medical surgical nursing - neuro

7/29/2019 Medical Surgical Nursing - Neuro

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PAMANTASAN NG LUNGSOD NG MAYNILA(University of the City of Manila)

Intramuros Manila

College of Nursing

A Case Study of Transient Ischemic Attack

In partial fulfillment for the requirement inMedical-Surgical Nursing I

Submitted By:

ESTEVES, Christian C.BSN III 1


2/19

BSN III 1

I. CASE

INTRODUCTION

Transient Ischemic Attack is the temporary episode of neurologic dysfunction thatmay last a few seconds or minutes but not longer than 24 hours. It occurs when theblood supply to part of the brain is briefly interrupted. It occurs when an area in the brainloses blood supply. As a compensatory mechanism, brain tries to restore blood flow. If blood supply is restored, affected brain cells function may return, permitting the return of function to the affected body part.

It is also called as mini-stroke , hemorrhagic stroke, or ischemic stroke.Generally, Transient Ischemic Attack happens when blood clot is present in the arteries,making blood flow to a part of the brain be reduced or blocked. Within 24 hours, bloodflows again.

Below is a presentation of case on Transient Ischemic Attack.

CASE REPORT

This is a case of a 33 year-old, married, female, Filipino, who is currently residingat Quiapo,Manila, and admitted at Ospital ng Maynila on March 6, 2010 diagnosed withTransient Ischemic Attack , with chief complaint of Syncope.

Upon admission, patient had positive signs and symptoms of sudden onset of dyspnea followed by vomiting and syncope. The sequence of the appearance of signsand symptoms are as follows: During dinner, Mrs. PIE suddenly experienced difficulty of breathing Shortly after her dyspneic episode the patient vomited and experienced left-


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II. SCHEMATIC DIAGRAM OF PATHOPHYSIOLOGY


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III. DIAGNOSTIC PROCEDURES ANDLABORATORY ANALYSIS

NURSING HEALTH HISTORY

Past Health HistoryUpon interview, the patient confirmed that she was confined to

Ospital ng Tondo three years ago (2007) with a medical diagnosis of Gastroenteritis, and was also discharged after four (4) days. Other thanthat, there were no known past illness related to TIA.

Present Health HistoryThe Chief Complaint of the patient is Syncope . Prior to

Admission, Mrs. PIE experienced difficulty of breathing, vomiting and left-sided weakness followed by loss of consciousness.

Family Health - Illness HistoryPatient PIEs mother had a cerebrovascular accident in 2003 and

bedridden for 3 years. Also, one of her first degree relatives, her uncle(fathers brother) and auntie(mothers sister) was diagnosed of Hypertension in the year 2002. On 1999, Her father and auntie also hadTransient Ischemic Attack. Other than these, there were no other reportedillness-related case within her family and relatives.

PHYSICAL ASSESSMENT

On arrival at the emergency department, 2 hours after the onsent of symptoms,she reports vomiting, with no headache. She is a current smoker with a history of 1pack-year. Her blood pressure is 140/80 mm Hg, and her pulse is 97 beats per minute,and is regular. The patient has a capillary refill of 5 seconds on blunch test, the patientski i ld d l t t h d h l ki l l ti Th ti t h


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DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic/LaboratoryProcedure

Indications or Purposes

Results Normal Values(Units used inthe hospital)

Analysis and Interpretation of Results

Potassium To determinethe amount of Potassiumpresent in theblood.Potassium isan importantelectrolyte thathelps regulatethe flow of fluids in andout of the cells

3.3 3.6-5.0 mmo/L Decreased levels of potassiumindicate hypokalemia .

Creatinine The creatinine

blood test isusuallyordered alongwith a BUN(blood ureanitrogen) test to assesskidneyfunction

0.64 0.5-1.69 mg/dl Normal

Sodium The amount of Sodiumpresent in theblood

141 137-145 mEq/L Normal-low level of blood sodiummeans you have hyponatremia ,which is usually due to too much
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of energy for most cells.

BUN The BUN testis primarilyused, alongwith thecreatinine test ,to evaluatekidneyfunction under a wide rangeof circumstancesand to monitor patients withacute or chronic kidneydysfunction or failure

7.0 7-21 mg/dl Normal-Increased BUN levels suggestimpaired kidney function. Thismay be due to acute or chronickidney disease , damage, or failure.-Low BUN levels are notcommon and are not usually acause for concern. They may beseen in severe liver disease ,malnutrition, and sometimeswhen a patient is overhydrated(too much fluid volume), but theBUN test is not usually used todiagnose or monitor theseconditions.

Uric Acid The uric acidtest is used tolearn whether the body mightbe breakingdown cells tooquickly or notgetting rid of uric acidquicklyenough. Thetest also isused to

5.07 2.5-7 mg/dl Normal- Higher than normal uric acidlevels mean that the body is nothandling the breakdown of purines well. The doctor willhave to learn whether the causeis the over-production of uricacid, or if the body is unable toclear away the uric acid.- Low levels of uric acid in theblood are seen much lesscommonly than high levels andare seldom considered cause for
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diseasesTriglycerides Blood tests for

triglyceridesare usuallypart of a lipidprofile used toidentify therisk of developingheart disease.

As part of alipid profile, itmay be usedto monitor those whohave riskfactors for heart disease,those who

have had aheart attack ,or those whoare beingtreated for high lipidand/or triglyceridelevels.

115.0 35-135 mg/dl A normal level for fasting

triglycerides is less than 150mg/dL . It is unusual to havehigh triglycerides without alsohaving high cholesterol . Mosttreatments for heart disease riskwill be aimed at lowering LDLcholesterol. However, the type of treatment used to lower LDLcholesterol may differ dependingon whether triglycerides are highor normal.

SGOT/AST Used to detectliver damage.

13 5-35 u/L NormalVery high levels of AST (morethan 10 times the highest normallevel) are usually due to acute
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an importantelectrolyte that

helps regulatethe flow of fluids in andout of the cells

indicate hypokalemia .

Diagnostic/

LaboratoryProcedure

Indications or

Purposes

Results Normal Values Analysis and interpretation

HCT Hematocrit test

measures the

amount of

space

(volume) RBC

take up in the

blood.

36.9 37-47 Decreased hematocrit indicates

anemia , such as that caused by

iron deficiency or other

deficiencies

pH Blood gas

measurements

are used to

evaluate your

oxygenation

and acid/base

343 140-440 Normal

-Abnormal results of any of the

blood gas components may mean

that your body is not getting

eno gh o gen is not getting rid
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is an indicator

of immune

function and

helps to

determine

infection or

inflammation

leukemia , trauma, intense

exercise, or stress.

A decreased WBC count is called

leukopenia. It can result from

many different situations, such as

chemotherapy, radiation therapy,

or diseases of the immune

system.

Granulocytes

(x10/1)

Determines the

level of

granulocytes in

the blood. An

elevated level

means that

there is hgh

bacterial

infection

62

4.7

44.2-80.2

2.0-8.8

The result is within normal range

L h / S ll 38 28 48 Th lt i ithi l g
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HGB Measures the

amount of

hemoglobin in

blood and is a

good measure

of the bloods

ability to carry

oxygenthroughout the

body.

11.2 12-16may lead to anemia that can be

the result of iron deficiency

Diagnostic/LaboratoryProcedure

Indications or Purpose

Results Analysis and Interpretation of Results

Urinalysis To obtainclinicalinformation, todetect renaland metabolicdisease,diagnosis of disease or disorder on

kidneys or urinary tract.

Macroscopic:Color: yellowSpecific Gravity:1.015Sugar: negative

Appearance: slightlyturbidReaction: pH 6.0

Albumin: negative

Microscopic:Pus cells: 1-2Red Cells: 0-1Epithelial cells: few

The greater the concentration of theabnormal substance (such as greatlyincreased amounts of glucose, protein,or red blood cells), the more likely it willbe that there is a problem that needs tobe addressed.
http://labtestsonline.org/understanding/conditions/anemia.htmlhttp://labtestsonline.org/understanding/conditions/anemia.htmlhttp://labtestsonline.org/understanding/conditions/anemia.html


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Intravenous Fluid

MedicalManagement

General description Indications/ purpose

IVF D5NM It is a sterile,nonpyrogenic,

hypertonic solution of balanced

maintenanceelectrolytes and 5%dextrose injection inwater for injection.

The solution isadministered by

intravenous infusionfor parenteral

maintenance of

routine daily fluid andelectrolyterequirements with

minimal carbohydratecalories.

It is indicated for parenteralmaintenance of routine daily

fluid and electrolyterequirements with minimalcarbohydrate calories fromdextrose. Magnesium in theformula may help to prevent

iatrogenic magnesiumdeficiency in patientsreceiving prolongedparenteral therapy.

Drugs

Drugs Action Indication

G i N R l i T h k l i


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Generic Name:Mannitol

Brand Name:Osmitrol

Generic Name:omeprazoleBrand Name:Risek

Generic Name:ClopidogrelbisulfateBrand Name:Plavix

-Increases osmoticpressure of

glomerular filtrate,inhibiting tubular reabsorption of water and electrolytes; drug

elevates plasmaosmolality; increasing

water flow intoextracellular fluid.

inhibits secretion of gastric acid by

irreversibly blockingthe enzyme system

of hydrogen/potassium

adenosine

triphosphate (H+

/K+

ATPase), the protonpump of the gastric

parietal cell.

- Inhibits the bindingof adenosine

diphosphate (ADP) toits platelet receptor,

impeding ADP-mediated activation

and subsequent

To prevent oliguria or acuterenal failure

To prevent gastro-esophageal reflux and peptic

ulcer.

- to reduce thrombotic eventsin patients with

atherosclerosis documentedby recent stroke, MI, or

peripheral arterial disease


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Type of Diet General description Indications /purpose

Low salt and lowfat

To prevent the problems thatresult from the need towithhold food.

AcrivityType of Exercise General description Indications

/purpose

Turning exercise Turning the clientside to side on bedevery 2 hours

To prevent venous stasis,thrombophlebitis, pressureulcer formation andrespiratory complication.

Flexion-extensionexercise

Flexion andextension theunaffectedextremities.

To increase muscle strength.

V. NURSING MANAGEMENT

Encourage early ambulation when possible to enhance venous return Elevate the Head of Bed at night to increase gravitational blood flow Provide information on smoking cessation, low fat and low cholesterol diet, birth


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NURSING CARE PLAN

PATIENT: MRS. PIE AGE: 33 years old GENDER: Female Diagnosis: Transient Ischemic Attack

ASSESSMENT NURSINGDIAGNOSIS

INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Cues:Sumasakit yungpaa ko pagnaglalakad, peronawawala yungsakit pagnapapahinga,asverbalized by thepatient.

Objective Cues:

HR: 97 bpmBP: 140/80 mmHg

> Capillary Refill of 5 seconds> Cold, Clammyskin> Pale skin color on elevation(+) AlteredSensation(+) Homans Sign(+) Claudication

IneffectivePeripheralTissuePerfusionrelated toimpairedtransport of oxygen, asmanifested by:> Capillary Refillof 5 seconds> Cold, clammySkin> Pale skincolor onelevation(+) AlteredSensation(+) HomansSign(+) Claudication

History of Hypertensionand Stroke in

the family(Predisposing

Factor) andPrecipitating

Factors(Stress,

Smoking)

Formation of Lacunar

Infarction

DecreasedBlood Supplyin the Brain

DecreasedOxygen to the

brain

Hypoxia

Ischemia

TemporaryNeurologic

Within 2 daysof nursingintervention,the patient willdemonstrateincreasedperfusion, asmanifested by:- CapillaryRefill of lessthan or equal to3 seconds> Warm skin(-) HomansSign(-) Claudication(-) AlteredSensation

>Monitor vitalsigns q4

>Encourage quietand restfulenvironment

>Caution patient toavoid activities thatincreases cardiacworkload

>Encourage earlyambulation, if possible

>Elevate Head of Bed at night

>Apply anti-thromboembolichose bandages tolower extremitiesbefore arising frombed

>To obtainbaseline data

>To decreseOxygendemand

>To maximizetissueperfusion

>To enhancevenous return

>To increasegravitationalblood flow

> To preventvenous stasis

GOAL MET.Within 2 days of nursingintervention, thepatient willdemonstrateincreasedperfusion, asmanifested by:- Capillary Refillof less than or equal to 3seconds> Warm skin(-) HomansSign(-) Claudication(-) AlteredSensation


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Deficit

Alteredcerebral

metabolism

DecreasedCerebralPerfusion

S/SxCapillary Refillof 5 seconds(+) Homans

Sign

>Encouragesmoking cessation

>Demonstrate useof relaxationactivities,exercises or techniques

>Becausesmokingcausesvasoconstriction and mayfurther compromiseperfusion

>To decreasetension level


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INFERENCE OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective Cues:

Hindi mahimbingyung tulog ko, lagiakong nagigising-gising, asverbalized by thepatient

Objective Cues:BP: 140/80 mm HgHR: 97 bpm

(+) restlessness(+) fluctuation insleep-wake cycle(+) fluctuation inlevel of consciousness> CognitiveOrientation of 3[moderatelycompromised]

AcuteConfusionrelated todecreasedblood supply inthe brain, asmanifested by:(+) restlessness(+) fluctuation insleep-wakecycle(+) fluctuation inL.O.C.> CognitiveOrientation of 3




Factors(Stress,

Smoking)


Infarction



brain

Hypoxia

Ischemia

TemporaryNeurologic

Deficit

Within 2 daysof nursingintervention,the patient willdemonstraterestoration of cognitive statusto baseline, asmanifested by:(-) restlessness> Normalsleep-wakecycle> CognitiveOrientation of 5[notcompromised]

> Monitor vitalsigns q4

> Assess diet or nutritional status

> Orient client tosurroundings, staff,and necessaryactivities, asneeded.

> Maintain calmenvironment andeliminateextraneous noise/stimuli

> Discuss situationwith family andinvolve in planning

> To obtainbaseline data

>To identifypossibledeficiencies of essentialnutrients thatcould affectmental status

> For client notto feelendanger withhis safety

> To preventoverstimulation

> To diagnosepresence/severity of lungsdisease.

>To meetidentifiedneeds

GOAL MET.Within 2 days of nursingintervention, thepatient willdemonstraterestoration of cognitive statusto baseline, asmanifested by:(-) restlessness> Normal sleep-wake cycle> CognitiveOrientation of 5[notcompromised


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Alteredcerebral

metabolism

Confusion

>Discuss need for ongoing medicalreview of patientsmedications

>To limitpossibility of misuse or potentialdangerousside effects


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INFERENCE OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective data:

Nahihirapan akongigalaw tong left armko, parangnanghihina, asverbalized by thepatient.

Objective data:BP: 140/80 mm HgHR: 97 bpm

(+)left extremityweakness(+) fatigue

ActivityIntolerancerelated toneuromuscular impairment asmanifested by:(+) leftextremityweakness(+) fatigue




Factors(Stress,

Smoking)


Infarction



brain

Hypoxia

Ischemia

TemporaryNeurologic

Deficit

Hypoxia at the

Within 8 hoursof nursingintervention,the patient willparticipatewillingly innecessary/desiredactivities, asmanifested by:(-) leftextremityweakness(-) fatigue

>Encourage client tomaintain positiveattitude

>Provide referral toother disciplines,such as exercisephysiologist,psychologicalcounseling/therapy,etc.

> Provide positiveatmosphere, whileacknowledgingdifficulty of thesituation of thepatient

>Plan care tocarefully balance restperiods

>Assist with activitiesand monitor patientsuse of assistivedevices

>Plan care with restperiods betweenactivities

>To enhancesense of well-being

> To developindividuallyappropriatetherapeuticregimens.

> To helpminimizefrustration andrechannelenergy.

>To reducefatigue

>To protectclient frominjury

>To reducefatigue

GOAL MET.Within 8 hoursof nursingintervention, thepatient willparticipatewillingly innecessary/desiredactivities, asmanifested by:(-) left extremityweakness(-) fatigue


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brain

Left-sidedweakness

>Promote comfortmeasures andprovide relief of pain

>To enhanceability toparticipate inthe activities

medical surgical nursing - neuro

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