GOOD DAY!

T/C Cerebroscular Accident Probable Infarct Right, Diabetes Mellitus Type 2

I. INTRODUCTION

BACKGROUND OF THE STUDY

There are 18.2 million people in the United States who have diabetes mellitus (DM). The prevalence of this medical disorder increases with age. Half of all cases occur in people over the age of 55, and it is estimated that 18% of the United States population over the age of 60 have DM. Patients with DM are more prone to develop vascular diseases, including strokes. In addition to being a deadly disorder in diabetics, stroke is a disabling disorder. Most stroke survivors are left with some physical and/or cognitive deficits. Stroke is the leading cause of permanent disability in the United States and it is the second leading cause of cognitive decline. Thus healthcare providers who care for patients with DM should be knowledgeable about the inter-

relationship between DM and stroke, as well as interventions that can minimize their patients risk of primary and secondary stroke. In this article we will discuss epidemiologic relationships between DM and stroke, effects of DM on outcome from stroke, and stroke prevention strategies for the diabetic patient. (Nader Antonios, MD and Scott Silliman, MD. Diabetes Mellitus and Stroke.http://www.dcmsonline.org) A person with diabetes is at higher risk than others for stroke and other cardiovascular diseases. As with many of the health problems associated with diabetes, higher-than-normal blood glucose (blood sugar) levels are factors.(www.ask.com)

A. RATIONALE FOR CHOOSING THE CASE

1. 2. 3. 4.

The case was studied for the following reasons: To have critical thinking skills necessary for providing safe and effective nursing care. To have a comprehensive assessment and implement care base on our knowledge and skills of the condition To familiarize ourselves with effective interpersonal skills to emphasized health promotion and illness prevention. To impart the learning experience from direct patient care.

The presenters aim to recognize the actual and probable health problems of the client in relation to his health practices as an individual and understand fully the process of the occurrence of this disease through applying the theoretical frameworks and the nursing processes.

B. OBJECTIVES OF THE STUDY

Specific Objectives
1.To thoroughly assess the clinical manifestations of patient with CVA based on the patients history. 2.To formulate comprehensive nursing diagnosis for a client with CVA. 3.To formulate a plan of care for patients with CVA. 4.To formulate appropriate nursing interventions that can be applied for a patient with CVA. 5.To evaluate the plan of care for a patient with CVA

After the completion of the study, a nurse shall be able to:

II. ASSESSMENT

A. Client Profile

NAME: J.M. AGE: 50 years old GENDER: Male ADDRESS: Mandaluyong City BIRTH DATE: October 28, 1961 NATIONALITY: Filipino RELIGION: Roman Catholic CIVIL STATUS: Married OCCUPATION: Retired taxi driver (2004-2011) HEALTH CARE FINANCING: Fortune Health Insurance ADMISSION DATE: August 13,2012 ADMISSION TIME: 11:55 AM ADMITTING PHYSICIAN: Dr. Estacion ADMITTING DIAGNOSIS: T/C Cerebrovascular Accident Probable Infarct Right Diabetes Mellitus Type 2 FINAL DIAGNOSIS:

B. Chief Complaint

Nanghihina ang kaliwang bahagi ng katawan ko tapos di ako makapagsalita ng ayos as verbalized by the patient.

C. History of Present Illness

D. Past Medical History

Few hours prior to admission, patient is having a left sided body weakness associated with numbness. According to him, he suddenly fell from his seat and couldnt talk straight.

Last 2011, he stated that he undergone an amputation of his left big toe because of diabetes and was prescribed with some medications for 3months: > Apidra (fast acting, mealtime insulin) >Lantus (long-acting insulin)

E. Personal History

Last 2002, the patient had a boils/abscess on his back. Hes been wondering why it doesnt heal and agonizing the pain for months. So he consulted a doctor and then tried to obtain a blood glucose test and they found out that the blood glucose level is high and diagnosed to have Type 2 Diabetes Mellitus. Client was not aware of the signs and symptoms of diabetes since he believe that he is healthy. He was prescribed by his doctor an antibiotic only for the faster healing of his boils/abscess. He stated that he also tried controlling his food intake by avoiding sugar rich and cholesterol rich food. But he failed to do regular exercise since he is a taxi driver and wasnt able to manage his diet. And last 2011, he got a blister on his left big toe and doesnt heal

E. Personal History

again until it became a wound. Then he consulted a doctor and advised him that his left big toe should be amputated before the wound increase its size since he is diabetic. Visual problems were verbalized by the patient. During his childhood when he was 10 years old, he stated that he was bumped by a car and was hospitalized. The patient wasnt able to recall his childhood illnesses.

F. Family History of Illness

Family History interpretation

of

Illness

The figure is a 3rd generation family history of illness. Patients grandfather on both side died of old age. His grandmother on the father side died of cancer of the glands and grandmother on the mother side died because of DM complications. His father was a heavy drinker and died with a liver cirrhosis disease and his mother passed away because of kidney disease.

G. Gordons Functional Assessment

Health Perception and Management

Before Hospitalization

Client verbalizes that he has been pampered starting when his left big toe was amputated this year because of diabetes. Last year, he and his wife decided that he should stop from working because he easily gets tired. Whenever he feels sick he treated it immediately by taking OTC drugs for headache.

During Hospitalization

Client stated that he obediently follow all the orders of the doctors. He believes that doctors, nurses and other medical members will help him for faster recovery.

G. Gordons Functional Assessment

Nutritional Metabolic

Before Hospitalization During Hospitalization

Client stated that he eats everything he wants and sees. Often failed to follow his DM diet. He eats 3 times a day with 3 cups of rice per meal. She drinks 6-8glasses of water a day.

Client stated that he has difficulty eating since his left side of the body is weak and he cant chew and swallow his food properly. Still on DM diet

G. Gordons Functional Assessment

24 Hour Diet Recall

Meal
Lunch

Breakfast

Food

Dinner

Suman Water Rice Pakbit Rice Adobong manok

Quantity

2 pieces 1 glass (240 ml) cup 1 serving cup 1 serving

G. Gordons Functional Assessment

Elimination

Before Hospitalization During hospitalization

Client verbalizes that he defecates three times a week formed and brown in color. He voids 6-8 times a day with yellowish in color. Client stated that he defecates once a day since admission with a semi-formed stool and brown in color. He voids 4-5 times with yellowish color and needs assistance when voiding.

G. Gordons Functional Assessment

Activity Exercise

Before Hospitalization During hospitalization

Client verbalizes that he lacks Still he was not able to carry exercise ever since he became out any other activities. a taxi driver. He also added that he easily gets tired with shortness of breath.

G. Gordons Functional Assessment

Sleep Rest

Before Hospitalization During hospitalization

Client normally gets 6 hours of continuous sleep. He stated that he can consumed 4 cups of coffee and it doesnt affect his sleeping pattern. He does have difficulty in breathing when lying and he snores. He sleeps in prone position. He claimed that hospitalization affect his sleeping pattern. He sleeps in a semi fowlers position. He stated that he doesnt feels rested after sleeping because of the environment.

G. Gordons Functional Assessment

Cognitive Perceptual

Before Hospitalization During hospitalization

The client can remember remote, immediate, and recent memory when being asked. He has no hearing problems. He is able to follow instructions and answer questions accordingly. But he has attention deficit when being asked. The client is aware about his present situation but not that knowledgeable about the disease condition when being asked. He also verbalized decreased sensation and doesnt feel pain easily.

G. Gordons Functional Assessment

Self Perception Self Concept

Before Hospitalization During hospitalization

Client claimed that he was He stated that his self esteem is already satisfied with life prior low because of his to hospitalization although he hospitalization and his disease. is experiencing some signs and symptoms.

G. Gordons Functional Assessment

Role Relationship

Before Hospitalization During hospitalization

Client lives with his wife and four The client presently feels the children. Even before hospitalization support of his family and he is he stated that he is already unable to happy about it. support his family in financial needs since he decided and his wife to stop working and just stay at home. His wife is a public teacher and he feels a bit sad because he cant help in financial needs. He and his wife make the decision in the family. They have open communication with each other.

G. Gordons Functional Assessment

Sexuality Reproductive

Before Hospitalization During hospitalization

The patient has 4 sons and he also stated that they didnt practice family planning. Prior to hospitalization, the client verbalized impotence by having lessened sensation during intimacy. He claimed that he lost his sexual interest due to the physical changes that he is experiencing.

G. Gordons Functional Assessment

Coping Stress Tolerance

Before Hospitalization During hospitalization

When he is tired, he sleeps for him to rest and not to stress himself. He stated that he is not ill tempered and a happy person. Though he is in stressful state because of his hospitalization he just calm himself and take his bed rest.

G. Gordons Functional Assessment

Value Belief

Before Hospitalization During hospitalization

Prior to hospitalization, client When he was hospitalized, he admitted that he doesnt go to still prays and asks for Gods church. protection despite of what happened to him.

H. Physical Examination

General Survey Client is lying on bed, has a proportionate body built. Hygiene and grooming is unkempt and has acetone breath. He has no signs of distress, cooperative, and a bit difficulty in speaking but understandable. Vital signs His temperature is 36.4 C axillary, blood pressure taken in supine position is 140/100 mmHg, Radial Pulse Rate is 84 beats per minute , weak and Respiratory rate is 26 cycles per minute in cheyne-stokes respiration.

H. Physical Examination

Skin His skin is brown in color, rough and has poor skin turgor. Symmetry of color is uniform. Edema +2 is present on both feet, moderate pitting and indentation subsides rapidly. Skin is moist and warm to touch. Hair His hair is evenly distributed, thick curly hair with flaking. Nails His nails are convex in curvature and angle with grooves texture, nail bed color is pallor with intact surrounding tissue. Capillary refill is delayed.

H. Physical Examination

Skull and face His head is normocephalic and has negative masses. Asymmetrical facial gestures and facial movements. Eye Structures and Visual Acuity His eyebrows and eyelashes are evenly distributed, symmetrical eyelids with intact skin and 18 involuntary blinks. He has pale conjunctiva, anicteric sclera, smooth and clear cornea. Pupils is black, Pupils, Equal, Round, React to Light and Acommodation. Peripheral vision is intact, coordinated extraocular movement but has difficulty in reading newsprint.

H. Physical Examination

Ears and Hearing His external pinnae is uniform color with skin, symmetrical and firm. Ear canal has wet cerumen. It is not tender and has no gross abnormalities. His external ear canal has no discharges. He has sluggish hearing acuity. Nose and Sinuses He has symmetrical nasolabial fold. His septum is in midline, non-deviated and has no perforation. Its mucosa is pinkish and has no discharges. It is both patent. He has symmetrical gross smell. Sinuses are not tender.

H. Physical Examination

Mouth and Oropharynx His lips are pale, dry and have no lesions. His tongue is deviated with white coating. He has incomplete set of teeth with a missing lower 1st premolar. There are no dentures, braces and retainers. Gums are red, palate, oropharynx and tonsils is light pink. Uvula is in midline. Gag reflex is intact. Neck His movement is coordinated with limited range of motion and unequal muscle strength. Lymph nodes are not palpable. Trachea is in midline, thyroid glands and jugular veins are not visible and carotid pulse is symmetrical. There are neither neck masses nor rigidity.

H. Physical Examination

Thorax and Lungs His inspiration/expiration ratio is 1:2, cheyne-strokes breathing pattern. He has positive use of accessory muscles and difficulty of breathing with abnormal sound on the left lower lung field. Shape is symmetrical, aligned spine, skin is smooth. Positive for crackles on the left lower lung field. Heart He has normo dynamic precordium. There are neither thrills nor heaves. Point of maximal impulse (PMI) and apical beat is located at the 5th intercostals space (ICS) left mid clavicular line (LMCL).

H. Physical Examination

Breast and Axilla His breasts are symmetrical in size and shape. There is no gynecomastia. It has no lesions. It is smooth and nontender. There are no retractions, dimplings and edema. Abdomen His abdomen is generally smooth. It is symmetrically globular and has no lesions. Bowel sounds are normoactive and heard 12 times/minute. It is tymphanitic upon percussion. There is no fluid wave. Genito-Urinary System Client refused to have his genitalia examined. There is no dysuria and oliguria.

H. Physical Examination

Upper and Lower Extremities Muscle strength is unequal, tenderness in bones and joints deformities.

H. Physical Examination
Date
8/13/12 Complete Blood Count (CBC)

Diagnostic Indication Test

CBC is ordered to determine presence of bleeding, anemia and evaluate fluid volume balance

Normal Values

Hemoglobin Hematocrit RBC WBC

140180gm/L 0.40-0.54 4.36.2x106/L 4.110.9x103/ L

Actual Values
93 0.29 3.1 6.1

Hemoglobin, Hematocrit and RBC is decreased indicates Anemia which can be due to destruction of blood cells internally because of the viscosity of the blood. Diabetes mellitus decreases RBC lifespan. Decreased in haemoglobin decreases the amount of oxygen-carrying protein causes to have difficulty in breathing which manifest in the client. WBC is within the normal value.

Clinical Interpretation