Republic of the Philippines

CAVITE STATE UNIVERSITY

Don Severino de las Alas Campus
Indang, Cavite



College of Nursing


Gerontology
(Stroke)




Presented by:

BSN 4-1 Group 3

Dala, Roxanne Jade
Masenas, Ayr Hershel
Millamena, Cirmarie Hope
Pastores, Flora Angeli
Puedan, Jenivic
Torevillas, Jeth Viel


Presented to:

Prof. Antoniette Viray
Clinical Instructors, Level IV








July 31, 2014

VISION
A premier university in historic
Cavite recognized for
excellence in the development
of morally upright and globally
competitive individuals.
MISSION
Cavite State University shall provide
excellent, equitable and relevant
educational opportunities in the arts,
science and technology through quality
instruction and relevant research and
development activities. It shall provide
professional, skilled and morally upright
individuals for global competitiveness.
I. DEMOGRAPHIC DATA

A. Clients Name: R.S
B. Address: Gen. Trias Cavite
C. Age:70 years old Date of Interview: July 14, 2014
D. Birth Date: March 11, 1944 Primary Informant: Patient RS
E. Birth Place: Amadeo Cavite Secondary Informant: Grand daughter
F. Gender: Female Other Sources: Patients Laboratory Tests
G. Civil Status: Married
H. Religion: Iglesia ni Cristo
I. Family Monthly Income: 10,000 php
J. Family Monthly Expenses: 10, 000 php



PAST-MEDICAL HISTORY

Patient RS was not fully immunized. But she mention that she want to have a flu
vaccine. She experienced childhood diseases such as chicken pox, measles and,
mumps. According to her, when she was not feeling well, she takes medicines first
rather than seeking medical care immediately.

Patient RS had stroke on January 1 2005, and the second was on September 2, 2012.
According to her, after her jogging on the second incident she felt dizzy and
weakness. She actively attending her physical therapy in General Emilio Aguinaldo
Medical Hospital twice a week.

According to patient RS, she was hospitalized many times. On 1996, she underwent
Appendectomy exlaparatomy in Divine Grace Hospital Grace,and Salphingectomy
Oophorectomy (left part). Also, she underwent cholecystectomy last 2005 at UMC.

OBSTETRIC-GYNECOLOGICAL HISTORY

Patient had her first menstruation at the age of 12. Her menstruation lasts for about 3
days with a regular amount and noted to be normal in color and odor She uses 4-3
pads a day. No discomforts were stated. However, she cant identify the date of her
last menstruation.




Intepretation:
The table shows the OB scoring done with the client, her OB score is Gravida 5, Para
5, Term 5, Preterm 1, Abortion 0, and Living 4. According to patient RS, she
delivered her fourth baby premature 7 months. All her children were born via Normal
Spontaneous Delivery at home and with no complications.
According to Pilitteri, the average age of a female to begin menstruation is 9-17
having an interval of 28 days and an average flow of 2-7 days with the amount of 30-
80 mL.



Medical History

A. Health Status:
Cardiomegaly
Hypertension
Blood pressure of 150/90 mmHg
With chest pain when lying on her left side.

Stroke
January 1, 2005 First stroke experience
September 7, 2013 Second stroke experience
With vertigo

Diabetes
Medication: Metformin
Family History of DM

Surgeries
Cholecystectomy
Salphyngo Oophorectomy
G P T P A L
5 5 5 0 0 4
Appendectomy



B. Medications
Amlodipine Besilate 10 mg Tablet Calcium Channel Blocker Anti-hypertensive
Fenofibrate Lipiduce 350 mg Antilipidemia
Sitagliptin Phosphate Metformin HCl 50mg|1g film coated tablet - Antidiabetic
Metformin HCl Glomet 1g tablet / oral hypoglycemic- Antidiabetic
Vitamins: Revicon, Enervon
Quetiapine Anit-Psychotic


C. Exercise History
Jogging every mornin at 5am before she had
















Stroke
A stroke or "brain attack" occurs when a blood clot blocks an artery (a blood vessel that carries
blood from the heart to the body) or a blood vessel (a tube through which the blood moves
through the body) breaks, interrupting blood flow to an area of the brain. When either of these
things happen, brain cells begin to die and brain damage occurs.
When brain cells die during a stroke, abilities controlled by that area of the brain are lost. These
abilities include speech, movement and memory. How a stroke patient is affected depends on
where the stroke occurs in the brain and how much the brain is damaged.

Types of stroke
Ischemic Stroke
In everyday life, blood clotting is beneficial. When you are bleeding from a wound, blood clots
work to slow and eventually stop the bleeding. In the case of stroke, however, blood clots are
dangerous because they can block arteries and cut off blood flow, a process called ischemia. An
ischemic stroke can occur in two ways: embolic and thrombotic strokes.
Embolic Stroke
In an embolic stroke, a blood clot forms somewhere in the body (usually the heart) and travels
through the bloodstream to your brain. Once in your brain, the clot eventually travels to a blood
vessel small enough to block its passage. The clot lodges there, blocking the blood vessel and
causing a stroke. The medical word for this type of blood clot is embolus.
Thrombotic Stroke
In the second type of blood-clot stroke, blood flow is impaired because of a blockage to one or
more of the arteries supplying blood to the brain. The process leading to this blockage is known
as thrombosis. Strokes caused in this way are called thrombotic strokes. That's because the
medical word for a clot that forms on a blood-vessel deposit is thrombus.
Blood-clot strokes can also happen as the result of unhealthy blood vessels clogged with a
buildup of fatty deposits and cholesterol. Your body regards these buildups as multiple, tiny and
repeated injuries to the blood vessel wall. So your body reacts to these injuries just as it would if
you were bleeding from a wound; it responds by forming clots. Two types of thrombosis can
cause stroke: large vessel thrombosis and small vessel disease (or lacunar infarction.)
Large Vessel Thrombosis
Thrombotic stroke occurs most often in the large arteries, so large vessel thrombosis is the most
common and best understood type of thrombotic stroke. Most large vessel thrombosis is caused
by a combination of long-term atherosclerosis followed by rapid blood clot formation.
Thrombotic stroke patients are also likely to have coronary artery disease, and heart attack is a
frequent cause of death in patients who have suffered this type of brain attack.
Small Vessel Disease/Lacunar Infarction
Small vessel disease, or lacunar infarction, occurs when blood flow is blocked to a very small
arterial vessel. The term's origin is from the Latin word lacuna which means hole, and describes
the small cavity remaining after the products of deep infarct have been removed by other cells in
the body. Little is known about the causes of small vessel disease, but it is closely linked to
hypertension (high blood pressure).
Hemorrhagic Stroke
Strokes caused by the breakage or "blowout" of a blood vessel in the brain are called
hemorrhagic strokes. The medical word for this type of breakage is hemorrhage. Hemorrhages
can be caused by a number of disorders which affect the blood vessels, including long-standing
high blood pressure and cerebral aneurysms. An aneurysm is a weak or thin spot on a blood
vessel wall. These weak spots are usually present at birth. Aneurysms develop over a number of
years and usually don't cause detectable problems until they break. There are two types of
hemorrhagic stroke: subarachnoid and intracerebral.
In an intracerebral hemorrhage, bleeding occurs from vessels within the brain itself.
Hypertension (high blood pressure) is the primary cause of this type of hemorrhage.
In a subarachnoid hemorrhage, an aneurysm bursts in a large artery on or near the thin, delicate
membrane surrounding the brain. Blood spills into the area around the brain, which is filled with
a protective fluid, causing the brain to be surrounded by blood-contaminated fluid.
Get more information about hemorrhagic strokes.
The FDA issued a voluntary recall of non-prescription medications containing PPA
(phenylpropanolamine) after they were linked to an increased risk of hemorrhagic stroke in
women.

Treatment
Thrombolytics
Thrombolytic (fibrinolytic) drugs help reestablish blood flow to the brain by dissolving the
clots, which are blocking the flow. In June, 1996, the clot-buster Activase (Alteplase
recombinant) became the first acute ischemic stroke treatment to be approved by the Federal
Food and Drug Administration (FDA). Activase is also known as tissue plasminogen activator
(tPA). To be effective, thrombolytic therapy should be given as quickly as possible.
tPA
tPA is an enzyme found naturally in the body that converts, or activates, plasminogen into
another enzyme to dissolve a blood clot. It may also be used in an IV by doctors to speed up the
dissolving of a clot. tPA should be given within three hours of symptom onset. It is important for
people to understand stroke warning signs and get to a hospital FAST in case they are eligible to
receive tPA. Time is an important factor associated with determining whether a patient can
receive it or not.
The results of a five-year trial, conducted by the National Institute of Neurological Disorders and
Stroke (NINDS) found that carefully selected stroke patients who received Activase within three
hours of the beginning of stroke symptoms were at least 33 percent more likely than patients
given a placebo to recover from their stroke with little or no disability after three months. The
most common complication associated with Activase is brain hemorrhage. However, studies
have shown that tPA does not increase the death rate of stroke patients when compared with
placebo.
MERCI Retrieval System
In 2004 the FDA cleared Concentric Medical's innovative Merci Retriever for patients who are
ineligible for IV-tPA or fail to respond to IV-tPA. The system can be used for patients who are
beyond the 3-hour time window for IV-tPA and it does not have a time limit for its intended use.
This device offers physicians and patients long-awaited options for stroke intervention and
creates a departure from the historic method of caring for stroke patients. The Merci Retriever
has repeatedly been proven to restore blood flow in the larger vessels of the brain by removing
blood clots. Over 8,000 patients world-wide have undergone this procedure and it has been
performed at over 300 US hospitals. The system is a tiny cork-screw shaped device that works
by wrapping around the clot and trapping it. The clot is then retrieved and removed from the
body.
Penumbra System
At the beginning of 2008 it was announced that the Penumbra System is now available for use.
The system allows for safe revascularization of occluded vessels after an ischemic stroke. The
system also helps restore brain blood flow by using suction to grab blood clots in the brain for
treatment of acute ischemic stroke. For doctors and patients alike, this system is revolutionary.
Previously doctors had limited treatment options with acute ischemic stroke if patients were
beyond the three-hour window for intravenous thrombolysis. The Penumbra System is a device
that is effective if used within eight hours of symptom onset.

Symptoms
Common stroke symptoms seen in both men and women:
Sudden numbness or weakness of face, arm or leg -- especially on one side of the body
Sudden confusion, trouble speaking or understanding
Sudden trouble seeing in one or both eyes
Sudden trouble walking, dizziness, loss of balance or coordination
Sudden severe headache with no known cause
Women may report unique stroke symptoms:
sudden face and limb pain
sudden hiccups
sudden nausea
sudden general weakness
sudden chest pain
sudden shortness of breath
sudden palpitations

Nursing Management



Republic of the Philippines
CAVITE STATE UNIVERSITY
(CvSU)
DON SEVERINO DE LAS ALAS CAMPUS
Indang, Cavite
College of Nursing

NURSING CARE PLAN
Name of patient: R.S
Age:70y/o Diagnosis: Stroke
Sex: Female

ASESSMEN
T
NURSING
DIAGNOSIS
SCIENTIFIC
RATIONALE
OBJECTIVE NURSING
INTERVENTION
SCIENTIFIC
RATIONALE
EVALUATI
ON
Subjective
cues:
Hindi ko na
nagagalaw
ang kaliwa
kamay at paa
nya as
verbalized
by the
patient

Objective
cues:

-General
malaise
-Inabilty to

Impaired
physical
mobility
related to
neuromuscular
blockage of
lipid as
manifested by
limited range
of motion, and
inability to
change
position
independently
secondary to
stroke.
The patient
was unable to
move her left
extremities
and lost the
energy
reserve.
Because of
that she has
limited
movement.
The inability
to perform
activities of
After 2 hours of
nursing
intervention, the
client/relative
would be able to:
-Verbalize
understanding
about the situation

-Know the proper
safety measures
for the client

-Demonstrate
behaviors on how
to assist in
increasing clients
Establish rapport

Assess patients
condition and
determine the
diagnosis that
contribute to
immobility

Monitor Vital Sign




Explain the patient
condition and the
risk effects of
To gain patients trust

Useful in identifying and
qualifying the degree of
problem on the involved
body part that restrict
movement

Serves as baseline data for
modification of action that
could be done to client

To promote awareness in
properly managing the
disease.
Immobility may result to
skin breakdown, muscle
Goal met, as
manifested
by caregiver
was able to
understand
the px
condition and
was able to
know and
demonstrate
the use of
measures that
promotes px
safety
VISION
A premier university in historic Cavite
recognized for excellence in the
development of morally upright and
globally competitive individuals.
MISSION
Cavite State University shall provide
excellent, equitable and relevant
educational opportunities in the arts,
science and technology through quality
instruction and relevant research and
development activities.
It shall produce professional, skilled and
morally upright individuals for global
competitiveness.
move from
supine to
sitting
position
-Limited
range of
motion
-Requires
help from
relative


V/S as
follows:
T- 35.9
PR-80
RR-24
BP- 140/80
daily living is
also due to
neuromuscula
r blockage of
lipid.













strength and
function
immobility



Interview relative
regarding specific
changes observed
on the client

Instruct in use of
siderails

Assess nutritional
status

Assess elimination
status

Instruct to turn and
position patient
every 2 hours or as
needed

Encourage
appropriate use of
assistive devices in
home setting




weakness,
thrombophlebitis,
constipation and
pneumonia

Px was not able to
verbalize feelings or relate
meaningful information

To promote safety during
position changes and
transfer

Proper nutrition provides
needed energy

Immobility promotes
constipation

To optimize circulation to
tissues and to relieve
pressure

Proper use of wheelchairs,
canes and other assistance
can promote activity and
reduce danger of falls





Assessment Nursing
Diagnosis
Scientific
Rationale
Objective Nursing
Intervention
Scientific
Rationale
Evaluation
Subjective:

5 hours lang lagi
tulog ko automatic 2
am gising na ako as
verbalized by the
patient

Objective:

Total
number of
hours of
sleep less
than 8 hours
irritable
Being
uncomfortabl
e due to hot
Sleep
deprivation
related to
emotional
distress
secondary to
illness and
loss of loved
ones.


Constant stress puts
the brain in a
perpetual state
of "fight or
flight



brain becomes
flooded with
hormones like
adrenaline and
cortisol



Elevated Blood
pressure,
Hypertension



Continuous stress
causes
irritablity

After 8 hours
of nursing
intervention,
the client will:
verbalize
sense of
comfort or
contentment
by stating to
the relative
that she feels
better. The
client
will
show
signs
of
improv
ed
feeling
of
comfor
t such
Establish rapport




Assess patient
sleeping pattern


Determine type of
discomfort client
is experiencing


Improve client's
surrounding by:
fixing the
beddings
opening
Allows more
effectiveness of
nursing
interventions

Will serve as a
baseline data to
identify what
action to elicit.

To determine
the appropriate
nursing
interventions
for the client

Enhances
patient's
comfort by
lessening the
factors that
contributes to
Goal partially
met. Client was
able to sleep but
with intervals of
being awake.
Maximum time
for single
continuous sleep
is 30-45 minutes.

Goal met. Last
blood pressure
for the shift if
150/90mmHg.
environment
initial vital
signs of:
BP: 160/90
mmHg
RR: 21 cpm
PR: 90 bpm
Temp: 36.0




Stressors continue
to stress the
patient



Decreased comfort



Decreased sleeping
hours


Impaired comfort
due to sleep
deprivation



as:
- increased
time of sleep
from 5 hours
to at least 8
hours
- decrease in
blood pressure
by atleast
10mmHg
within the
shift
the
curtains
and
windows
for
ventilation
opening
the electric
fans for
circulation
of air

Plan
care/activities to
allow individually
adequate rest
periods

Give food to the
patient according
to her prescribed
diet.

Monitor vital
signs at an
appropriate and
patient's feeling
of discomfort.








Prevents
fatigue and
promotes more
time for sleep.

Alleviates
hunger.



Allows more
resting time for
planned time. the patient.