HOLY ANGEL UNIVERSITY

ANGELES CITY

COLLEGE OF NURSING

TRANSIENT ISCHEMIC ATTACK

A CASE STUDY

March 5, 2009

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. TIAs are the precursor in 15% of all strokes and if unrecognized,
can represent the greatest morbidity and mortality for stroke patients in the first thirtyninety days after their first TIA.
Fifty-percent of patients who experience a TIA fail to notify their healthcare
provider. Approximately one-third of TIAs 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.

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.

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. Attacks 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
mothers 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.

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.

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

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
7

With long and polished toenails and fingernails

With numbness and inability to move the left lower extremity

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.

IV. DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic/
Laboratory
Procedure

Potassium

Creatinine

Sodium

Indications or
Purposes

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
The creatinine
blood test is
usually
ordered along
with a BUN
(blood urea
nitrogen) test
to assess
kidney
function
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.

Date
Ordered
Date
Results
were
released
February
22, 2009

Results

3.3

Normal
Values
(Units
used in
the
hospital)
3.6-5.0
mmo/L

Analysis and
Interpretation
of Results

Decreased
levels of
potassium
indicate
hypokalemia.

February
22, 2009

0.64

0.5-1.69
mg/dl

Normal

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).
-high blood

Glucose: FBS

BUN

Glucose,
formed by
digestion of
carbohydrates
and the
conversion of
glycogen by
the liver, is the
primary source
of energy for
most cells.
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

sodium level
means you have
hypernatremia,
almost always
due to
excessive loss
of water
(dehydration)
without enough
water intake.
Normal

February
22, 2009

83.8

76-111
mg/ dl

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
is overhydrated

10

Uric Acid

The uric acid

February
test is used to
22, 2009
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.

5.07

2.5-7
mg/dl

(too much fluid

volume), but
the BUN test is
not usually used
to diagnose or
monitor these
conditions.
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
compounds,
and rarely as

11

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

Triglycerides

To determine
your
nutritional
status or to
screen for
certain liver
and kidney
disorders as
well as other
diseases
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
for high lipid
and/or

February
22, 2009

187.9

up to 200
mg/dl

Normal

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
treatment used
to lower LDL
cholesterol may

12

triglyceride
levels.

SGOT/AST

used to detect
liver damage.

February
22, 2009

13

5-35 u/L

SGPT/ ALT

To detects
liver injury.

February
22, 2009

7-56 u/L

Potassium

To determine
the amount of
Potassium
present in the
blood.
Potassium is
an important
electrolyte that
helps regulate
the flow of

February
23, 2009

3.7

3.6-5.0
mmo/L

differ
depending on
whether
triglycerides are
high or normal.
Normal
Very high levels
of AST (more
than 10 times
the highest
normal level)
are usually due
to acute
hepatitis, often
due to a virus
infection.
Normal
Very 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
12 months, but
can take as long
as 36 months
to come back to
normal.
Normal
-Increased
potassium
levels indicate
hyperkalemia.
Decreased
levels of
potassium
indicate
hypokalemia

13

fluids in and
out of the cells

-Decreased
levels of
potassium
indicate
hypokalemia.

Diagnostic/

Indications

Date

Laboratory

or Purposes

Procedure

Results

Normal

Analysis and

Ordered

Values

interpretation

Date

(units used

Results

in the

were

hospital)

released
HCT

Hematocrit

February

test measures

22, 2009

36.9

37-47

Decreased
hematocrit

the amount of

indicates

space

anemia, such

(volume)

as that caused

RBC take up

by iron

in the blood.

deficiency or
other

pH

Blood gas

February

343

140-440

deficiencies
Normal

measurements 22, 2009

are used to

-Abnormal

evaluate your

results of any

oxygenation

of the blood

and acid/base

gas

status.

components
may mean that
your body is
not getting
enough
oxygen, is not
14

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
WBC

Determines

February

the number of

22, 2009

7.6

4.3-10.0

threatening.
Normal

circulating

-An elevated

WBCs per

number of

cubic ml of

white blood

whole blood.

cells is called

It is an

leukocytosis.

indicator of

This can result

immune

from bacterial

function and

infections,

helps to

inflammation,

determine

leukemia,

infection or

trauma,

inflammation

intense
exercise, or

15

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

February

the level of

22, 2009

62

44.2-80.2

The result is
wihtion

granulocytes

normal range

in the blood.
An elevated
level means
that there is
hgh bacterial
infection
(x10/1)
Lympho/

Small

February

monocytes

agranulocytic

22, 2009

4.7
38

2.0-8.8
28-48

The result is
within normal

16

leukocytes

range

originating
from fetal
stem cells. It
is especially
helpful in the
evaluation of
the patient
with
HGB

infection.
Measures the

February

amount of

22, 2009

11.2

12-16

Below-normal
hemoglobin

hemoglobin

levels may

in blood and

lead to anemia

is a good

that can be the

measure of

result of iron

the bloods

deficiency

ability to
carry oxygen
throughout
the body.

Nursing Responsibilities for Blood Chemistry:

A. Before the procedure:
1. Check the Doctors order.
2. Identify the patient.
3. Check the vital signs.
4. Decrease patients anxiety by explaining the procedure and why it has
to be performed.
17

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
Urinalysis

Indications or
Purpose

Date Ordered
Results
Date Results
were released
To
obtain February
23, Macroscopic:
clinical
2009
Color: yellow
information, to
Specific
detect renal and
Gravity:1.015
metabolisc
Sugar: negative
disease,
Appearance:
diagnosis
of
slightly turbid
disease
or
Reaction: pH
disorder
on
6.0
kidneys
or
Albumin:
urinary tract.
negative

Analysis and
Interpretation
of Results
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
Microscopic:
there
is
a
Pus cells: 1-2
problem
that
Red Cells: 0-1
needs to be
Epithelial cells: addressed.
few
Mucus threads:
rare

Nursing Responsibilities for Urinalysis:

A. Before the Procedure
1. Explain the procedure to the patients significant other.
2. Obtain materials needed in the procedure.

18

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 patients chart.
Diagnostic/
Laboratory
Procedure
Brain Scan

Indications or
Purpose

Date Ordered
Results
Date Results
were released
To
identify February
23. Lacunar Infarct,
structural
2009
subcortical
lesions whether
portion,
left
vascular
or
parietal lobe
tumors.

Analysis and
Interpretation
of Results
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
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.

19

B. During the procedure:

1. Stay with the patient.
C. After the procedure:
1. Document the procedure.
2. Attach the result in the patients chart

20

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

21

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.

22

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.

23

2. Pathophysiology
A. Book-Based
a. Schematic Diagram
Predisposing factors
- age
- sex
- history of TIA/stroke & HTN on the family
- sedentary lifestyle
- personal HTN

Precipitating factors
- cigarette smoking
- Diabetes Mellitus
- thromboembolism
- stress

Decrease blood supply on the brain leads to hypoxia, thus

Ischemia occurs on the brain.
Short-term ischemia leads to temporary neurologic deficits or a TIA
If blood flow is restored,
brain tissue will
reverse the damage
within 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
24

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
results;

The area of edema after ischemia may lead to

temporary neurologic deficits

Leads to secondary neuronal injury

If edema subsides, client may regain some function
25

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.
vessels

Excessive pressure on the walls of

speeds up hardening and narrowing of the arteries

(atherosclerosis).
Precipitating Factors

26

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 2 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

27

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.

28

B. Client-Centered
a. Schematic Diagram
Predisposing factors
- history of HPN on Aunt (Mothers side)
- history of stroke (Aunt and Father)

Fromation of Lacunar infarction

Precipitating factors
- use of birth control pills
- increased fatty food on diet
- stress

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
also known as Transient Ischemic Attack

Ischemia quickly alters cerebral

metabolism
29

decrease cerebral perfusion

affects blood flow n the body

Leading to Hypoxia on the brain will cause further

damage if not be reversed and will
furtherresult to higher damaged to the brain

Leading to hypotension

leading to syncope and chest pain, and left sided weakness of the body

Leading to Transient Ischemic Attack

30

B. Synthesis of the Disease

b.1. Predisposing/Precipitating Factors
Predisposing factors
History of HPN and stroke on Aunt (mothers 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.

31

VI. THE PATIENT AND HER CARE

1. Medical Management
A. IVF
Medical
Management

General
description

IVF D5NM
It 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.

Indications/
purpose

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.

Date ordered,
date performed,
date changed or
D/C
02-21-09

Clients response
to treatment

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.

32

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 patients therapeutic response to treatment.

Check the IV insertion site for signs of infiltration, bulging, heat, pain and
redness.

B. Drugs
Drugs

Action

Indication

Generic Name:
Potassium
Chloride
Brand Name:
Kalium Durule

-Replaces
potassium and
maintains
potassium level

-To prevent
hypokalemia

Generic Name:
Citicoline
Brand Name:
Somazine

-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.

To increase
brain
metabolism

Date ordered,
date
performed,
date changed
or D/C
Date Ordered:
02-22-09

Clients
Response

The patients
potassium
level
returned to
normal
range.
There is
improvement
in the
affected
(paralyzed)
areas.

33

Generic Name:
Mannitol
Brand Name:
Osmitrol

-Increases osmotic
pressure of
glomerular filtrate,
inhibiting tubular
reabsorption of
water and
electrolytes; drug
elevates plasma
osmolality;
increasing water
flow into
extracellular fluid.

-to prevent
oliguria or
acute renal
failure

The patients
urinary
function
returned to
normal.

Generic Name:
omeprazole
Brand Name:
Risek

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.

To prevent
gastoesophageal
reflux and
peptic ulcer.

The patient
did not
experience
reflux and
did not
manifest
ulcerations.

Generic Name:
Clopidogrel
bisulfate
Brand Name:
Plavix

- 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.

Generic Name:

-increases the

- to reduce
02-23-09
thrombotic
events in
patients with
atherosclerotisis
documented by
recent stroke,
MI, or
peripheral
arterial disease

to increase

02-24-09

The patients
blood
circulation
improved
and was
increased.

There is

34

Citicoline Na
Brand Name:
Cholinerv

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.

brain
metabolism

improvement
in the
affected
(paralyzed)
areas.

b. 1. Nursing responsibilities:
BEFORE ADMINISTRATION:

Check and clarify Doctors order

Prepare equipments

10 Rs of drugs

Performed skin testing

Check for the patients medication card and chart.

Performed hand washing

DURING ADMINISTRATION:

Read the name, amount, and expiration date three times

Check for patients identification

Explain the procedure to the client

AFTER ADMINISTRATION:

Document

Watch out for any side effects

D. Diet

35

Type of Diet

General
description

Low salt and

low fat

Indications
/purpose

Date
ordered, date
started, date
changed or
D/C

To prevent the 02/22/09

problems
that
result from the
need to withhold
food.

Clients
response
and/or
reaction to
the diet

- The patient
complied with
the doctors
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

Clients
response
and/or
reaction to
the activity

36

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

Flexionextension
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.

37

VII. NURSING CARE PLAN

Problem No. 1
Cues
Nursing
Diagnosis
S>
Ineffective
O> Body
peripheral
weakness
tissue
Paralysis
perfusion r/t
impaired
of left
transport of
lower
extremities the O2 across
alveolar and
BP of
capillary
100/60
membrane
AEB
paralysis of
left lower
extremity

Scientific
Explanation

Nursing
Objectives

Because
theres 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, pts
condition in
circulation of
the left lower
extremity
will have
progress.

Nursing
Rationale
interventions
Encourage
Enhance
early
venous
ambulation
return
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

To increase
gravitational
blood flow

Expected
Outcome
The pts
condition in
circulation of
the lower
extremity
shall have
progressed.

Heat
increases
the
metabolic
demands of
already
compromise
d tissue
Smoking
causes
vasoconstric
tion and
further
compromise
d perfusion

38

Problem No. 2
CUES
S > Di ko
magalaw
tong left
foot ko
Wala ring
pakiramda
m
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

NURSING
DIAGNOSIS

SCIENTIFIC
EXPLANATION

NURSING
OBJECTIVE

Impaired
physical
mobility r/t
neuromuscular
impairment
AEB paralysis
of the lower
left extremity.

Due to the
impairment of
blood flow in the
brains
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 pts
ability to perform
desired and
necessary
activities.

After 1 of
nursing
intervention,
the pt. will be
able to
participate in
ADLs and
with the
desired
activities.

NURSING
INTERVENTIONS

RATIONALE

EXPECTED
OUTCOME

Assist in self-care
activities.

To promote
independence
and
enhancement of
self-concept.

Encourage energyconserving
techniques.

To prevent
fatigue and
overexertion.

The pt. shall

have
participated in
ADLs and
with the
desired
activities.

Provide pt. with

ample time to
perform mobilityrelated tasks.

To provide time
to rechannel
energy and to
prevent exertion
and
overexhaustion.

Place pillows on
the right side of the
bed.

To promote
safety and to
prevent injury.

Change lying
position every 2
hours.

To prevent
stasis of blood
and to reduce
the risk of
pressure ulcers.

Offer fluids and

reinforce nutritious

To aid in
supplementing

39

upon
ambulatio
n
with
paralysis
of the left
lower
extremity
PR:
54bpm

foods.

normal body
functions.

Reinforce low salt,

low fat diet.

To assure
compliance
with daily diet
regimen and to
provide a
continuous
recovery state.

Problem No. 3
CUES
S
O left
extremity
weakness
- inability to
move
purposefully

NURSING
DIAGNOSIS

SCIENTIFIC
EXPLANATION

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.

OBJECTIVE
After 2 hours
of Nursing
intervention
the patient
will
demonstrate
behaviors that
will improve
her present
condition.

INTERVENTION

Assist with
activities and
monitor c
lients use of
assistive
device

RATIONALE

to protect client
from injury

EVALUATION
The pt shall
have
demonstrated
behaviors that
will improve her
present
condition.

Adjust activities

to prevent
overexertio
Plan care with rest
n
periods
between
to reduce
activities
fatigue
Promote comfort
measures and
provide relief

40

Making the
patient unable to
move the left side
of her body most
especially the left
side of the body.

of pain

to enhance
ability to
participate
in activities

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.

41

VIII. DISCHARGE PLAN

OBJECTIVE
After NPI, the pt. will
be able to comply and
verbalize
understanding on
provided health
teachings and home
maintenance
management.

CONTENT

TIME ALLOTMENT

TEACHING
STRATEGIES

Exercise
Advise to:
Do deep breathing
exercises.
Have ambulation with
assistance and support
as tolerated.
Perform ADLs
involving hygiene and
self-care.

1 hour

Lecture-discussion and
demonstration

EXPECTED
OUTCOME
The pt. shall have
complied and have
verbalized
understanding on
provided health
teachings and home
maintenance
management.

Treatment
Instruct to:
Comply strictly with
drug treatment
regimen.
Health Teachings
Demonstrate 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

42

periods.
Provide energy
conservation
techniques.
Make up activities that
increase the well
being.
Out-Patient
Instruct to:
Return a week after
discharge as ordered
by the physician.
Diet
Reinforce to:
Maintain a low salt,
low fat diet.
Increase fluid, fruit
and vegetable intake.

43

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.
Weve 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 weve 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. Weve 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 weve learned
from the lectures and discussions within the four corners of the classroom. One can never
really appreciate what was learned until was experienced.

44