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

33

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

34

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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