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