transient ischemic attack: a case study
TRANSCRIPT
HOLY ANGEL UNIVERSITYANGELES CITY
COLLEGE OF NURSING
TRANSIENT ISCHEMIC ATTACKA CASE STUDY
March 5, 2009
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I. INTRODUCTION
1. Description of the disease
When an area of the brain loses its blood supply it stops working, the part of the
body it controls also stops working. This is what happens with a Transient Ischemic
Attack, better known as TIA.
When the brain loses blood supply, it tries to restore blood flow. If blood supply
is restored, function may return to the affected brain cells, permitting return of function to
the affected body part.
Transient ischemic attack is also known as a mini-stroke, a hemorrhagic stroke, or
an ischemic stroke. Some people call a TIA a mini-stroke, because the symptoms are like
those of a stroke but do not last long. Generally, a TIA happens when platelets in the
blood clump together in your arteries (a blood clot) making blood flow to a part of the
brain be blocked or reduced. After a short time, blood flows again and the symptoms go
away. Symptoms usually last only 10 - 15 minutes and clear up within 24 hours. With a
stroke, the blood flow stays blocked, and the brain has permanent damage. TIAs
sometimes happen before strokes, and they are considered a warning sign of stroke.
It is estimated that more than 300,000 TIAs occur each year in the United States.
The highest incidence for a second stroke is within the first seven days after a TIA. The
prevalence for cerebral infarct after TIA is 11% at the ages of 55 to 64, 22% between the
ages of 65 to 69, 28% at the ages of 70 to 74 years, 32% between 75 to 79 years and 40%
at ages 80 to 85 years. TIA’s are the precursor in 15% of all strokes and if unrecognized,
can represent the greatest morbidity and mortality for stroke patients in the first thirty-
ninety days after their first TIA.
Fifty-percent of patients who experience a TIA fail to notify their healthcare
provider. Approximately one-third of TIA’s would reveal as a true ischemic event by
diffusion-weighted magnetic resonance imaging. Within the first year of having their
first TIA, 25% of patients will die. It has been estimated that only 9% of the general
population is familiar with typical TIA symptoms, and as few as 22% of primary health
care workers even know the definition of a TIA. This education gap poses a great
challenge for health workers when eliciting a history from patients and families.
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While TIA itself has short term effects, the significance is that this can herald a
major stroke, which is why it requires timely and aggressive treatment to prevent death
and disability.
It has been shown that stroke and TIA patients alike decrease their secondary
stroke risk considerably by learning about their own cardiovascular health maintenance,
risk assessment and lifestyle behaviors.
TIA is a common marker of cerebrovascular disease which, when correctly
diagnosed and managed, can lead to the prevention of significant morbidity and
mortality.
2. Nurse-Centered Objectives
Upon the completion of this case study, the student-nurses shall have:
Described and explained what transient ischemic attack is.
Reviewed the anatomy and physiology of the organs involved.
Identified the risk factors contributing to the occurrence of the disease.
Expounded on the laboratory and diagnostic procedures done with the
patient, their purposes, and specific nursing responsibilities before, during
and after the procedure.
Enumerated the different medications administered for the disease their
indications, contraindications, side effects, and specific nursing
responsibilities.
Formulated significant nursing diagnoses, with their significantly related
nursing care plans.
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II. NURSING HISTORY
1. Personal History
a. Demographic Data
Mrs. Attack was born in Quezon City on February 17, 1980. She is 29 years old,
a Filipino citizen, married and has one child. She lives with her family, residing at
Pandan, Angeles City. She was admitted in a private hospital on February 22, 2009 at
12:05 in the morning with a chief complaint of syncope. She was discharged four days
after the admission.
b. Socio-Economic and Cultural Factors
Mrs. Attack finished her college degree at Republic Central Colleges with the
course Education. She has her job as a cashier in a casino. She and her family were
baptized as Roman Catholics. They regularly attend Sunday masses and novenas
together. With minor illnesses such as fever, cough and colds, self medication is applied.
Although they seek the advice of their physician, they also believe in the albularyo and
the manhihilot.
2. Family Health-Illness History
Mrs. Attack’s father had a cerebrovascular accident in the year 2000 and was then
bedridden for almost nine years. Also, one of her first degree relatives, her aunt (her
mother’s sister), had her cerebrovascular accident in the year 2001 and is suffering from
hypertension. Other than these incidents, there were no other reported illnesses within
her family and relatives.
3. History of Past Illness
Mrs. Attack was confined in the same hospital two years ago (year 2007) with a
diagnosis of Gastroenteritis and was healed and discharged after few days of
confinement. Other than that, there were no known related ailments and past illnesses
with the present one.
4. History of Present Illness
a. Chief Complaint: Syncope
b. Sequence of the appearance of signs and symptoms up to the time patient
was admitted.
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Before going to bed at almost before midnight, Mrs. Attack experienced sudden
chest pain and left-sided weakness followed by loss of consciousness. She was brought
to the hospital already awake and was admitted minutes after midnight.
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III. PHYSICAL ASSESSMENT
1. Assessment done upon admission: February 22, 2009 (copied from chart)
EENT: anicteric sclerae, pink palpebral conjunctiva
Lungs: Clear BS, no rales
Heart: NRRR, no murmur, soft full equal pulses
Abdomen: flabby, NABS,
2. Cephalocaudal assessment: February 26, 2009
Head
With long hair, black and equally distributed
Without palpable lumps
With ucombed hair
Skin
Dry and warm to touch
With fair skin complexion
With good skin turgor
Eyes
With dark brown iris
With white sclera
Pupils equally round and reactive to light accommodation (PERRLA)
With pink palpebral conjunctiva
Ears
Pinna recoils after folding
Absence of discharge
Without any obstructions
With ear piercing
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Nose and Sinuses
With thick nasal hair
Absence of scar
Absence of discharge
Positioned at the center/midline
Mouth and Throat
With pinkish lips
With complete number of teeth
With pink gums
Without halitosis
Neck
Absence of palpable masses
Absence of swelling
Without stiffness present
Without swollen lymph nodes
Breast
Symmetrical in shape
Abdomen
With presence of horizontal scar on the hypogastric region (from past caesarian
section incision)
With presence of striae
Flabby
Upper and Lower Extremities
With long and polished toenails and fingernails
With numbness and inability to move the left lower extremity
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CRANIAL NERVES:
OLFACTORY: able to smell alcohol in cotton.
OPTIC: able to read the newspaper at a readable distance.
OCULOMOTOR: pupil equally round and reactive to light and
accommodation.
TROCHLEAR: able to follow the up and down movement of the pen.
TRIGEMINAL: able to open mouth against resistance.
ABDUCENS: able to follow the left and right movement of the pen.
FACIAL: able to taste; no difficulty in swallowing.
AUDITORY: able to repeat whispered words
GLOSSOPHARYNGEAL: able to move the tongue in all directions.
VAGUS: able to say “aaahh”; with gag reflex.
ACCESSORY: able to elevate the shoulders against resistance.
HYPOGLOSSAL: able to protrude tongue.
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IV. DIAGNOSTIC AND LABORATORY PROCEDURES
Diagnostic/ Laboratory Procedure
Indications or Purposes
Date Ordered
Date Results
were released
Results Normal Values (Units used in
the hospital)
Analysis and Interpretation
of Results
Potassium To determine the amount of Potassium present in the blood. Potassium is an important electrolyte that helps regulate the flow of fluids in and out of the cells
February 22, 2009
3.3 3.6-5.0 mmo/L
Decreased levels of potassium indicate hypokalemia.
Creatinine The creatinine blood test is usually ordered along with a BUN (blood urea nitrogen) test to assess kidney function
February 22, 2009
0.64 0.5-1.69 mg/dl
Normal
Sodium The amount of Sodium present in the blood. Sodium is an important electrolyte that helps regulate the flow of fluids in and out of the cells.
February 22, 2009
141 137-145 mmo/L
Normal-low level of blood sodium means you have hyponatremia, which is usually due to too much sodium loss, too much water intake or retention, or to fluid accumulation in the body (edema).
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-high blood sodium level means you have hypernatremia, almost always due to excessive loss of water (dehydration) without enough water intake.
Glucose: FBS Glucose, formed by digestion of carbohydrates and the conversion of glycogen by the liver, is the primary source of energy for most cells.
February 22, 2009
83.8 76-111 mg/ dl
Normal
BUN The BUN test is primarily used, along with the creatinine test, to evaluate kidney function under a wide range of circumstances and to monitor patients with acute or chronic kidney dysfunction or failure
February 22, 2009
7.0 7-21 mg/dl Normal-Increased BUN levels suggest impaired kidney function. This may be due to acute or chronic kidney disease, damage, or failure.-Low BUN levels are not common and are not usually a cause for concern. They may be seen in severe liver disease, malnutrition, and sometimes when a patient
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is overhydrated (too much fluid volume), but the BUN test is not usually used to diagnose or monitor these conditions.
Uric Acid The uric acid test is used to learn whether the body might be breaking down cells too quickly or not getting rid of uric acid quickly enough. The test also is used to monitor levels of uric acid when a patient has had chemotherapy or radiation treatments.
February 22, 2009
5.07 2.5-7 mg/dl
Normal- Higher than normal uric acid levels mean that the body is not handling the breakdown of purines well. The doctor will have to learn whether the cause is the over-production of uric acid, or if the body is unable to clear away the uric acid.- Low levels of uric acid in the blood are seen much less commonly than high levels and are seldom considered cause for concern. Although low values can be associated with some kinds of liver or kidney diseases, exposure to toxic
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compounds, and rarely as the result of an inherited metabolic defect, these conditions are typically identified by other tests and symptoms and not by an isolated low uric acid result.
Cholesterol To determine your nutritional status or to screen for certain liver and kidney disorders as well as other diseases
February 22, 2009
187.9 up to 200 mg/dl
Normal
Triglycerides Blood tests for triglycerides are usually part of a lipid profile used to identify the risk of developing heart disease. As part of a lipid profile, it may be used to monitor those who have risk factors for heart disease, those who have had a heart attack, or those who are being treated
February 22, 2009
115.0 35-135 mg/dl
A normal level for fasting triglycerides is less than 150 mg/dL (1.70 mmol/L). It is unusual to have high triglycerides without also having high cholesterol. Most treatments for heart disease risk will be aimed at lowering LDL cholesterol. However, the type of
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for high lipid and/or triglyceride levels.
treatment used to lower LDL cholesterol may differ depending on whether triglycerides are high or normal.
SGOT/AST used to detect liver damage.
February 22, 2009
13 5-35 u/L NormalVery high levels of AST (more than 10 times the highest normal level) are usually due to acute hepatitis, often due to a virus infection.
SGPT/ ALT To detects liver injury.
February 22, 2009
9 7-56 u/L NormalVery high levels of ALT (more than 10 times the highest normal level) are usually due to acute hepatitis, often due to a virus infection. In acute hepatitis, ALT levels usually stay high for about 1–2 months, but can take as long as 3–6 months to come back to normal.
Potassium To determine the amount of Potassium present in the blood.
February 23, 2009
3.7 3.6-5.0 mmo/L
Normal-Increased potassium levels indicate hyperkalemia.
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Potassium is an important electrolyte that helps regulate the flow of fluids in and out of the cells
Decreased levels of potassium indicate hypokalemia-Decreased levels of potassium indicate hypokalemia.
Diagnostic/
Laboratory
Procedure
Indications
or Purposes
Date
Ordered
Date
Results
were
released
Results Normal
Values
(units used
in the
hospital)
Analysis and
interpretation
HCT Hematocrit
test measures
the amount of
space
(volume)
RBC take up
in the blood.
February
22, 2009
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
status.
February
22, 2009
343 140-440 Normal
-Abnormal
results of any
of the blood
gas
components
may mean that
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your body is
not getting
enough
oxygen, is not
getting rid of
enough carbon
dioxide, or
that there is a
problem with
kidney
function. If
left untreated,
these
conditions
create an
imbalance that
could
eventually be
life
threatening.
WBC Determines
the number of
circulating
WBCs per
cubic ml of
whole blood.
It is an
indicator of
immune
function and
helps to
February
22, 2009
7.6 4.3-10.0 Normal
-An elevated
number of
white blood
cells is called
leukocytosis.
This can result
from bacterial
infections,
inflammation,
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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 Determines
the level of
granulocytes
in the blood.
An elevated
level means
that there is
hgh bacterial
infection
February
22, 2009
62 44.2-80.2 The result is
wihtion
normal range
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(x10/1) 4.7 2.0-8.8
Lympho/
monocytes
Small
agranulocytic
leukocytes
originating
from fetal
stem cells. It
is especially
helpful in the
evaluation of
the patient
with
infection.
February
22, 2009
38 28-48 The result is
within normal
range
HGB Measures the
amount of
hemoglobin
in blood and
is a good
measure of
the bloods
ability to
carry oxygen
throughout
the body.
February
22, 2009
11.2 12-16 Below-normal
hemoglobin
levels may
lead to anemia
that can be the
result of iron
deficiency
Nursing Responsibilities for Blood Chemistry:
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A. Before the procedure:
1. Check the Doctor’s order.
2. Identify the patient.
3. Check the vital signs.
4. Decrease patient’s anxiety by explaining the procedure and why it has
to be performed.
5. For blood sample, instruct that the medical technician will perform
venipuncture to extract blood.
6. Acknowledge questions regarding the safety of the procedure.
B. During the procedure:
1. If the test is to be done at bedside, remain with the patient.
2. Assist with the collection of specimen if allowed.
C. After the procedure:
1. Check the site for bleeding, cyanosis, or swelling.
2. Apply pressure and warm compress.
3. Check vital signs for any changes.
4. Document the data (attach result in the chart).
Diagnostic/ Laboratory Procedure
Indications or Purpose
Date Ordered Date Results were released
Results Analysis and Interpretation
of ResultsUrinalysis To obtain
clinical information, to detect renal and metabolisc disease, diagnosis of disease or disorder on kidneys or urinary tract.
February 23, 2009
Macroscopic:Color: yellowSpecific Gravity:1.015Sugar: negativeAppearance: slightly turbidReaction: pH 6.0Albumin: negative
Microscopic:Pus cells: 1-2Red Cells: 0-1Epithelial cells: few
The greater the concentration of the abnormal substance (such as greatly increased amounts of glucose, protein, or red blood cells), the more likely it will be that there is a problem that needs to be addressed.
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Mucus threads: rare
Nursing Responsibilities for Urinalysis:
A. Before the Procedure
1. Explain the procedure to the patient’s significant other.
2. Obtain materials needed in the procedure.
3. Advise the significant other to wash perineal area prior to collection of specimen.
B. During the Procedure
1. Collect a fresh urine specimen in a urine container.
2. Obtain clean catch midstream urine if possible.
C. After the Procedure
1. Transfer the urine specimen to the laboratory promptly.
2. Document the procedure.
3. Attach the result in the patient’s chart.
Diagnostic/ Laboratory Procedure
Indications or Purpose
Date Ordered Date Results were released
Results Analysis and Interpretation
of ResultsBrain Scan To identify
structural lesions whether vascular or tumors.
February 23. 2009
Lacunar Infarct, subcortical portion, left parietal lobe
Plain multiple axial views of the head reveals a small, hyperlucent focus on the subcortical portion of the left parietal lobe. The ventricles and cistern are not dilated. The midline structures are not displaced. The sella turtica, posterior fossae and basal skull structures are
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intact.
Nursing Responsibilities for Brain Scan:
A. Before the procedure:
1. Explain the procedure to the pt and the SO.
2. Obtain the consent.
3. Restrict food and fluids.
B. During the procedure:
1. Stay with the patient.
C. After the procedure:
1. Document the procedure.
2. Attach the result in the patient’s chart
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V. THE PATIENT AND HER ILLNESS
1. Anatomy and Physiology
The systems involved in giving
part to the development of TIA are the
circulatory system and the nervous
system.
The circulatory system is a
network that carries blood throughout
the body.
The human circulatory system
supplies the cells of the body with the
food and oxygen they need to survive.
At the same time, it carries carbon
dioxide and other wastes away from
the cells. The circulatory system also
helps regulate the temperature of the
body and carries substances that
protect the body from disease. In
addition, the system transports
chemical substances called hormones,
which help regulate the activities of
various parts of the body.
One of the parts of the circulatory system is the heart. It is a hollow, muscular
organ that pumps blood. It consists of two pumps that lie side by side. These pumps relax
when taking in blood and contract as they send out blood. The left side of the heart is a
stronger pump than the right side. The stronger pump receives blood from the lungs and
sends it to cells throughout the body. The weaker pump receives blood from the cells
throughout the body and sends the blood to the lungs.
Another of the parts of the circulatory system are the blood vessels. They form a
complicated system of connecting tubes throughout the body. There are three major types
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of these vessels. Arteries carry blood from the heart. Veins return blood to the heart.
Capillaries are extremely tiny vessels that connect the arteries and the veins.
The blood consists chiefly of liquid called plasma, and three kinds of solid
particles known as formed elements. Plasma is made up mostly of water, but it also
contains proteins, minerals, and other substances. The three types of formed elements are
called red blood cells, white blood cells, and platelets. Red blood cells carry oxygen and
carbon dioxide throughout the body.
White blood cells help protect the body
from disease. Platelets release substances
that enable blood to clot. Platelets thus aid
in preventing the loss of blood from
injured vessels.
The nervous system is a very
complex system in the body. It has many,
many parts. The nervous system is divided
into two main systems, the central nervous
system (CNS) and the peripheral nervous
system. The spinal cord and the brain
make up the CNS. Its main job is to get the
information from the body and send out
instructions. The peripheral nervous
system is made up of all of the nerves and
the wiring. This system sends the
messages from the brain to the rest of the
body.
One of the parts of the CNS is the brain. It keeps the body in order. It helps to
control all of the body systems and organs, keeping them working like they should. The
brain also allows us to think, feel, remember and imagine. In general, the brain is what
makes us behave as human beings.
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The brain communicates with the rest of the body through the spinal cord and the
nerves. They tell the brain what is going on in the body at all times. This system also
gives instructions to all parts of the body about what to do and when to do it.
There are five main senses - touch, smell, taste, hearing and sight. These are the
external sensory system, because they tell you about the world outside your body. Your
senses tell you what is happening in the outside world. Your body's sense organs
constantly send signals about what is happening outside and inside it to your control
center - the brain.
The cerebrum is part of the forebrain. The cerebral cortex is the outer layer of the
cerebrum. Certain areas of the cerebral cortex are involved with certain functions.
Sensory areas such as touch, smell, taste, hearing and sight receive messages from
the skin, nose, mouth, ears and eyes. We feel, taste, hear and see when these messages are
received by the sensory parts of the brain.
The second main part of the nervous system is the peripheral nervous system.
The nervous system is made up of nerve cells or neurons that are "wired" together
throughout the body, somewhat like communication system. Neurons carry messages in
the form of electrical impulses. The messages move from one neuron to another to keep
the body functioning.
Neurons have a limited ability to repair themselves. Unlike other body tissues,
nerve cells cannot also be repaired if damaged due to injury or disease.
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2. Pathophysiology A. Book-Based
a. Schematic Diagram
Predisposing factors Precipitating factors- age - cigarette smoking- sex - Diabetes Mellitus- history of TIA/stroke & HTN on the family - thromboembolism- sedentary lifestyle - stress- personal HTN
Decrease blood supply on the brain leads to hypoxia, thusIschemia occurs on the brain.
Short-term ischemia leads to temporary neurologic deficits or a TIA
If blood flow is restored,brain tissue willreverse the damagewithin minutes
if blood flow is not restored, brain tissue sustains irreversible damage of infarction w/in minutes
the extend of infarction depends on the location and size of the occluded artery
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and the adequacy of collateral circulation to the area it supplies.
Ischemia quickly alters cerebral metabolism thus decrease cerebral perfusion leading to further damage to the brain.
Lead to damaging both hemispheres of the brain thus leading to paralysis of the body, speech, and ECG changes of the heart
A cascades of biochemical processes occurs within minutes of cerebral ischemia, thus membrane depolarization occurs
Results to influx of calcium and sodium
Leads to cytotoxic edema and cell death area The area of edema after ischemia may lead to results; temporary neurologic deficits
Leads to secondary neuronal injury
If edema subsides, client may regain some function
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b. Synthesis of the Disease
b.1. Definition of the Disease
The definition of TIA continues to evolve. Traditionally, TIA has been defined as
the presence of neurologic symptoms of vascular etiology in one area of the brain
lasting less than 24 hours. Implicit in this definition is neuronal injury that is not
permanent in nature. However, there are several problems with this definition. It is
now clear through newer diagnostic modalities such as diffusion-weighted magnetic
resonance imaging (MRI) that this time- and symptom-based definition can be
clinically misleading. It assumes a complete correlation between the resolution of
symptoms and normalization of tissue reperfusion, which often underestimates the
potential tissue damage detected by diffusion-weighted MRI. Nearly 50% of patients
who meet the classic definition of TIA have in fact suffered subclinical strokes with
detectable cerebrovascular infarction.
A more accurate definition of TIA has been proposed by the Transient Ischemic
Attack Working Group formed by Albers and Caplan: “a brief episode of neurologic
dysfunction caused by focal brain or retinal ischemia, with clinical symptoms
typically lasting less than one hour, and without evidence of acute infarction”.
b.2. Predisposing/Precipitating Factors
Predisposing Factors
Age: Advancing age is one of the most significant risk factors of stroke.
Sex: Stroke has higher incidence in men due to physical needs and built.
History of TIA/Stroke & HTN in the family: Genetic predisposition of
stroke.
Sedentary lifestyle: Persons with a sedentary life style are at higher risk
for stroke than those with active life styles.
History of HTN: High blood pressure increases the pressure inside
arteries, causing damage. Excessive pressure on the walls of
vessels speeds up hardening and narrowing of the arteries
(atherosclerosis).
Precipitating Factors
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Cigarette smoking: Smoking injures blood vessel walls and speeds up
hardening of the arteries (atherosclerosis). As a result, the heart
works harder, and blood pressure may increase. Heavy smokers are at
greater risk for TIA and stroke. Daily cigarette smoking can
increase the risk of stroke by 2½ times.
Diabetes Mellitus: People who have diabetes are at increased risk for
many serious health problems, including hardening of the arteries
(atherosclerosis) and heart problems, eye problems that can
lead to blindness, circulation and nerve problems, and kidney
disease and kidney failure.
Thromboembolism: A blood clot or other tissue in the blood (such as
fat) from a part of the body other than the brain can travel through blood
vessels and become wedged in a smaller brain artery. This free-roaming
clot or tissue is called an embolus (emboli is plural). Emboli often form in
the heart. They also commonly form in the neck arteries or within the
aorta.
Stress:
b.3. Signs and Symptoms with Rationale
Blurred vision in both eyes, brief blindness, or double vision
Parietal and temporal lobe strokes may interrupt visual fibers of the optic
tract and route to the occipital cortex and impair visual acuity.
Difficulty speaking
It is caused by cranial nerve dysfunction from a stroke in vertebrobasilar
artery or its branches. It may result from the weakness or paralysis of the muscles of
the lips, tongue, and larynx or form loss of sensation.
Weakness, sometimes on only one side of the body
The deficit is usually caused by a stroke in the anterior or middle cerebral
artery, leading to infarction of motor strip of the frontal cortex.
Vertigo (a whirling or spinning feeling), headache, confusion
They occur due to decreasing oxygen level or total oxygen deprivation.
Loss of consciousness
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It occurs due to impaired Oxygen absorption, altering or disturbing brain
cell metabolism and functioning.
Chest pain
Anything that compresses a nerve root (like a disc or multiple discs) due
to cardiac ischemia will hurt.
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B. Client-Centereda. Schematic Diagram
Predisposing factors Precipitating factors- history of HPN on Aunt (Mother’s side) - use of birth control pills- history of stroke (Aunt and Father) - increased fatty food on diet
- stress
Fromation of Lacunar infarction Dx. Brain Scan (02-22-09)Lacunar infarction, subcortical portion, left parietal lobe
Infarct causing decrease blood supply n the brain
Decrease blood supply leads to O2 and glucose supply brain thus Hypoxia occurs
Hypoxia can cause Ischemia which may lead to temporary neurologic deficits or a TIA Ischemia quickly alters cerebral also known as Transient Ischemic Attack metabolism
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decrease cerebral perfusion
affects blood flow n the body
Leading to Hypoxia on the brain will cause further Leading to hypotension damage if not be reversed and will furtherresult to higher damaged to the brain
leading to syncope and chest pain, and left sided weakness of the body
Leading to Transient Ischemic Attack
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B. Synthesis of the Diseaseb.1. Predisposing/Precipitating Factors
Predisposing factors
History of HPN and stroke on Aunt (mother’s side) & history of
stroke on father: Genetic predisposition of stroke.
Precipitating Factors
Use of birth control pills: Taking birth control pills increases the risk for
TIA because they are said to interfere with peripheral blood flow most
especially when they are taken by cigarette smokers.
Increased fatty food on diet: Too much cholesterol in the blood is not
healthy because it can build up in the walls of arteries, narrowing and
hardening blood vessels (atherosclerosis).
Stress: A person with a stress reaction experiences symptoms of anxiety
when exposed to very stressful events. It is a factor in your environment
that causes your mind or body to be tense. You may react to the stress by
feeling tension, anxiety, fear, anger, frustration or depression and even
loss of body function.
b.2. Signs and Symptoms with Rationale
Weakness, left side of the body
The deficit is usually caused by a stroke in the anterior or middle cerebral
artery, leading to infarction of motor strip of the frontal cortex.
Loss of consciousness
Occur due to impaired Oxygen absorption, altering or disturbing brain cell
metabolism and functioning.
Chest pain
Anything that compresses a nerve root (like a disc or multiple discs) due
to cardiac ischemia will hurt.
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VI. THE PATIENT AND HER CARE
1. Medical Management
A. IVF
Medical Management
General description
Indications/ purpose
Date ordered, date performed, date changed or
D/C
Client’s response to treatment
IVF D5NMIt is a sterile, nonpyrogenic, hypertonic solution of balanced maintenance electrolytes and 5% dextrose injection in water for injection.
The solution is administered by intravenous infusion for parenteral maintenance of routine daily fluid and electrolyte requirements with minimal carbohydrate calories.
It is indicated for parenteral maintenance of routine daily fluid and electrolyte requirements with minimal carbohydrate calories from dextrose. Magnesium in the formula may help to prevent iatrogenic magnesium deficiency in patients receiving prolonged parenteral therapy.
02-21-09 The patient was able to maintain a normal hydration status.
a. 1. Nursing responsibilities:
PRIOR TO INSERTION:
When inserting an IV line to a patient, always prepare all the materials to
be used prior to the insertion.
Wash hands thoroughly before performing the procedure.
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Identify the correct patient by checking the name on the chart or by asking
directly the patient.
Explain the procedure to the patient.
DURING ADMINISTRATION:
Insert the IV catheter accordingly.
Regulate and monitor infusion rate.
AFTER ADMINISTRATION:
Monitor patient’s therapeutic response to treatment.
Check the IV insertion site for signs of infiltration, bulging, heat, pain and
redness.
B. DrugsDrugs Action Indication Date ordered,
date performed,
date changed or D/C
Client’s Response
Generic Name:Potassium ChlorideBrand Name: Kalium Durule
Generic Name: CiticolineBrand Name: Somazine
Generic Name:
-Replaces potassium and
maintains potassium level
-increases the neurotransmission levels because it
favors the synthesis and production
speed of dopamine in the striatum, acting then as dopominergic
agonist through the inhibition of
tyrosine hydroxilase.
-Increases osmotic
-To prevent hypokalemia
To increase brain
metabolism
-to prevent
Date Ordered: 02-22-09
The patient’s potassium level returned to normal range.
There is improvement in the affected (paralyzed) areas.
The patient’s
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MannitolBrand Name: Osmitrol
Generic Name: omeprazoleBrand Name:Risek
Generic Name: Clopidogrel bisulfateBrand Name: Plavix
Generic Name: Citicoline Na
pressure of glomerular filtrate, inhibiting tubular reabsorption of
water and electrolytes; drug elevates plasma
osmolality; increasing water
flow into extracellular fluid.
inhibits secretion of gastric acid by
irreversibly blocking the
enzyme system of hydrogen/potassium
adenosine triphosphate (H+/K+
ATPase), the proton pump of the gastric
parietal cell.
- Inhibits the binding of adenosine
diphosphate (ADP) to its platelet
receptor, impeding ADP-mediated activation and
subsequent platelet aggregation, and
irreversibly modifies the platelet ADP
receptor.
-increases the neurotransmission
oliguria or acute renal
failure
To prevent gasto-
esophageal reflux and
peptic ulcer.
- to reduce thrombotic events in
patients with atherosclerotisis documented by recent stroke,
MI, or peripheral
arterial disease
to increase brain
02-23-09
02-24-09
urinary function returned to normal.
The patient did not experience reflux and did not manifest ulcerations.
The patient’s blood circulation improved and was increased.
There is improvement
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Brand Name: Cholinerv
levels because it favors the synthesis
and production speed of dopamine
in the striatum, acting then as dopominergic
agonist through the inhibition of
tyrosine hydroxilase.
metabolism in the affected (paralyzed) areas.
b. 1. Nursing responsibilities:
BEFORE ADMINISTRATION:
Check and clarify Doctors order
Prepare equipments
10 R’s of drugs
Performed skin testing
Check for the patient’s medication card and chart.
Performed hand washing
DURING ADMINISTRATION:
Read the name, amount, and expiration date three times
Check for patient’s identification
Explain the procedure to the client
AFTER ADMINISTRATION:
Document
Watch out for any side effects
D. Diet
Type of Diet General description
Indications/purpose
Date ordered, date started, date changed or
D/C
Client’s response and/or
reaction to the diet
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Low salt and low fat
To prevent the problems that result from the need to withhold food.
02/22/09 - The patient complied with the doctor’s order.
c. 1. Nursing responsibilities:
PRIOR TO INITIATION OF DIET:
Explain why diet is desired to client.
DURING INITIATION OF DIET:
Instruct patient and SO to eat healthy foods to promote wellness except those
allergic to the patient.
AFTER INITIATION OF DIET:
Explain to the patient foods that are good for fast recovery.
Instruct SO to observe strictly the diet to improve the nutrition of the patient.
D. Activity
Type of Exercise
General description
Indications/purpose
Date ordered, date started, date changed or
D/C
Client’s response and/or
reaction to the activity
Turning exercise
Turning the client side to side on bed every 2 hours
To prevent venous stasis, thrombophlebitis, pressure ulcer formation and respiratory complication.
02/23/09 Compliance
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Flexion-extension exercise
Flexion and extension the unaffected extremities.
To increase muscle strength.
02/24/09 Compliance
d.1 Nursing Responsibilities prior to during and after start of the activity
1. Explain the significance of the activity.
2. Assist the patient and the SO in doing the procedure.
3. Place pillows to prevent falls.
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VII. NURSING CARE PLANProblem No. 1Cues Nursing
DiagnosisScientific Explanation
Nursing Objectives
Nursing interventions
Rationale Expected Outcome
S> Ø
O> Body weakness
Paralysis of left lower extremities
BP of 100/60
Ineffective peripheral tissue perfusion r/t impaired transport of the O2 across alveolar and capillary membrane AEB paralysis of left lower extremity
Because there’s an decrease in oxygen supply in our body it fails to nourish the tissues at the capillary level resulting to tissue perfusion
After 1 hour of NPI, pt’s condition in circulation of the left lower extremity will have progress.
Encourage early ambulation when possible
Elevate HOB at night
Exercise caution in use hot water bottles or heating pads
Encourage to minimize places that are high in smoke
Enhance venous return
To increase gravitational blood flow
Heat increases the metabolic demands of already compromised tissue
Smoking causes vasoconstriction and further compromised perfusion
The pt’s condition in circulation of the lower extremity shall have progressed.
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Problem No. 2CUES NURSING
DIAGNOSISSCIENTIFIC
EXPLANATIONNURSING
OBJECTIVENURSING
INTERVENTIONSRATIONALE EXPECTED
OUTCOME
S > “Di ko magalaw ‘tong left foot ko… Wala ring pakiramdam hanggang waist…”
O > The pt. manifested the ff:
with limited ability to perform gross motor skills
with difficulty in turning
with slowed movement
needs assistance
Impaired physical mobility r/t neuromuscular impairment AEB paralysis of the lower left extremity.
Due to the impairment of blood flow in the brain’s neurologic branches, dysfunction occurs resulting to ineffective impulses sent to different body parts specifically the extremities. Numbness and inability to move the affected area occurs and decreases the pt’s ability to perform desired and necessary activities.
After 1° of nursing intervention, the pt. will be able to participate in ADL’s and with the desired activities.
Assist in self-care activities.
Encourage energy-conserving techniques.
Provide pt. with ample time to perform mobility-related tasks.
Place pillows on the right side of the bed.
Change lying position every 2 hours.
Offer fluids and reinforce nutritious
To promote independence and enhancement of self-concept.
To prevent fatigue and overexertion.
To provide time to rechannel energy and to prevent exertion and overexhaustion.
To promote safety and to prevent injury.
To prevent stasis of blood and to reduce the risk of pressure ulcers.
To aid in supplementing
The pt. shall have participated in ADL’s and with the desired activities.
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upon ambulation
with paralysis of the left lower extremity
PR: 54bpm
foods.
Reinforce low salt, low fat diet.
normal body functions.
To assure compliance with daily diet regimen and to provide a continuous recovery state.
Problem No. 3
CUESNURSING
DIAGNOSISSCIENTIFIC
EXPLANATIONOBJECTIVE INTERVENTION RATIONALE EVALUATION
S – Ø
O – left extremity weakness- inability to move purposefully
Activity Intolerance related to neuromuscular impairment as evidenced by left sided weakness and inability to move without SO support secondary to disease process.
The patient is suffering from Cerebrovascular Accident wherein there is a sudden loss of brain function resulting from a disruption of the blood supply to a part of the brain. As a result, brain cells are starved of oxygen causing some cells to die and leaving other cells damaged.
After 2 hours of Nursing intervention the patient will demonstrate behaviors that will improve her present condition.
Assist with activities and monitor c lient’s use of assistive device
Adjust activities
Plan care with rest periods between activities
Promote comfort measures and provide relief
to protect client from injury
to prevent overexertion
to reduce fatigue
The pt shall have demonstrated behaviors that will improve her present condition.
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Making the patient unable to move the left side of her body most especially the left side of the body.
Thus, the patient was unable to turn side to side, sit or stand and move on bed without support
Leading the patient to suffer Activity Intolerance.
of pain to enhance ability to participate in activities
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VIII. DISCHARGE PLAN
OBJECTIVE CONTENT TIME ALLOTMENT TEACHING STRATEGIES
EXPECTED OUTCOME
After NPI, the pt. will be able to comply and verbalize understanding on provided health teachings and home maintenance management.
ExerciseAdvise to:Do deep breathing exercises.Have ambulation with assistance and support as tolerated.Perform ADLs involving hygiene and self-care.
TreatmentInstruct to:Comply strictly with drug treatment regimen.
Health TeachingsDemonstrate to:Place pillows on bed when asleep to prevent injury and other accident precautions.Support the affected part to prevent development of pressure ulcers.Provide adequate rest
1 hour Lecture-discussion and demonstration
The pt. shall have complied and have verbalized understanding on provided health teachings and home maintenance management.
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periods.Provide energy conservation techniques.Make up activities that increase the well being.
Out-PatientInstruct to:Return a week after discharge as ordered by the physician.
DietReinforce to:Maintain a low salt, low fat diet.Increase fluid, fruit and vegetable intake.
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IX. LEARNING DERIVED FROM THE STUDY
Confusions between Transient Ischemic Attack and Stroke were identified
by the student-nurses wherein TIA is a sign of a possible impending stroke. Proper diet
modification and increase in activities will reduce the risk of having an attack. Also,
health care workers have a great responsibility towards making the disease known to
patients and the population as a whole.
Taking care of an ill patient is our responsibilities being a nurse. We have
to give the proper care they need, identifying the problem to give appropriate
interventions in their disease.
We’ve encountered different kinds of diseases, behavior of each patient,
and knowing the causes of each diseases. Being a nurse is not that easy because we are
dealing in the life of the patient. Nurses must be competent or knowledgeable enough in
doing the care in a patient because one mistake of it can cause more complications or
death to the patient.
In this case study we’ve learned the causes, factors or signs and symptoms
of the disease, how it was started and what are the appropriate interventions and
medications given to the patient. We’ve learned and more appreciated the meaning of the
disease. This is the essence of being a nurse, though we are encountering some patients
quite not good to deal with.
Related learning experiences help us more to apply what we’ve learned
from the lectures and discussions within the four corners of the classroom. One can never
really appreciate what was learned until was experienced.
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