Submitted By :
Smita Rai
ACKNOWLEDGEMENT
The case study report on “Multiple Isehemic stroke is prepared on the basis of the study performed on this problem during 8 month duty at home care. This case study report is prepared for the fulfillment of requirements of Home care to assist the acknowledgment gained by the staff regarding their allocated Patient.
First of all, I would like to extend my thanks to Home come, Baluwatar for providing me an opportunity to fulfill the requirement.
It is a great pleasure for us to express and grants my special thanks to Home care team and Mrs. Yamuna. Our supervision for the continuous supervision, guidance, encouragement and help. It is indeed a great honor to express our heartfelt gratitude to my co-worker (Nursing staff) and Paradhananga family members for their kind support, help and valuable information.
BACKGROUND
Home care requires a case study on the disease condition of the patient allocated to each staff during 6 month of their regular service so I have done case study on Multiple Isehemic Stroke.
It aims to enable us as home care to get knowledge about Multiple Isehemic Stroke.
With the help of this case study we will be able to identify the conditions that are responsible to physiological and psychological problems and means by which these problems can be minimize and give holistic nursing care applying nursing process.
OBJECTIVES
General objectives
At the end of six month of home nursing care practices at Kamaladi at Bharat Bdr. Paradhananga home I will be able to observe and provide holistic care to the clients with problems of Multiple Isehemic Stroke.
By applying nursing process and theory within home itself.
Specific objectives
- To provide holistic nursing care to patient
- To apply the knowledge of nursing process.
- To communicate effectively with client and family members.
- To gain and upgrade advance knowledge about these disease.
- To provide health education and preventive measure.
- To client’s family member.
- To minimize the stress of patient and his family.
Chief Complain Multiple Isehemic Stroke
- unilateral body
- weakness | hemi paresis
- altered | decreased
- consciousness
- slurred | loss of speech
- headaches
- convulsions
- unilateral parenthesis
- orbital muscle palsy
- double | loss of vision
- vomiting | nausea | dizziness
- facial droop
HISTORY TAKING
Past History
There is the history of heart surgery before 7 yrs ago.
Present History
According to informant patient started showing the sign and symptoms sudden numbness or weakness of the face. Arm or leg, especially on side of the body sudden confusion, sudden trouble speaking, sudden trouble walking, unconsciousness.
Recently patient has half body paralysis.
Personal History
- Habits –patients had no history of smoking and drinking alcohol
- Rest and sleep pattern sleep 7 hours at night 11pm to 6 am hare day time nap for 2 hours.
- Exercise pattern – per day 2 times exercise and 2 times walk.
- Nutritional pattern – he is non vegetarian. Have a glass of milk at breakfast, rice, dal and vegetable as lunch and dinner.
PHYSICAL EXAMINATION
-
Systemic Examination
Blood Pressure – 150/100 mm of Hg
Pulse – 82 beats /min
Respiration – 22 breaths /min
Temperature – 98.5 F
Height – 165 cm
Weight – 69 kg
-
General appearance
Weight – unbalance
Posture – Curved
Body build – healthy and wet Nourished
Activity – Passive
Orientation – disorientated
Cleanliness – Maintained
-
Mental Status
Consciousness – Conscious
Orientation – Well oriented
-
Skin condition
Color – White in Color
Texture – wrinkle Present
Temperature – warm.
Scar – No Scar
Edema – lower extremity edema
-
Head and face
Head – Round in shape, presence of sea
Hair – Black and white evenly distributed in head
Face – Is one side of their face drooping and hard to move
-
Eyes
Eyelids – No swelling and edema
Eye brows – Evenly distributed and symmetrical
Saliva – white in color
Cornea – Clear
Conjunctiva – Pallor
-
Ears
- Size and position – symmetrical
- No any discharge
- Hearing capacity intact.
-
Nose
- Symmetrical
- Nasal discharge present.
-
Mouth – No swelling and bleeding.
Teeth – No artificial teeth
Tongue – Pink and uncoated
Tonsils – Not enlarged.
-
Neck
- Symmetrical
- Thyroid gland not palpable
- No Lymph Node enlargement.
-
Chest
Inspection
- Symmetrical absence of scar.
Palpation
- No Lymph node enlargement
- Bilateral symmetrical factice fermatas.
Percussion
- Resonant sound over scapula
- dull sound over heart, liver and stomach
- Flat sound over bone.
-
Abdomen
Inspection
- Flat in shape
- No scar and lesion.
- Normal skin elasticity
Auscultation
Percussion
- Dull sound over 3 plane and liver
- Tympany over stomach.
Palpation
- Liver and spleen wasn’t palpable.
-
Upper limbs and lower limbs.
- Symmetrical
- No extra finger
- Muscle rigidity with stiffness.
- Reflex was Present
- Lower extremity edema.
-
Genitalia and Anus
- No swelling, Redness
- Irritation during urination.
- No genital deformity.
MENTAL STATUS EXAMINATION
-
General Appearance and Behavior
Physical appearance – Well Nourished
Height – 165cm
Weight – 69 kg
Level of consciousness – Semi conscious
Eye to Eye contact – Not Maintained
Motor and speech activity – Passive
Gait – Uncoordinated
-
Speed
Reaction time – delay
Productivity – Monosyllable
Volume – Self muttering
Relevant – Mostly of target
-
Mood – Normal
-
Thought
Stream – thought Normal
Form – self mottering
Delusion – absent
Idea – Present
Phobia – absent
-
Perception.
Illusion & hallucination – absent
-
Cognition
Orientation – Yes oriented to time, place, Person.
|
· Difficulty in learning.
· General deterioration in personal hygiene.
· Inability to concentrate.
|
· Numbness or weakness in your face, arm, or leg especially on one side.
· Confusion of trouble understanding other people.
· Difficulty speaking.
· Problems walking of staying balanced of coordinated. |
Complications
- Blood clots (deep vein thrombosis of Pulmonary Embolism
- Urinary tract infections of UTF.
- Bowel and bladder problems.
- Risk of Pneumonia
- Muscle Weakness.
- Bed Sores
- Mobility Problems and falls
Diagnostic Investigation
- CT Scan
- Carotid Ultra-Sonography
- Blood test
- Angiography
- Electrocardiography
- Cerebral angiography
- Tran cranial Doppler
- Magnetic resonance angiography
Treatment
Emergency IV medication.
Emergency endovascular procedures.
- Medications delivered directly to the brain
- Removing the clot with a stent retriever
Other procedures
- Carotid Endraterectomy
- Angioplasty and stents
DISEASE CONDITION
Multiple Isehemic Stroke
Definition
The blockage reduces the blood flow and oxygen to the brain leading to damage of death of brain cells.
Incidence
About 8.12 / 1000 person Years, 74 years affected.
Etiology
- Genetic factors
- Lifestyle
- Environment factors.
Clinical manifestations
- Right-sided weakness or Paralysis and sensory impairment.
- Problems with Speech and under understanding language (aphasia).
- Visual Problems, including the inability to see the right visual field of each eye.
- Impaired ability to do math of to organize reason, and analyze items.
Complications
- Blood Clots (deep Vein thrombosis or pulmonary embolism)
- Urinary tract infections or OTI Bowel and bladder Problems
- Risk of Pneumonia
- Muscle weakness.
- Bed Sores.
- Mobility problems and falls.
Diagnostic Investigations
- Physical exam
- Blood sugar test
- Cranial CT Scan
- MIR
- Electrocardiogram (ECG or EKG) to test for abnormal heart rhythms.
- angiography
- Cholesterol
Treatment
- An IV injection of recombinant Tissue plasminogen activator (TPA) – also called alleplase (Activase) or tenecteplase (TNK case)
DRUG PROFILE
| S.N |
Name |
Dose |
Route |
Indication |
Contra Indication |
Nursing responsibility |
| 1 |
Pantop |
40 mg |
oral |
Gastrities
(GERD) |
Headache
Dizziness
Joint pain |
Follow the 6 night of drugs |
| 2 |
Ecosprin |
75 mg |
oral |
Heart attack stroke and chest pain. Heart related
|
Blood clotting
Disorder bleeding asthma
Liver/kidney problem |
Assess pain and pyrexia or hour before or after meditation |
| 3 |
Clopid |
75 mg |
oral |
Chest discomfort /pain
Insufficient oxygen supply to heart muscle, heart attack |
Active pathological
Bleeding such as peptic ulcer or intracranial hemorrhage |
Monitor patient for signs of thrombotic thrombocytopenic purpura |
| 4 |
Urader |
4 mg |
oral |
Lower urinary track symptoms (LUTS)and prostatic hyperplasia |
Hypersen Sensitivity |
Monitor the side effect of drug |
| 5 |
Mylodl |
5 mg |
oral |
Hypertension |
Nausea , Headache |
Monitor vital signs |
| 6 |
Rozovel |
20mg |
oral |
High cholesterol |
Kidney Problems Thyroid Gland Problems |
Provide medication on time. |
| 7 |
Mirtaz |
7.5mg |
oral |
Depression |
Epilepsy
Lower blood pressure |
Monitor vital signs |
| 8 |
Seloken XL |
50 mg |
oral |
High blood pressure
Heart related
Chest pain |
Diabetes
Thyroid disease
Asthma |
Provide medication on time . |
INVESTIGATIONS
Hematology Investigation
| SN |
Examination
|
Result
|
unit
|
Reference
|
| 1 |
Total Count |
8230 |
Cells / cumm |
4000 – 11000 |
| 2 |
Differential count |
|
|
|
| 3 |
Polymorphs |
70 |
% |
20 – 70 |
| 4 |
Lymphocytes |
25 |
% |
20 – 45 |
| 5 |
Eosinophis |
1 |
% |
1 – 6 |
| 6 |
Monocyte |
4 |
% |
2 – 15 |
| 7 |
Basophis |
0 |
% |
0 – 1 |
| 8 |
PACKED CELL VOLUME (HCT) |
35.5 |
% |
L 42 – 52 |
| 9 |
Electrical Impedance RBC COUNT |
3.98 |
Minions / cumm |
L 4.7-6.0 |
| 10 |
MCV |
89.2 |
FL |
78 – 100 |
| 11 |
MCH |
27.6 |
PG |
27.31 |
| 12 |
MCHC (Electrical Impedance ) |
31.0 |
G/dl |
L32 – 36 |
| 13 |
PLATELET COUNT electrical impendence |
372 |
103/HL |
150 – 400 |
OTHER INVESTIGATION
| SN |
Test |
Result |
Reference |
| 1 |
Urea |
16.2 |
15 – 45 |
| 2 |
Creatinine |
1.2 |
0.7 – 1.2 |
| 3 |
Sodium |
137.4 |
135 – 150 |
| 4 |
Potassium |
3.99 |
3.5 – 5.1 |
| 5 |
Chloride |
101.3 |
96 – 108 |
URINE ANALYSIS
| Physical Examination |
| Color |
Light Yellow |
| Appearance |
Slightly Turbid |
CHEMICAL EXAMINATION
| Reaction |
Alkaline |
| Albumin |
Present (+) |
| Sugar |
Nil |
MICROSCOPIC EXAMINATION
| Pub cells |
3.29 |
| RBC |
1-2 |
| Epithelial cells |
Nil |
| Ca-oxalates |
Plenty |
DAILY ACTIVITIES REPORT
2078-01-03
Today Patient general condition is weak and seems to be sleepy. Patient is disoriented to Place and person and time patient is in normal diet patient frequent urination. Patient Sleep well at night.
Temp – 98.5 F
Pulse – 82 b/m
Respiration – 20 breaths / min.
Blood Pressure -160/90mm of HG
Urine output -10 times decrease urine output
2078-01-04
Today Patient Condition is seems to be sleepy. Patient is an aggressive. Patient is in normal diet.
Temp – 978F
Pulse – 80 b/m
Respiration – 22 breaths /min
Blood Pressure – 155/90 mm of HG
Urine output -15 times decrease urine output
2078-01-05
Today Patient looks lethargic and sleepy. Patient Sleep well at night High fever though out the night.
Temp -102 F
Pulse – 98 b/m
Respiration – 24 b/m
Blood Pressure – 160/100 mm of Hg
Urine output – 10 times decrease urine output.
2078-01-06
Today Patient looks weak but seems to be sleepy. Patient is in normal diet sleep well at night. Patient is bed ridden.
Temp – 98.5 F
Pulse – 82 b/m
Respiration – 22 b/m
Blood pressure – 170/90 mm of Hg.
Urine output – 10 times decrease urine output
Nursing Care Plan
| SN |
Assessment
|
Nursing
Diagnosis |
Goal
|
planning
|
Implementation
|
Rational
|
Evaluation
|
| 1
|
Subjective Data
Client family verbalize
He gets anger and attack to anybody.
|
Altered thought Processes related to irreversible degeneration.
|
To improve thought Process.
|
Assess the condition of Patient.
|
Assessed the neurological
Status.
|
To enhance neurological status.
|
The Goal met as patient is aware of social values. |
|
2 |
Objective Data
Patient is unable to think what is right and wrong and lacks social values. |
|
|
Provided safety measure.
|
Provided side rails to prevent fall.
|
To provide Safety.
|
|
| 3 |
|
|
|
Provide cognitive therapy.
|
Provided Music therapy.
|
To improve thought process and entertainment |
|
| 4 |
|
|
|
Aware Patient about social norms.
|
Award patient What is right and wrong. |
To enhance though process. |
|
| SN |
Assessment
|
Nursing
Diagnosis |
Goal
|
planning
|
Implementation
|
Rational
|
Evaluation
|
| 1
|
Subjective Data
Patient family Complain he wasn’t able to perform daily activities.
|
Activity intolerance
related to
Muscle stiffness.
|
To increase
Daily activities performance.
|
Assess patient in daily activities.
|
Assessed the neurological
Status.
|
To enhance performance.
|
The goal was met as client increase desire to engage in activities. |
|
2 |
Objective Data
Tiredness and unable to perform daily activities.
|
|
|
Providing oil massage to extremities twice a day.
|
Provided side rails to prevent fall.
|
To reduce Muscle
Stiffness. |
|
| 3 |
|
|
|
Assist in performing daily exercise. |
Assisted in doing exercise of leg and hands.
|
To improve activity Performance.
|
|
| 4 |
|
|
|
Reasons the condition.
|
Client condition was reassessed. |
To evaluate outcome.
|
|
| SN |
Assessment
|
Nursing
Diagnosis |
Goal
|
planning
|
Implementation
|
Rational
|
Evaluation
|
| 1
|
Subjective Data
Client family verbalize
is having Painful urination and bed wet.
|
Risk of infection related to compromised personal hygiene and genital care due to urinary incontinence. |
To reduce risk of infection.
|
Assess the condition of Patient.
|
Assessed the urinary incontinence pattern.
|
To know the pattern of incontinence.
|
Goal was met as Patient Feels. |
|
2 |
Objective Data
Patient is having urinary incontinence
|
|
|
Perform regularly genital hygiene.
|
Performed genital care using dettol and warm water.
|
To reduce risk of infection.
|
|
| 3 |
|
|
|
Change the bed sheet and cloth regularly.
|
Changed the bed Sheet and cloth after each
bed wet.
|
To enhance Personal hygiene.
|
|
HEALTH EDUCATION
Health education is a social science that draws from biological, environmental, Psychological, physical and Medical science to promote hearth and prevent disease, disability and premature death through education.
In order to promote health, I provided health education on.
Diet and hydration
- Provide easily digestible and label food.
- Provide small amount of food but frequently.
- Provide vitamin rich food.
Rest and sleep and Exercise
- Encourage patient to perform passive range of motion.
- Provide help to perform activities as the ability of patient.
Personal Hygiene
- Change the cloth and bed sheet regularly.
- Provide bed bath.
- provide Nail care and genital hygiene
Medication
- Provide medication on time.
SERVICE IMPACT ON PATIENT AND FAMILY MEMBERS
I started working as a home care nurse since 2073/11/01 till the date from the day of beginning today. I have observed a vast improvement in patient health. Initially the sleeping pattern of patient was altered and Nutritional status was compromised. Further personal hygiene was very poor. But at instant the Nutritional status and personal hygiene of patient highly improved. Patient looks activate and well nourished. We are providing genital care, Nail Care and other Morning care every day that has enhanced the personal hygiene of patient. Moreover patient has improved his physical activities as we are continuously assing patient in Ambulation and defecation.
In addition the family members of patient have got great relief from their responsibilities towards patient. Family members can go to office and outside for their personal work. Patient family members are totally satisfied with Home Care and management team and we nurses.
LEARNING IN PERSONAL AND PROFESSIONAL LIFE
Nursing a practical based professional profession. How more engaged on nursing care the move we will learn and improve our knowledge and efficiency. Hence I have to say that this home care experience has totally altered my skill and concepts regarding the care of elderly people.
Following are the aspect of improvement in my professional life.
- Improved my practical knowledge in Geriatric Nursing
- Develop myself confidence and ability to handle the geriatric cases.
- Improved My IPR (Inter personal relationship) as I have to directly deal with family members.
- I got chance to know about the norms and values of different ethnic groups.
CHALLENGES AND OPPORTUNITIES IN HOME HEALTH CARE DELIVERING SERVICE
Challenges
- Limited Medical resources
- Dealing with family members
- Managing Manpower
Opportunities
- Learning about Geriatric case.
- Improving communication skill.
- Improve IPR.
- Enhance practical knowledge.
