents, the third leading cause of death, occurring as brain ischemia or brain hemorrhage. Cigarette smoking has been recognized as a risk factor in the four most common cause of death for older adults: heart disease, cancer, stroke and lung disease. Dental carries, gingivitis, broken or missing teeth and ill-fitting or missing dentures may affect nutritional adequacy, cause pain, and lead to infection.

2. Diagnostic Results

|Diagnostic Test |Normal Values |Patient’s Result |Significance |

|Hematology | | | |

|Hemoglobin |11.5-16 g/dl |11.5 g/dl |Normal |

|Hematocrit |35-49 vol % |35 vol % |Normal |

|RBC |4.5-5.3x10^6/dl |4.73x10^6/dl |Normal |

| | | |Elevated in acute disease. |

|WBC |4.5-15.0x10^3/dl |12.2x10^3/dl |Source: Brunner and Suddarth’s |

| | | |Textbook of Medical – |

| | | |Surgical Nursing, 9th Ed. |

| | | |Smeltzer, Suzanne C. |

| | | |Bare, Brenda G., p.1954 |

|MCV |72-98 fl. |91 fl. |Normal |

|MCH |25-35 pg |30.3 pg |Normal |

|MCHC |30-37 g/dl |33.3 g/dl |Normal |

|Platelets |150,000-450000 cu/mm |361,000 cu/mm |Normal |

|Segmenters |54-62% |84% |Elevated in acute disease. |

| | | |Source: Brunner and Suddarth’s |

| | | |Textbook of Medical – |

| | | |Surgical Nursing, 9th Ed. |

| | | |Smeltzer, Suzanne C. |

| | | |Bare, Brenda G., 1953 |

|Eosinophils |1-3% |01% |Normal |

|Lymphocytes |25-33% |10% |Normal |

|Urinalysis | | | |

|Macroscopic | | | |

|Color |Yellow |Yellow |Normal |

|Appearance |Clear |Slightly cloudy |Not normal |

|Reaction |5.5-7.5 |6.0 |Normal |

|Specific gravity |1.001-1.045 |1.020 |Normal |

|Protein |Negative |Trace |Not normal |

|Glucose |Negative |Negative |Normal |

|Ketones |Negative |Negative |Normal |

|Blood |Negative |Negative |Normal |

|Macroscopic | | | |

|RBC | ................
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