case presentation cvd-group 16
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CEREBROVASCULAR CEREBROVASCULAR DISEASEDISEASE
CASE PRESENTATION OF BSN III-4 CASE PRESENTATION OF BSN III-4 GROUP 16 @ ARMED FORCES OF GROUP 16 @ ARMED FORCES OF
THE PHILIPPINES MEDICAL THE PHILIPPINES MEDICAL HOSPITALHOSPITAL
IntroductionIntroduction Cerebrovascular diseaseCerebrovascular disease is a group of brain dysfunctions is a group of brain dysfunctions
related to disease of the blood vessels supplying the brain. related to disease of the blood vessels supplying the brain. Hypertension is the most important cause. Hypertension is the most important cause. Cerebrovascular disease includes all disorders in which an Cerebrovascular disease includes all disorders in which an area of the brain is temporarily or permanently affected by area of the brain is temporarily or permanently affected by bleeding or lack of blood flow. Cerebrovascular diseases bleeding or lack of blood flow. Cerebrovascular diseases included stroke, carotid stenosis, vertebral stenosis and included stroke, carotid stenosis, vertebral stenosis and intracranial stenosis, aneurysms and vascular intracranial stenosis, aneurysms and vascular malformations.malformations.
Restrictions in blood flow may occur from vessel Restrictions in blood flow may occur from vessel narrowing (stenosis), clot formation (thrombosis), blockage narrowing (stenosis), clot formation (thrombosis), blockage (embolism), or blood vessel rupture (hemorrhage). Lack (embolism), or blood vessel rupture (hemorrhage). Lack of sufficient blood flow (ischemia) affects brain tissue and of sufficient blood flow (ischemia) affects brain tissue and may cause a stroke.may cause a stroke.
Cerebrovascular Disease StatisticsCerebrovascular Disease Statistics
Stroke is the third leading cause of death in Stroke is the third leading cause of death in the United States. Of the more than 700,000 people the United States. Of the more than 700,000 people affected every year, about 500,000 of these are first affected every year, about 500,000 of these are first attacks, and 200,000 are recurrent. About 25 attacks, and 200,000 are recurrent. About 25 percent of people who recover from their first stroke percent of people who recover from their first stroke will have another stroke within five years.will have another stroke within five years.• Stroke is a leading cause of serious long-term • Stroke is a leading cause of serious long-term disability.disability.• Each year, an estimated 30,000 people in the • Each year, an estimated 30,000 people in the United States experience a ruptured cerebral United States experience a ruptured cerebral aneurysm and as many as 6 percent may have an aneurysm and as many as 6 percent may have an unruptured aneurysm.unruptured aneurysm.
Objectives Objectives
At the end of the presentation, nursing At the end of the presentation, nursing students will be able to..students will be able to..
- learn about the topic or the disease- learn about the topic or the disease
- know how this disease affect people- know how this disease affect people
- understand the disease- understand the disease
- know the signs and symptoms and as well - know the signs and symptoms and as well as the causes of the disease.as the causes of the disease.
Nursing History Nursing History
A. A. Biographical Data :Biographical Data :Name: Normita EsplanaName: Normita EsplanaAge: 56 years oldAge: 56 years oldSex: FemaleSex: FemaleNationality: FilipinoNationality: FilipinoReligion: Roman CatholicReligion: Roman CatholicAddress: # 53 Bogna Legaspi City, AlbayAddress: # 53 Bogna Legaspi City, AlbayBirth Day: August 8, 1954Birth Day: August 8, 1954Birth Place: Ilocos NorteBirth Place: Ilocos NorteDate of Admission: July 28, 2011Date of Admission: July 28, 2011Chief Complaint: Body WeaknessChief Complaint: Body WeaknessDiagnosis: Cerebro Vascular Disease Fronto Parietal Area Diagnosis: Cerebro Vascular Disease Fronto Parietal Area Bilateral with hemorrhagic Conversion Parietal Area Bilateral with hemorrhagic Conversion Parietal Area
The patient has experiencing The patient has experiencing body weakness 2 weeks ago, when body weakness 2 weeks ago, when we was interviewed her.we was interviewed her.
B. Reasons for Seeking Health Care :B. Reasons for Seeking Health Care :
CC. History of Past Illness. History of Past Illness
Upon Interview to the patient, she Upon Interview to the patient, she said that in her childhood times she said that in her childhood times she never experienced any major illness. never experienced any major illness. She also said that she only experienced She also said that she only experienced those common illness like fever, colds, those common illness like fever, colds, cough and flu. The patient cannot tell cough and flu. The patient cannot tell about her immunization because she about her immunization because she has forgotten if she is fully immunized has forgotten if she is fully immunized or not. The patient has no allergy to any or not. The patient has no allergy to any foods, medicines and environment. The foods, medicines and environment. The patient also told that she had never patient also told that she had never been hospitalized and never had a been hospitalized and never had a major accidents.major accidents.
CC. History of Present Illness. History of Present Illness
Patient N.E was admitted in V.Luna Patient N.E was admitted in V.Luna General Hospital (Female Medical Ward) General Hospital (Female Medical Ward) last July 28. Prior to admission, the last July 28. Prior to admission, the patient stated that the onset of her patient stated that the onset of her illness was occur 2 weeks ago before illness was occur 2 weeks ago before she was admitted. Patient N.E started she was admitted. Patient N.E started complaining of left sided body complaining of left sided body weakness associated difficulty in weakness associated difficulty in ambulation. There was no associated of ambulation. There was no associated of difficulty of breathing, Diabetes Mellitus, difficulty of breathing, Diabetes Mellitus, Headache and Level of consciousness.Headache and Level of consciousness.
D.D. Family HistoryFamily History
There is a history of illnesses There is a history of illnesses in there family.in there family.
HypertensionHypertensionDiabetes Mellitus Diabetes Mellitus AsthmaAsthma
Anatomy & Physiology Anatomy & Physiology
PATHO-PHYSIOLOGYPATHO-PHYSIOLOGYmodifiablemodifiable non modifiable non modifiable
Increase triglycerides: 242.48mg/dLIncrease triglycerides: 242.48mg/dL
Decrease HDL:29.73mg/dLDecrease HDL:29.73mg/dL
Carotid stenosisCarotid stenosis
Decrease cardiac outputDecrease cardiac output
Compensatory aldosterone ADHCompensatory aldosterone ADH cathecolamine compensatory cathecolamine compensatory releaserelease
Adequate or increase blood volumeAdequate or increase blood volume increase increase SVRSVR
Increase preload, stroke volume and heart rateIncrease preload, stroke volume and heart rate
Systemic andSystemic and
pulmonary edemapulmonary edema increase myocardial oxygen requirementsincrease myocardial oxygen requirements
EDEMAEDEMA decrease cardiac output, decrease ejection decrease cardiac output, decrease ejection fractionfraction
Increase BPIncrease BP decrease tissue decrease tissue perfusionperfusion
Impaired cellular metabolismImpaired cellular metabolism
Gordon’s Functional Health Gordon’s Functional Health Health perception- health management:Health perception- health management:
The patient understands her condition she is taking The patient understands her condition she is taking medications prescribed by her physician & follows all the advice in medications prescribed by her physician & follows all the advice in order to improve her healthorder to improve her health
Nutrition metabolic :Nutrition metabolic :She is advised to eat low fat low sodium foods & she takes She is advised to eat low fat low sodium foods & she takes
consideration of it. Although sometimes she cannot eat, she feels so consideration of it. Although sometimes she cannot eat, she feels so dizzy & nauseated. Before she used to eat fatty foods but now it dizzy & nauseated. Before she used to eat fatty foods but now it was changed.was changed.
Elimination:Elimination:She frequently urinate during daytime & defecate every She frequently urinate during daytime & defecate every
other day, she don’t have any problem in urinating or defecating other day, she don’t have any problem in urinating or defecating even before hospitalization.even before hospitalization.
Activity-exercise:Activity-exercise:The patient stays on bed all day long she ambulates The patient stays on bed all day long she ambulates
only when she’s urinating. She experienced shortness of only when she’s urinating. She experienced shortness of breath when she is walking & leg cramps. According to her breath when she is walking & leg cramps. According to her son even before hospitalization the patient stays on bed son even before hospitalization the patient stays on bed oftentimes.oftentimes.
Sleep & rest:Sleep & rest:The patient sometimes suffering from difficulty of The patient sometimes suffering from difficulty of
sleeping due to her leg cramps & headache even before she sleeping due to her leg cramps & headache even before she was hospitalizedwas hospitalized
Cognitive-perceptual :Cognitive-perceptual :The patient sometimes was disoriented she cannot The patient sometimes was disoriented she cannot
verbalized what she feels & sometimes cannot recognize verbalized what she feels & sometimes cannot recognize some of her family member also due to her age. Most of the some of her family member also due to her age. Most of the times she feels restless & dizzy at bed she also experiences times she feels restless & dizzy at bed she also experiences some sort of pain in her leg, shortness of breath. Headache some sort of pain in her leg, shortness of breath. Headache & nausea.& nausea.
Role relationship:Role relationship:
According to her son her mom is a plain According to her son her mom is a plain housewife living with them before she was still strong housewife living with them before she was still strong she can cook food for them & clean their house but she can cook food for them & clean their house but when she gets old & her condition worsen she can no when she gets old & her condition worsen she can no longer do the things she used to do before.longer do the things she used to do before.
Sexuality reproductiveSexuality reproductive::Of course because of her age & condition she can no Of course because of her age & condition she can no
longer engage in any sexual activities.longer engage in any sexual activities.
Coping stress:Coping stress:When the patient have problems she verbalized it in her When the patient have problems she verbalized it in her
children & husband mostly problems regarding her condition. children & husband mostly problems regarding her condition. The patient cannot effectively cope up with stress by her own, The patient cannot effectively cope up with stress by her own, basically she needs her family supportbasically she needs her family support
Physical Assessment Physical Assessment Area Assessed Technique Normal Findings Actual Findings Evaluation
SkinColor
Inspection Light brown, tanned skin (vary
according to race)
brown Normal
Lips, nail beds, soles and
palms
Inspection Lighter colored palms, soles, lips and nail
beds
Pallor nail beds Pallor nail beds Normal
Moisture Inspection/Palpation
Skin normally dry Dry Dry Normal
Temperature Palpation Normally warm Warm to touch Warm to touch Normal
Texture Palpation Smooth, soft and flexible palms
and soles (thicker)
SmoothSmooth Normal
Turgor Palpation Skin snaps back immediately
Goes back Goes back immediately immediately
Normal
Skin appendagesa. Nails
Inspection Transparent, smooth and convex
Pinkish, Convex Pinkish, Convex Normal
Nail beds Inspection Pinkish Pinkish Pinkish Normal
Nail base Inspection Firm Firm Firm Normal
Capillary refill Inspection/ Palpation White color of nail bed under pressure should return to pink within 2-3
seconds
White color of nail beds White color of nail beds under pressure returned to under pressure returned to
pink within 2-3 secondspink within 2-3 seconds
Normal
b. HairDistribution
Inspection Evenly distributed Evenly distributed Evenly distributed Normal
Color Inspection Black Grayish Grayish Normal because of old age
Texture Inspection/ Palpation Smooth Uneven Uneven Normal
c. Eyes Eyes
Inspection Parallel to each other Parallel to each otherParallel to each other Normal
Visual Acuity Inspection (penlight) PERRLA- Pupils equally round react to light and
accommodation
PERRLA- Pupils equally PERRLA- Pupils equally round react to light and round react to light and
accommodationaccommodation
Normal
Eyebrows Inspection Symmetrical in size, extension, hair texture and
movement
Symmetrical in size, Symmetrical in size, extension, hair texture and extension, hair texture and
movementmovement
Normal
Eyelashes Inspection Distributed evenly and curved outward
Distributed evenly and Distributed evenly and curved outwardcurved outward
Normal
Conjunctiva Inspection Transparent with light pink color
Transparent with light pink Transparent with light pink colorcolor
Normal
Sclera Inspection Color is white Color is whiteColor is white Normal
Cornea Inspection Transparent, shiny Transparent, shinyTransparent, shiny Normal
Pupils Inspection Black, constrict briskly Black, constrict brisklyBlack, constrict briskly Normal
Iris Inspection Clearly visible Clearly visibleClearly visible Normal
Ears Ear canal opening
Inspection Free of lesions, discharge of inflammationCanal walls pink
Free of lesions, discharge of inflammation
Canal walls pink
NormalNormal
Hearing Acuity Inspection Client normally hears words when whispered
Client sometimes doesn’t’ hear words when
whispered, sometimes you have to speak louder
Abnormal , d/t old age
Nose Shape, size and skin
color
Inspection Smooth, symmetric with same color as the face
Smooth, symmetric with same color as the face
Normal
Nasal septum Inspection Close to midline, thicker anteriorly than posteriorly
Close to midline, thicker anteriorly than posteriorly
Normal
Nares Inspection Oval, symmetric and without discharge
Oval, symmetric and without discharge
Normal
Mouth and PharynxLips
Inspection Pink, moist symmetric Dry and pale Dry and pale Normal
Buccal mucosa Inspection Glistening pink soft moist Dry Dry d/t the mouth is always open
Gums Inspection Slightly pink color, moist and tightly fit against each
tooth
Slightly pink color, Dry and not tightly fit against each
tooth
Normal
Tongue Inspection Moist, slightly rough on dorsal surface medium or
dull red
Moist, slightly rough on dorsal surface medium or dull red
Normal
Teeth Inspection Firmly set, shiny pt. has bite plane pt. has bite plane To prevent dislocation of teeth
Hard and soft palate Inspection Hard palate- dome-shapedSoft Palate- light pink
Hard palate- dome-shapedSoft Palate- light pink
Normal
Neck Symmetry of neck
muscles, alignment of trachea
Inspection Neck is slightly hyper extended, without
masses or asymmetry
Neck is slightly hyper extended, without
masses or asymmetry
Normal
Neck Rom Inspection Neck moves freely, without discomfort
Neck moves freely, without discomfort
Normal
Thorax and Lungs Auscultation Clear breath sounds Clear breath sounds Normal
Abdomen Inspection Skin same color with the rest of the body
Skin same color with the rest of the body
Normal
Bowel sounds Auscultation Clicks or gurgling sounds occur irregularly
Clicks or gurgling sounds occur irregularly
Normal
Neurology systemLevel of
consciousness
Inspection Fully conscious, respond to questions quickly
Lethargic , do not respond to questions quickly
Abnormal
Behavior and appearance
Inspection Makes eye contact with examiner, hyperactive
expresses feelings with response to the
situation
Sometimes doesn't makes eye contact with
examiner, not hyperactive in
expressing feelings with response to the situation
Abnormal
Diagnostic/ Laboratory Diagnostic/ Laboratory Examinations Examinations
Lipid profile Lipid profile
TypeType Normal Findings Normal Findings Actual Actual findingsfindings
ElevatedElevated DecreasedDecreased
TriglyceridesTriglycerides <150 mg/ml <150 mg/ml 121121 hyperlipoprotenemiahyperlipoprotenemia hyperthyroidismhyperthyroidism
Myoglobulin Myoglobulin 5-70 mg/ml 5-70 mg/ml 6464 Angina, other muscle Angina, other muscle injuryinjury
Rheumatoid Rheumatoid arthritisarthritis
CholesterolCholesterol <200mg/dl<200mg/dl 188188 Type 11 Type 11 hypercholesterolemiahypercholesterolemia
Severe Severe hepatocellular hepatocellular diseasedisease
HDLHDL 35-80 mg/dl35-80 mg/dl 9292 Chronic liver diseaseChronic liver disease Familial Familial hypolipotremiahypolipotremia
LDLLDL <130 mg/dl<130 mg/dl 127127 hyperlipidemiahyperlipidemia hypolypoprotenemhypolypoprotenemiaia
TypeType Normal Findings Normal Findings Actual Actual findingsfindings
ElevatedElevated DecreasedDecreased
RBCRBC
4.1-5.1 million/mm4.1-5.1 million/mm 4.74.7 Chronic lung diseaseChronic lung disease Abnormal loss of Abnormal loss of erythrocyteerythrocyte
HemoglobinHemoglobin 12-16g/dl12-16g/dl 1212 polycythemiapolycythemia Blood loss, anemiaBlood loss, anemia
HematocritHematocrit 36% -46% 36% -46% 3939 Polycythemia, burns Polycythemia, burns Blood loss, anemiaBlood loss, anemia
WBC WBC 4,500-11,000/mm4,500-11,000/mm
11.6-14.011.6-14.0
12.412.4 Leukocytosis infection Leukocytosis infection Leukepenia, Auto Leukepenia, Auto Immune disease Immune disease
Neutrophils Neutrophils 55%-70%55%-70% 88 Stress, Acute Infection Stress, Acute Infection Viral Disease Viral Disease
LymphocyteLymphocyte 20% - 40%20% - 40% 3232 Viral infection,Tuberculosis , Leukemia Viral infection,Tuberculosis , Leukemia Autoimmune disease Autoimmune disease
MonocyteMonocyte 2 – 8 %2 – 8 % 66 Chronic Inflammatory disorders Chronic Inflammatory disorders Drug theraphy Drug theraphy prednisone prednisone
EosinophilsEosinophils 1-4 %1-4 % 33 Allergic Reactions, asthma Allergic Reactions, asthma Corticosteroid theraphy Corticosteroid theraphy
BasophilsBasophils 0 – 2% 0 – 2% 11 Leukemia Leukemia Acute allergic reaction Acute allergic reaction
Platelet Count Platelet Count 150,000- 350,000/mm 150,000- 350,000/mm
150-350150-350
167167 Malignant Tumors Malignant Tumors Thrombocytopenic Thrombocytopenic purpura purpura
Blood Test
Drug Study Drug Study GENERIC NAME / BRAND NAME
INDICATION / DOSAGE
ACTION CONTRAINDICATIO
N
SIDE EFFECTS NURSING RESPONSIBILITI
ES
Generic Name:
Losartan Potassium
Brand Name:
Cozaar
Classification:
cardiovascular agent; angiotensin ii receptor antagonist; antihypertensive
Hypertension
Dosage:
Adult: PO 25–50 mg in 1–2 divided doses (max: 100 mg/d); start with 25 mg/d if volume depleted (i.e., on diuretics)
Angiotensin II receptor (type AT1)
antagonist acts as a potent vasoconstrictor and primary vasoactive hormone of the renin–angiotensin–aldosterone system.
Hypersensitivity to losartan, pregnancy [category C (first trimester), category D (second and third trimesters)], lactation
CNS: Dizziness, insomnia, headacheGI: Diarrhea, dyspepsia.Musculoskeletal: Muscle cramps, myalgia, back or leg pain.Respiratory: Nasal congestion, cough, upper respiratory infection, sinusitis.
Monitor BP at drug trough (prior to a scheduled dose).Inadequate response may be improved by splitting the daily dose into twice-daily doseLab tests: Monitor CBC, electrolytes, liver & kidney function with long-term therapy.
GENERIC NAME / BRAND NAME
INDICATION / DOSAGE
ACTION CONTRAINDICATI
ON
SIDE EFFECTS NURSING RESPONSIBILITI
ES
Generic Name:
Simvastatin Brand Name:
Zocor.Classification:
CV agent, antilipemic, HMG-COA reductase inhibitor (statin)
Adjunct to diet in the treatment of elevated total cholestrol and LDL cholesterol with primary hypercholesterolemia (types IIa and IIb) in those unresponsive to dietary restriction of saturated fat and cholesterol and other nonpharmacologic measuresTo reduce the risk of coronary disease, mortality, and CV events, including stroke, TIA, MI and reduction in need for bypass surgery and angionplasty in patients with coronary heart disease and hypercholesterolemiahypertriglyceridemiaTreatment of type III hyperlipoproteinemiaTreatment of adolescents 10-17 yr with heterozygous familial hypercholesterolemiaDosage: 40mg/tab 1 tab OD at hs (p.o.)
Inhibits HMG-CoA reductase, the enzyme that catalyzes the first step in the cholesterol synthesis pathway, resulting in a decrease in serum cholesterol, serum LDLs, and either an increase or no change in serum HDLs.
Contraindicated with allergy to simvastatin, fungal byproducts, pregnancy, lactation.
CNS: Headache, asthenia, sleep disturbancesGI: Flatulence, diarrhea, abdominal pain, cramps, constipation, nausea, dyspepsia, heartburn, liver failureRespiratory: Sinusitis, pharyngitisOther: Rhabdomyolysis, acute renal failure, arthralgia, myalgia
Assess nutrition: fat, protein, carbohydratesMonitor bowel pattern dailyMonitor triglycerides, cholesterol baseline throughout treatmentPrecautions to Past liver disease, alcoholism, severe acute infections, trauma, severe metabolic disorders, electrolyte imbalances, elderly, renal disease
GENERIC NAME / BRAND NAME
INDICATION /
DOSAGE
ACTION CONTRAINDICATION
SIDE EFFECTS NURSING RESPONSIBILITIES
Generic Name:DexamethasoneBrand Name: Cortastat, Dalalone, Decadrol, Decaject, Deronil, Dexacorten, Dexameth, Dexasone, Dexone, Hexadrol, Primethasone, SolurexClassification: Long- acting corticosteroid
Management of cerebral edemaDiagnostic agent in adrenal disordersRelieves inflammationAllergic disordersAsthmaArthritisDosage: Cerebral Edema:PO (Adults): 2 mg q 8-12 hoursIM, IV (adults): 10 mg initially IV, 4 mg q 6 hr, may be decreased to 2 mg q 8-12 hr, then change PO.Adrenocortical Insufficiency/Anti-inflammatoryPO (Adults): 0.5-9 mg daily in single or divided dosesPO (children): 23.3 mcg/kg in 3 divided doses.IV (Adults): 0.5-24 gm/dayIM (Adults): 8-16 mg q 1-3 wk
Dexamethasone suppresses
inflammation and the normal immune
response. It prevents the release of substances in the
body that causes inflammation.
Hypersensitivity to dexamethasoneActive untreated infectionLactationSystemic fungal infection
AcneDecreased wound healingDepressionVomitingEasy bruisingHeadacheIncreased hair growthInsomniaRestlessnessStomach irritationIrregular or absent menstruationDizziness
Monitor intake and output of patient.Observe the patient for peripheral edema, steady weight gain, rales or crackles or dyspnea. Notify the physician immediately if these clinical manifestations are noted.Periodic growth evaluation for children should be done time to time.For patients with cerebral edema, assess then for level of consciousness changes and headache during the therapy.Guaiac-test stools should be carried out. Guaiac-positive stools should be reported to the physician immediately.Administer with meals to minimize GI irritation.For patients with difficulty swallowing, tablets can be crushed and administered with fluids or food. However, capsules should be swallowed whole.Educate the patient to take missed doses as soon as remembered, unless almost time for the next dose skip the missed dose and continue your regular dosing schedule. Do not take a double dose to make up for a missed one.Instruct patient to avoid people with known infection and contagious illnesses ascorticosteroids causes immunosuppression and may mask symptoms of infection.
GENERIC GENERIC
NAMENAMEBRAND BRAND
NAMENAMEDOSAGDOSAG
EEINDICATIONINDICATION MECHANISM MECHANISM
OF ACTIONOF ACTIONCONTRAINDICATIOCONTRAINDICATIO
NNADVERSE ADVERSE
EFFECTEFFECTNURSING NURSING
RESPONSIBILITIRESPONSIBILITI
ESES
CiticholineCiticholine ZynapseZynapse 500mg 500mg
IV q8IV q8
DiscontinDiscontin
ued on ued on
SeptembSeptemb
er 9, er 9,
20092009
CerebrovascuCerebrovascu
lar Diseases, lar Diseases,
accelerates accelerates
the recovery the recovery
of of
consciousnesconsciousnes
s and s and
overcoming overcoming
motor deficit.motor deficit.
Citicoline Citicoline
activates the activates the
biosynthesis of biosynthesis of
structural structural
phospholipids phospholipids
in the neuronal in the neuronal
membrane, membrane,
increases increases
cerebral cerebral
metabolism metabolism
and increases and increases
the level of the level of
various various
neurotransmitteneurotransmitte
rs, including rs, including
acetylcholine acetylcholine
and dopamine. and dopamine.
Citicoline has Citicoline has
shown shown
neuroprotective neuroprotective
effects in effects in
situations of situations of
hypoxia and hypoxia and
ischemia.ischemia.
hypertonia of the hypertonia of the
parasympatheticparasympatheticciticoline may citicoline may
exert a exert a
stimulating stimulating
action of the action of the
parasympathetiparasympatheti
c, as well as a c, as well as a
fleeting and fleeting and
discrete discrete
hypotensor hypotensor
effecteffect
Watch out for Watch out for
hypotensive hypotensive
effectseffects Somazine Somazine
must not be must not be
administered administered
along with along with
medicaments medicaments
containingcontaining
Nursing Care Plan Nursing Care Plan
ASSESSMENT NURSINGDIAGNOSIS
PLANNING INTERVENTION RATIONALE EVALUATION
S - “Hindi sya makagalaw ng maayos at nahihirapan syang igalaw ang kanyang katawan kahit ang kanyang mga kamay at binti." as verbalized by pt. relative.
O - Limited range of motion ( client cant fully extend her extremities ) - Limited ability and difficulty to perform gross motor skills like extending and lifting extremities. - Slowed movement. -Inability to purposefully move involved body parts. -Decreased muscle strength. -Functional level : level 2 - requires help from another person.
Impaired Physical mobility r/t neuromuscular damage involvement
Short term :
After 4 hours of nursing intervention, the patient and the patient's relative will verbalize understanding situation or riskfactors and individual treatment regimen and safety measures
Long term :
After 4 days of continuous , effective and collaborative nursing interventions. client would possibly be able to increase her range of mobility and decrease difficulty of moving.
• Montitor V/S
•Determine the diagnosis that contributes to immobility
•Encourage and facilitate early ambulation and other ADLs when possible.Assist with each initial change :dangling, sitting in chair, ambulation
•Perform passive or active ROM exercises to all extremities
•Turn and position every 2 hours or as needed
To note changes and for baseline comparison
To be informed about the situations that may restrict movements.)
The longer the patient remains immobile the greater the level of debilitation that will occur
Exercise promotes increased venousr eturn, prevents stiffness, and maintains muscle strength and endurance
This optimizes circulation to all tissues and relieves pressure
Short tem : After 4 hours of nursing intervention the patient and the patient's relatives was able to verbalize understanding situation or risk factors and individual treatment regimen and safety measures. Goal was met.
Long term : After 4 days of continuous ,effective and collaborative nursing interventions, patient was able to increase physical mobility and decrease difficulty of moving. Goal was met
ASSESSMENT NURSINGDIAGNOSIS
PLANNING INTERVENTION RATIONALE EVALUATION
•Provide safety measures(side rails,using pillow tosupport body part
•Massage back and bony prominences
To provide safety and reduce the risk of pressure ulcers
it provides comfort to the patient and promote good circulation
Discharge Plan Discharge Plan Medication Patient will continue take medicine such as Losartan Potassium 50 mg OD, Simvastatin 40mg/tab 1 tab
OD.
ExercisePatient will verbalize need importance of exercise and demonstrate proper initiation of appropriate exercise and needs to rest in between periods of activities.
Treatment
Patient will know appropriate treatment like using nebulization. Hygiene
The patient must take a bath daily and know the proper oral hygiene Outpatient
Patient must come back after 2 weeks at the OPD Diet
Low salt low fat diet Spiritual The patient should go to mass and know how to pray to God
Prepared by: Prepared by: BSN III-4 Group 16 BSN III-4 Group 16
Tuazon, Gian PaulTuazon, Gian PaulVarsovia, Paul Joram Varsovia, Paul Joram Viacrucis, Vianne MaigViacrucis, Vianne MaigVidal, Kimberly Mae Vidal, Kimberly Mae Villafuerte, Janella Marie Villafuerte, Janella Marie Villanueva, Cheryl AnnVillanueva, Cheryl AnnVillarina, Fidel Villarina, Fidel Vinco, Maria Karmela Louise T. Vinco, Maria Karmela Louise T.
Submitted to: Submitted to:
Mr. Arnel Ipapo Mr. Arnel Ipapo
Area: AFPMC -5D Area: AFPMC -5D
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