V.

Present History of Illness

The Patient x , a 50-year-old male from Besao, Mt. Province was admitted at Benguet General
Hospital last November 3, 2021 at 7am with chief complaints of decreased sensorium, dizziness,
nausea and right sided body weakness. A week prior to admission, he experienced episodes of
severe headache and dizziness a few hours after his meal. During this incident, he took Ibuprofen
to relieve the headache and decided to have a rest, but no medical consultation was made. Two
days prior to admission, the said condition worsened, accompanied by nape pain. The patient
was known hypertensive. One day prior to admission, his wife noticed the flagging condition of
the patient when she found him lying on the bathroom floor, unable to speak and move the right
side of his body. The patient was then rushed to Luis Hora District Hospital and was prescribed
to start on clonidine drip + mannitol 100 cc IV and furosemide. The patient was referred later to
Benguet General Hospital and was subsequently admitted for further evaluation and
management. At the ER, he was seen stuporous, with vital signs of: BP: 280/120 mmHg CR: 125
bpm RR: 28 bpm T: 38.0oC

A. Head to Toe Assessment 

1.     Head Hair well distributed, oiliness and flaking, not able to

move his head to his right, no tenderness during
palpation. Decreased sensorium. . Facial drop on the
right side.

2.     Eyes Too weak to respond to the eye assessment

questions asked, sclera is anicteric, pupils are
equally round, reactive to light and accommodation,
EOM is intact, able to follow penlight with gaze, no
detectable oscillations, mucous membranes are
moist and light pink. Feels dizzy.

3.     Ears Able to understand and hear spoken language

correctly, with minimal cerumen build – up in the ear
canal, sliver and intact tympanic membrane.

4.     Nose and sinuses Nose is patent, septum is located midline, no flaring

noted, and no episodes of epistaxis during the shift

5.     Mouth Complete set of adult teeth. Oral mucosa is moist

and pinkish, no lesions noted, with slurred speech.

6.     Neck Stiff neck and not able to change direction of head

towards his right and with complaints of pain and stiff
neck during palpation.
 7.     Chest                Decreased breath sounds in the right, no crackles,
no wheeze, no stridor, With limited movement on the
right shoulder. Patient is observed to guard area and
grimaces when a painful stimulus is felt. Maintains
the supine position with head of bed elevated to a
moderate high back rest.

8.     Cardiac             Cardiac rate of 125 bpm, no murmur noted, no

visible pulsations in the precordium, palpable apical
pulse.

9.     Breast/Chest               Skin color is similar with the rest of the body, nipple
is dark colored, no discharges.

10.   Abdomen        Flat, with normoactive bowels sounds heard in all the
quadrants, soft, no direct tenderness or rebound
tenderness upon palpation, tympanic, no
organomegaly.

11.   Genitals              No complaints of dysuria or urinary retention or

incontinence.

12.   Musculoskeletal        Not able to move the right part of the body.

13.   Integumentary        No various interruptions in skin integrity

XV. Nursing Care Plan (ibekwe)

ASSESSMEN EXPLANATION OBJECTIVES INTERVENTION RATIONALE EVALUATION 

T OF THE S
PROBLEM

Cerebrovascula
S> I feel dizzy r accident STO Dx STO
as verbalized (CVA), also Provides
by the patient. known as After 1 to 8 Assessed general baseline data  After 1 to 8
stroke, cerebral hours of health status. for nursing hours of
  infarction, brain effective care. effective
attack, is any nursing nursing
functional or interventions intervention
structural
 abnormality of
O> dizziness the brain the patient Monitored for the patient
caused by a will verbalize other signs of was able to
right-sided pathological understandin ineffective tissue To accurately understand
weakness, condition of the g of condition perfusion. gauge his condition
cerebral and therapy severity of and comply
 facial vessels of the regimen condition. with the
asymmetry, entire therapeutic
cerebrovascular LTO Monitored and regimen. 
speech system. It is the recorded vital
slurring, sudden  After 24 signs. Radical LTO
impairment of hours to 48 changes may
unexplained cerebral hours  of indicate that  After 24 hours
headache at circulation in effective the condition to 48 hours of
the occipital one or more nursing got worse. effective
and nape blood vessels interventions nursing
area, supplying the the patient Tx   interventions,
brain. This will verbalize the  patient
Dyspnea. pathology either understandin head of the bed.   was able to
causes g of understand
Nursing hemorrhage condition, To promote his condition,
Diagnosis from a tear in therapy circulation / complies with
the vessel wall regimen, side increase therapeutic
Ineffective or impairs the effects of gravitational regimen, was
tissue cerebral medications blood flow fully aware of
perfusion circulation by and when to possible side-
related to partial or contact effects of
complete Administered
interruption of healthcare medication
occlusion of the medications
blood flow provider.. Anticoagulant and when to
secondary to vessel lumen s and contact a
CVD/CVA with transient or hypertensive healthcare
permanent drugs help to provider.
effects. The prevent
sooner the further
circulation damage
 
returns to
normal after a Performed  
stroke, the assistive/active
better the range-of-motion Alleviates the
chances are for exercises effects of the
a full recovery.
stroke
However, about
half of those
 
who survived a  Edx
stroke remain
 
disabled Encouraged early
permanently ambulation
and experience Enhances
the recurrence venous
within weeks, return.
months, or
Promoted quiet,  
years.
restful
atmosphere Conserves
energy /
   lowers tissue
O2 demands
Reiterated
importance of  
medical
restrictions. Encourages
compliance to
therapeutic
regimen.
Discussed
necessary  
changes in
lifestyle. To assist
patient in
incorporating
disease
management
 
into ADLs.
Encouraged
verbalization of
feelings. Provides
basis for
nursing care.

NCP 5 (IBEKWE)

ASSESSMEN Explanation of Objective  Nursing Rationale Evaluation 

T the Problem   Intervention 

Dx;
S>  I can't  Clot, thrombus or STO STO
move my right embolism forms Assessed the Describe right
side as within After 1 to 6 type and and left After 1 to 6
verbalized by cardiovascular hours of degree of hemisphere hours of
the patient. system effective hemisphere injuries. effective
nursing injury the nursing
  ↓ interventions patient interventions
the patient exhibits. the patient
O> fatigue Cerebral artery will interact was able to
appropriatel interact
Slurred speech                  ↓ y with his appropriatel
Evaluated for The presence
environment y with his
visual deficits. of visual
Facial grimace                Brain .  environment
disorders can . 
negatively
Limited range of                  ↓ affect a
 patient’s ability
motion.  Blood flow is LTO to perceive the  LTO
disrupted environment
Nursing  After 24  After 24 hours
Diagnosis ↓ hours to 48 Assessed to 48 hours  of
hours  of sensory Diminished effective
Risk for injury Oxygen and effective awareness: sensory nursing
related to Glucose cannot nursing dull from awareness and interventions
altered sensory reach part of brain interventions sharp, hot impairment of the client was
reception  the client will from a cold, kinesthetic not able to
                  ↓ not exhibit position of sense exhibit
         Brain cells evidence of body parts, negatively evidence of
die          injury joint sense. affect balance injury caused
(infarction) caused by and positioning by sensory /
sensory / and perceptual
perceptual appropriatenes deficit.
deficit.  s of movement.

Tx;

Provided the Inability to

patient with orient self in
restraint or space: They
wheelchair may not know
belt for if they are
support. standing,
sitting, or
leaning.

Assisted Difficulty
patients with recognizing
eating. and
Monitor the associating
environment familiar
for safety objects:
hazards, and Patients may
remove not know the
hazardous purpose of
objects such silverware.
as scissors
from the
bedside.

 Gave short,
simple May have poor
messages or abstract
questions and thinking skills.
step-by-step tend to be
directions. slow, cautious,
Keep the and
conversation disorganized
on a concrete when
level approaching
an unfamiliar
problem.

Edx;

 
Encouraged Patients may
making a have visual
conscious field deficits in
effort to scan which they can
the rest of the physically see
environment only a portion
by turning (usually left or
head from right side) of
side to side the normal
visual field
(homonymous
hemianopsia).

Encouraged Patients with

patient to non-dominant
slow down (right)
and check hemisphere
each step or injury may also
task as it is have
completed. decreased pain
sensation and
sense of and
visual field
deficit but are
typically
unconcerned
or unaware of
or deny deficits
or lost abilities.
They tend to
be impulsive
and too quick
with
movements.