BACHELOR OF SCIENCE IN NURSING:

NCMB316 – MEDICAL SURGICAL NURSING

RLE MODULE RLE UNIT WEEK
2 6 7

CVA

 Read course and laboratory unit objectives

 Read study guide prior to class attendance
 Read required learning resources; refer to course unit terminologies for jargons
 Participate in weekly discussion board (Canvas)
 Answer and submit course unit tasks

At the end of this unit, the students are expected to:

General Objective:

This case study aims to broaden the students’ knowledge regarding CVA and it is designed to
develop and enhance the skills and attitude in the application of different nursing processes
and management of the patient with CVA
Specific Objectives:

1. To be able to acquire knowledge regarding CVA , its background and epidemiology through
research.
2. To recognize the contributing risk factors and signs and symptoms associated in the
development of CVA.
3. To understand the anatomical and physiological structures involved together with its
pathophysiology.
4. To formulate a comprehensive nursing care plan in the care for the patient with CVA
5. To acquire the knowledge on the role of drug therapy and medical and nursing management.
6. To learn the nursing implications and prioritize responsibilities to improve patient’s condition.
7. To provide recommendations to ensure the continuity of the nursing care management
8. To provide health teaching about CVA.

Hinkle, J., Cheever, K. (2017) Brunner & Suddarth’s Textbook of Medical-Surgical

Nursing 14th Edition. Philadelphia: Wolters Kluwer Health/ Lippincott Williams &
Wilkins.

At the end of this unit, the students are expected to:

1.Apply the nursing process in the care of critically ill clients:
a. Assess the client’s total health condition and his/her resources.
b. Formulate nursing diagnoses based on the priority needs of the client.
c. Develop a plan of care based on priority needs.
d. Implement a plan of care applying the appropriate nursing concepts,
principles, and guidelines in caring for critically ill clients.
e. Evaluate the outcomes(s) of care.
2.Demonstrate competencies of a beginning staff nurse, nurse leader, and researcher in the
care of critically ill clients.
3. Promote personal and professional growth by showing independence in performing varied
tasks and responsibilities.

CLINICAL SCENARIO:

NURSING HEALTH HISTORY

Sept. 23 , 2021 @ 5am Mr. HJK a 43 y/o lived in Val. City , Filipino , Roman Catholic , a Jeepney
driver his birthday is on March 13, 1978 , was been confined again in the hospital of FUMC under the
service of Dr. Jose with initial admitting diagnosis of CVA probable infarct vs. Hemorrhage, with chief
complain of impaired verbal communication and he spent more than 7 days in the hospital. Mr. HJK’s
wife said that while Mr. HJK is talking with his friend and drinking alcohol he experienced severe
headache, sudden dizziness, paralysis in the right part of his body, numbness, blurred vision and loss
of consciousness. And made his family to bring him into the hospital. Mr. K’s wife verbalized that Mr. K
was already been confined on the hospital before due to mild stroke last year December 2020 , while
he is in their house he experienced sudden headache, dizziness, numbness, blurred vision and that
made his wife to bring him into the hospital. Mr. K was confined for 4 days and after a week he was
able to work again as jeepney driver though the doctor said he need to take rest from work, avoid
stress, smoking, alcohol intake, and high fat/ salt food to avoid the stroke
The patient’s family history has hypertension in her mother side, diabetes mellitus And his
father and grand father die because of stroke but there are no other medical illnesses
indicated.No known allergies.
Mrs. HJK wife said that his husband was a smoker, he consumed more than 30-40 pieces a day (1 1/2
pack) since 20 years old and he also drink 1 bottle of alcohol since 23 years old. Mrs. K said that her
husband likes to eat pork after a long day of handling his jeep.
COURSE IN THE WARD :
 The pt. lying on bed, unconscious with an IVF of PNSS 1 L regulated @ KVO level
infusing well @ left hand using gauge 20 . With Nasogastric Tube inserted.Start OF 1,
600 kcal/day divide into 6 equal feeding, plus 60 cc of water after each feeding
 With Foley catheter inserted with 2000 ml. urine bag with in your shift
 “Nahihirapan siyang magsalita, kung minsan umuungol din siya, as verbalized by Mr.
K’s wife.”
 (+) difficulty in speaking,(+) weakness ,(+) headache,(+) dizziness,(+) blurred vision
(+)Paralysis on right part of the body
 Citicoline 1 gram TIV every 12 hrs (9am-9pm)
 Aspirin 8o mg 1 tab OD @1pm
 Metropolol (Neobloc) 100 mg I tab. OD (9am)
 Hydralazine (Apresoline) 25 mg 1 tab. every 6 hrs. (12 mn , 6am , 12 noon , 6pm)
 Mannitol 100 mg thru soluset IV every 6 hrs. (12 mn , 6am , 12 noon , 6pm)
Lab. Request for CBC with platelet count , HDL, crea , ECG, CT scan of the Brain Stat , urinalysis

GENERAL SURVEY
September 23, 2021@ 6:00 AM

VITAL SIGNS FINDINGS

Temperature 37.3
Pulse Rate 77 bpm
Oxygen Saturation 94%
Respiratory Rate 21 cpm
Blood Pressure 200/110 mmHg
MAP:
Wt: 60 kg
Ht: 5’6”
 PHYSICAL ASSESSMENT:

Area Assessed Actual Findings

SKIN
color Pale
Texture Smooth, soft
Turgor Skin snaps back immediately
When pinched
Hair Distribution Evenly distributed
Temperature Warm to touch
Moisture Dry, skin folds are normally moist
NAILS
Color of Nail bed Pink and clear
Texture Smooth
Shape Convex curvature
Nail base Firm
Capillary refill 4 sec.
time
HAIR
Color Black (varies)
Distribution Evenly distributed
Moisture Neither
excessively dry nor oily
Texture Silky, resilient
HEAD

Scalp symmetry Symmetrical

Skull size Normocephalic

Shape Round
Nodules/ masses Absence of nodules and masses
FACE
Symmetry Symmetrical

Facial movement Symmetrical

Skin color Pale
EYES Symmetrically aligned, equal movement
Eyebrows
Eyelashes Slightly curved upward
Eyelids Smooth, tan, do not cover pupil as sclera,
close symmetrically
Ability to blink Blinks involuntarily.
Frequency of To speech.
blinking
Ocular movement Lack of eye movement
Position Drawn from lateral angel
Size Medium
Texture Mobile, firm and non-tender
CONJUCTIVA
Color Transparent with light color
Texture Shiny and smooth
Presence of No lesions
lesions
APPARATUS

Cornea
Color Black
Texture Shiny and smooth
PUPILS
Color Black
Reaction to light Pupils Equally Round and React to Light
Accommodation (PERRLA)
Size Equal
Shape Round and constrict briskly
Symmetry Equal in size
Visual Acuity Cannot able to real news print.

Visual Fields With blurred vision and cannot classify objects

in periphery.
Ocular Eyes move freely
NOSE
Symmetry, shape, Symmetrical, smooth and tan
size and color
Mucosa color Reddish to pinkish
NASAL SEPTUM
Nares
Oval, symmetrical
Nasal discharge No discharge
Sinuses Not tender
MOUTH
Secretion without mucus production

Lips Dark and brown and cracking lips

Color
Symmetry Symmetrical
Texture Crack, rough s
Moisture Dry
GUMS
Color Pale
Moisture Moist
BUCCAL
MUCOSA
Color Slightly pale
Texture Soft
Moisture Moist
TOUNGE
Color Slightly pinkish
Size Medium
Symmetry Symmetrical
Mobility Moves freely
UVULA
Location At the midline
Symmetry Symmetrical
TONSILS
Color Pinkish
Discharges No discharges
TEETH
Color Yellowish
Number of teeth 28
NECK
Position Head-centered
Movement Moves freely
Range of motion No ROM
Consistency No enlargement
HEART
Heart rate 77 bpm
Heart sounds Clear
Lung field Resonant
THORAX &
LUNGS
POSTERIOR
THORAX
Symmetry Symmetrical

Respiratory rate 21 cpm

Spinal Alignment Spine vertically align
Skin integrity Skin intact
ANTERIOR
THORAX
Breathing pattern Breathing is automatic and effortless, regular
and even and produces no
noise
Lung/ breath Bronchia-vesicular
sounds
ABDOMEN
Contour Flat
Texture Smooth
Frequency and Audible; soft gurgling sound occur irregularly
character and rages from 5-30 mins
UPPER /LOWER (+)Paralysis on right part of the body
EXTREMITY

NEUROLOGICAL
Level of Unconscious
consciousness
Behavioral and Does not make eye contact with the examiner.
appearance
Mood Expresses feelings which corresponds to the
examiner
MANNERISMS &
ACTIONS
LANGUAGE
Voice inflection Aphasia
Tone Aphasia
Manner and Cannot give answer or talk.
speech
MENTAL
STATUS
Orientation Disoriented with time
TIME
Recall recent and Cannot recall events readily, immediate recall
remote memory of remote information
Judgments and Cannot make logical decisions
thoughts

Neurological Assessment (September 23, 2021)

Gloscow Result Total GCS
Coma Scale
Eyes To speech- 3 Total GCS=
Verbal None- 1
Motor Flexion pain- 4

Cranial Nerve Actual Result

Olfactory Nerve Cannot able to extinguish smell

Optic Nerve Without 20/20 vision.

Occulomotor PERRLA
Nerve
Abducens Nerve Cannot move eyes in lateral direction.
Trochlear Nerve Pt. cannot move eyes up and down.

Trigeminal Nerve Pt. cannot localize sensation.

Facial Nerve Cannot follow specific command.
Acoustic Nerve Cannot follow specific command.
Glossopharengeal Inability to swallow due to presence of NGT.
 Vagus Nerve With NGT inserted.
Accessory Nerve With no muscle strength.

Hypoglossal Cannot localize taste.

Nerve
5. Laboratory Procedures
Laboratory Result Interpretation
Procedure Sept .
23, 2021
Creatine 63.6
HDL 1.30
Hematocrit 0.44 g/l
Hgb 10.2 g/l
Leucocytes 12.4 x 10
g/l
Platelets 648 x 10/l

Laboratory Result Interpretation

Procedure
Yellow
URINALYSIS
Turbid

Ph 6.0
Specific 1.030
gravity
Pus Negative

Diagnostic Procedure
Diagnostic Result
Procedure
Electrocardiogram Rhythm:
Report Sinus
AL:
 120/m
PR:
0.20 sec.
QRS:
0.40 sec.
QT:
0.32 sec.
Axis:
+250

CT Scan result:

Axial unenhanced CT images 2 hours after stroke show a hyperdense left MCA (thick arrow) and loss of
the insular ribbon (thin arrow). Patient received intravenous thrombolysis after the CT. Axial
unenhanced CT images show petechial hemorrhages in the striatocapsular area and a hematoma
within the left lentiform nucleus, consistent with hemorrhagic transformation after thrombolysis.
Stage HI CT perfusion image shows a large area of delayed mean transit time on the left. CT angiogram
shows truncation of mid M1 segment of the left middle cerebral artery (arrow).

Gordon’s Functional Health Pattern (This is just a pattern hypothetically make your own)
1. Health Perception and Health Management
Prior to Admission During Hospitalization
He claimed he doesn't get sick often. Every
time he had a fever and cough his mother just
gave him paracetamol and lagundi capsule as
medication.

2. Nutritional and Metabolic Pattern

Prior to Admission During Hospitalization
According to the client;s wife likes to eat pork
after a long day of handling his jeep he claimed
he has a good appetite.

3. Elimination Pattern
Prior to Admission During Hospitalization
he claimed that he defecated once a day with
brown and formed stool. He had not
experienced any difficulties in defecation and
he never used any laxatives and stool
softeners. He said she urinated 3 times a day
with yellow urine and has no foul smell. And he
did not experience any difficulties in voiding

4. Activity-Exercise Pattern
Prior to Admission During Hospitalization
He did not usually exercise because of his job.

5. Sleep-Rest Pattern
Prior to Admission During Hospitalization
He went to bed at 9 pm and wakes up 5 am
and takes a nap from 3pm- 4pm on his
jeepney

6. Cognitive-Perceptional Pattern
Prior to Admission During Hospitalization
According to the client, He does not have any
problems in hearing, sight as well as memory.

7. Self-Perception/ Self-Concept Pattern

Prior to Admission During Hospitalization
He always go out to socialize with his to drink
liquor

8. Role Relationship Pattern

Prior to Admission During Hospitalization
He stays together with his wife and his family.

9. Sexually Reproductive Pattern

Prior to Admission During Hospitalization
The client is sexually active. He had one
sexual partner.

10. Coping/Stress Tolerance

Prior to Admission During Hospitalization
Client talked to his wife whenever he felt
anxious.

11. Value / Belief Pattern

Prior to Admission During Hospitalization
Client is a Roman Catholic but his family
rarely goes to church every Sunday.
 TASKS: Complete the following activities to provide high quality, individualized care
for the patient following proper and correct protocol / guidelines in the care of clients
with peritoneal dialysis.
1. Comprehensive Assessment (15 mins) – Collect, organize and document
information about the patient. Data will be used to:
a. Complete the client’s health record.
b. Perform a quick and comprehensive assessment of the client’s hospital admission.
c. Implement the relevant and appropriate assessment methods.
2. Implementing Care (20 minutes)
a. Perform the necessary nursing procedures (not limited to): placing client on
NGT feeding, client oxygenation, GCS
b. Prepare, administer, and document the ordered medications. (Recall correct
procedure in medication administration.)
3. Ongoing Care (15 minutes) - document the care that has been provided as
follows:
a. Using the FDAR format – so that this is communicated with the healthcare team.
b. Discharge instructions (METHODS)

WORKSHEET

Patient Records
Name:
Gender:
Age:
Birth date:
Birth place:
Civil Status:
Address:
Nationality:
Religion:
Occupation :
Date of Admission:
Time of Admission:
Admitting Diagnosis:
Chief Complaint:
Compute for MAP
History of Present Illness

Family History:

Past Medical History:

Allergies:

Social History:

MEDICATION SHEET
MEDICATION: dose, route, frequency TIME DATE DATE
 Nurse’s Notes
F: D:
A;

R:
Discharge Goal:
Return to Home (self-care)
Return to Home but needs Assistance
Transfer to other Level of Institutional Care
Referral to Support Community Services’
Home against medical advice

Discharge Plan
Date M

Patient’s Signature over Printed Name Nurse’s Signature over Printed Name

Hinkle, J., Cheever, K. (2017) Brunner & Suddarth’s Textbook of Medical-Surgical

Nursing 14th Edition. Philadelphia: Wolters Kluwer Health/ Lippincott Williams &
Wilkins.
Links: Can access to YouTube, Google and other electronic medical surgical nursing books
available