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ER & OPD

ISCHEMIC STROKE

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INTRODUCTION Stroke is the third most common cause of disability and second most common cause of death worldwide .

• An ischemic stroke result from inadequate

blood flow to the brain from partial or complete occlusion of an artery.

• Acute ischemic stroke is caused by thrombotic or embolic occlusion of a cerebral artery and is more common than hemorrhagic stroke.

Epidemiology • Strokes are a major cause of death and disability. • About 80% of strokes are ischemic/ thrombotic

and 20% are hemorrhagic. • A significant proportion of patients with a stroke

survive; rapid assessment and treatment are considered critical to reducing disability and mortality related to stroke.

• Men are at higher risk for stroke than women;

men have a stroke incidence of 62.8 per 100,000, with death being the final outcome in 26.3% of cases, while women have a stroke incidence of 59 per 100,000 and a death rate of 39.2%.

• Although stroke often is considered a disease of elderly persons, one third of strokes occur in persons younger than 65 years. Risk of stroke increases with age, especially in patients older than 64 years, in whom 75% of all strokes occur.

I - HEALTH ASSESSMENT

1.HEALTH HISTORY 1.I FILE NO : DEPARTMENT : DATES : 1.2 ADMISSION DATA :

00578953 ER 16.05.2019 TO 21/05/19 (5 days) ON 17.05.19 AT 0018 H Patient was admitted to female surgical ward with the diagnosis of Ischemic CVA

HEALTH HISTORY…. 1.3 COMPLAINT DATA :

On 16.05.19 at 2140H the patient was brought to the hospital by her relatives through ambulance with the complaints of left side weakness associated with dysarthria for 16H. She took treatment in private clinic before coming to KKH but no improvement.

HEALTH HISTORY…. 1.4 PERSONAL DATA - • AGE /GENDER : • MARITAL STATUS : • NO. OF CHILDREN : • & GENDER : • NATIONALITY : • LANGUAGE : • RELIGION : • EDUCATION LEVEL: • OCCUPATION : • RESIDENCE :

69 Years / female Married 4 children 2 female & 2 male Saudi Arabic Muslim Uneducated House wife Kamaza, Hail

HEALTH HISTORY…. 1.5 FAMILY HISTORY- • ILLNESS : • CAUSE OF DEATH :

– NO. – GENDER

• INTER/INTRA RELATIONSHIP :

No known family history Sudden infant death syndrome Male Good

HEALTH HISTORY…. 1.6 FIVE DAILY LIVING ACTIVITIES: She independently take bath and brushes her teeth every day, able to eat by her self, has good bowel and bladder habit before 16H, but now she was not able to perform the above activities by her self. She looks neat and tidy.

HEALTH HISTORY…. 1.7 PREVIOUS HISTORY- • MEDICAL : • SURGICAL : • PHYSICAL ILLNESS : • MENSTRUAL HISTORY:

• OBSTETRIC : • ALLERGY :

Known case of DM , on treatment tab. Metformin 500mg Po OD Gliclazide 60mg Po OD No surgical history Nil Menopausal stage NVD – 4 No known allergy

HEALTH HISTORY…. 1.8 HABITS : 1.9 CRIMINAL & ACCIDENT EVENTS : 1.10 SOURCE OF INFORMATION :

she use to drink coffee or tea frequently. No Patient & Family members

2. PHYSICAL EXAMINATION

PHYSICAL EXAMINATION 2.1 GENERAL SURVEY & BEHAVIOR - 2.2.1 Apparent Health State - 2.1.2 LOC - 2.1.3 Signs of Distress - 2.1.4 Built & height - 2.1.5 Nutritional status & - weight 2.1.6 Skin - 2.1.7 Dressing, Grooming & - personal Hygiene 2.1.8 Odor of body & breath -

Fair Fully conscious No Normal Normal 75 kg Normal Normal No

2.1 GENERAL SURVEY & BEHAVIOR - 2.1.9 Facial expression : Posture : Gait : Motor Activity : 2.1.10 BP : Pulse : Respiratory rate : Temperature :

Left side weakness (mild face droop) Decerebrate posture Abnormal - Unsteady gait Abnormal 170/90 mmHg 90 b/min 18 breath/min 36.9 c

PHYSICAL EXAMINATION 2.3 ABNORMAL FINDINGS FROM HEAD TO FOOT Motor Function

Gait Fine motor test for Upper Extremities

Finger to nose test Fine motor test for the Lower Extremities

Pain sensation

⁃ Unsteady gait ⁃ No co-ordination in left

side ⁃ Decreased sensation in

left side of the body.

2.3 ABNORMAL FINDINGS FROM HEAD TO FOOT

• Spinal accessory (Motor) -

• Hypoglossal

Motor - • ROM

– Upper left limb - – Lower left limb -

• STRENGTH – Upper left limb -

– Lower left limb -

Left restricted shoulder movement and limited head rotation Dysarthria 2/5 1/5 2/5 1/5

2.3 ABNORMAL FINDINGS FROM HEAD TO FOOT • Glasgow coma scale • NIH stroke scale

• 14/15 • Score 6 • Moderate stroke

Provisional Diagnosis• To R/o CVA

II – DIAGNOSTIC PROCEDURE

II – DIAGNOSTIC PROCEDURE • Physical Examination • Blood test • ECG • Computer tomography

(CT) scan • X- ray chest • Echocardiogram • Carotid Ultrasound • Magnetic Resonance

Imaging ( MRI)

DIAGNOSTIC PROCEDURE

Laboratory studies Laboratory tests performed in the diagnosis and evaluation of ischemic stroke include the following

ABNORMAL LAB RESULTS Complete blood count (CBC): • A baseline study that may reveal a cause for the

stroke (eg, polycythemia, thrombocytosis, leukemia), provide evidence of concurrent illness, and ensure absence of thrombocytopenia when considering fibrinolytic therapy.

Investigation

CBC

Normal values

Patient Value

16/5/19 17/5/19

WBC 10.03↑

8.62

CHEMISTRY

• Basic chemistry panel: A baseline study that may reveal a stroke mimic (eg, hypoglycemia, hyponatremia) or provide evidence of concurrent illness (eg, diabetes, renal insufficiency)

PTT PROFILE

• Coagulation studies: May reveal a coagulopathy and are useful when fibrinolytic or anticoagulants are to be used

PTT 16.05.19

NORMAL RANGE

RESULT REMARKS

PTT TEST 30.6-38.2 SEC 26.90 LOW PT- Prothrombin

Time 11.6- 12.2 SEC 11.40 LOW

INR 0.8-1.2 1 NORMAL

CARDIAC ENZYMES on 16.5.19 • Cardiac biomarkers: Important because

of the association of cerebral vascular disease and coronary artery disease.

• WITH IN NORMAL RANGE

DIAGNOSTIC PROCEDURE Blood test- Abnormal Result

Investigation Normal values Patient Value 19/5/19 21/5/19 HBA1C 4.8 – 6 % 11 � 10.60 � Lipid profile Sr. Cholesterol

0 – 5.2 mmol/L 7.20 � 6.09 �

Sr. Triglycerides

0.34 – 2.2 mmol/L 2.24 � 1.92

HDL 0.9 – 1.55 mmol/L 0.75 � 0.77 � LDL 0 – 3.88 mmol/L 5.66 � 4.95 � TFT

Free Thyroxine (FT4)

12 – 22 pmol/L 11.33 �

DIAGNOSTIC PROCEDURE

Which seeks the heart’s electrical activity, can help to determine whether heart problem cause stroke. An ECG is a quick, safe and painless test. No electricity is put into your body while it's carried out.

Electrocardiogram on 16.05.19

Electrocardiogram on 16.05.19 REPORT: • Sinus rhythm,

Normal axis • Right bundle branch

block

Computerized tomography (CT) scan. On 16.5.19 at 2201H

• A CT scan uses a series of X-rays to create a detailed image of the brain. A CT scan can show a hemorrhage, tumor, stroke and other conditions. Doctors may inject a dye into your bloodstream to view your blood vessels in your neck and brain in greater detail (computerized tomography angiography). There are different types of CT scans that your doctor may use depending on your situation.

DIAGNOSTIC PROCEDURE… RADIOLOGICAL – CT BRAIN

REPORT: • Bilateral

periventricular few faint hypodense foci keeping with small vessels disease.

• Right posterior ethmoid sinusitis changes

X- Ray chest done on 16.05.19 • Chest x-ray uses a very small dose of ionizing

radiation to produce pictures of the inside of the chest.

• Chest x-ray is fast and easy, it is particularly useful in emergency diagnosis and treatment.

• This exam requires little to no special preparation

X-RAY CHEST Report : No cardiomegaly Increased broncho-vascular marking

Carotid ultrasound Done on19.05.19 AT 0936H • In this test, sound waves create detailed images of

the inside of the carotid arteries in your neck. This test shows buildup of fatty deposits (plaques) and blood flow in your carotid arteries

DIAGNOSTIC PROCEDURE… US Carotid Doppler Bilateral:

REPORT • Mild thickened of

intima-media complex in examined arteries both (CCA & proximal ICA)

• Atheromatous plaque is seen in the right proximal ICA measuring about 7�2 mm with no significant luminal stenosis

Magnetic resonance imaging (MRI) Done on 19.05.19 at 1511H • An MRI uses powerful radio waves and magnets

to create a detailed view of your brain. An MRI can detect brain tissue damaged by an ischemic stroke and brain hemorrhages. Your doctor may inject a dye into a blood vessel to view the arteries and veins and highlight blood flow (magnetic resonance angiography, or magnetic resonance venography).

DIAGNOSTIC PROCEDURE… MRI BRAIN W/O CONTRAST:

REPORT • Right pontine low T1 & high

T2/T/ Flair signal are seen with the evidence of diffusion restriction denoting recent infraction.

• Bilateral basal ganglia dark signal on GRE images likely calcification.

• Obliterated right posterior ethmoid cells with T2 hypointense signal likely fungal infection

Echocardiogram. Done on 19.05.19

• An echocardiogram uses sound waves to create detailed images of your heart. An echocardiogram can find a source of clots in your heart that may have traveled from your heart to your brain and caused your stroke.

REPORT

Normal LV dysfunction EF: 65% Mild Mitral valve regurgitation Diastolic dysfunction grade – 1 Normal right ventricle Normal pericardium Pulmonary artery pressure 35mmHg.

III MEDICAL DIAGNOSIS

DEFINITION: A cerebrovascular accident (CVA), an ischemic stroke or “brain attack,” is a sudden loss of brain function resulting from Cerebral Vascular Accident (Ischemic Stroke) a disruption of the blood supply to a part of the brain.

PATHOPHYSIOLOGY Due to thrombosis or embolism, some neurons die

because of lack of oxygen and nutrients

Infraction of the cerebral vessels known as stroke

Tissue injury triggers an inflammatory response which increases intracranial pressure

The injury disrupts metabolism leading to changes in ionic transport, localized acidosis, & free radical

formation

Calcium, Sodium & water accumulate in the injured cells and excitatory neurotransmitters are released

Continued cell cellular injury & swelling both occurs resulting to further cell damage

Brain damage

CLINICAL MANIFESTATION

• General signs and symptoms include: • Numbness or weakness of face, arm, or leg

(especially on one side of body) • Confusion or change in mental status • Trouble speaking or understanding speech • Visual disturbances • Loss of balance • Dizziness • Difficulty walking • Sudden severe headache.

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• Motor Loss ➢Hemiplegia, hemiparesis ➢Flaccid paralysis and loss of or decrease in the

deep tendon reflexes (initial clinical feature) followed by (after 48 hours) reappearance of deep reflexes and abnormally increased muscle tone (spasticity)

• Communication Loss ➢Dysarthria (difficulty speaking) ➢Dysphasia (impaired speech) or aphasia (loss

of speech) ➢Apraxia (inability to perform a previously

learned action)

Perceptual Disturbances and Sensory Loss ➢Visual perceptual dysfunctions (homonymous

hemianopia [loss of half of the visual field]) ➢Disturbances in visual spatial relations

(perceiving the relation of two or more objects in spatial areas), frequently seen in patients with right hemispheric damage ➢Sensory losses: slight impairment of touch or

more severe with loss of proprioception; difficulty in interrupting visual, tactile, and auditory stimuli

• Impaired Cognitive and Psychological Effects ➢Frontal lobe damage: Learning capacity,

memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation. ➢Depression, other psychological problems:

emotional lability, hostility, frustration, resentment, and lack of cooperation.

PROGNOSIS • The prognosis after acute ischemic stroke varies

greatly in individual patients, depending on the stroke severity and on the patient’s premorbid condition, age, and post stroke complications

• The prognosis of our patient was good. For better improvement she is advised to do mild exercise and physiotherapy.

IV ) TREATMENT

(IV) TREATMENT • Generic Name : Aspirin/ Acetylsalicylic acid • Brand Name : Aspro Clear®, Disprin® • Dose : 81 mg • Route : oral • Ferquency : OD ● Classification : Analgesics, antipyretics,

Non steroidal, anti- inflammatory drug, also known as NSAID,

INDICATION CONTRAINDICATION SIDE EFFECTS

Mild to moderate pain Fever Swollen, red and tender body tissues Rheumatoid arthritis Rheumatic fever

It is also used in the prevention of blood clots, heart attacks, strokes and bowel cancer.

Inadequate vit K anemia Hemophilia �prothrombin �blood platelets Alcoholism liver problems bleeding of the stomach or intestines kidney disease with reduction in kidney function Allergies: Salicylates NSAIDS -Aspirin (Tartrazine Only)

Dizziness, ringing in the ears, blurred vision Drowsiness, fatigue, depression Thirst, sweating, fluid retention, swollen ankles Abdominal discomfort or bloating Nausea, heartburn, Diarrhoea, constipation

PHARMACODYNAMICS Mechanism of action:

• Action Reduces pain and inflammation by inhibiting prostaglandin production, acts on the hypothalamus heat – regulating center, and interferes with the production of thromboxane A, a substance that stimulates platelet aggregation.

PHARMACOTHERAPEUTIC Therapeutic effect:

• Reduces inflammatory response and intensity of pain; decreases fever; inhibit platelet aggregation.

PHARMACOKINETIC • Rapidly and completely absorbed from GI tract; enteric-

coated absorption delayed; rectal absorption delayed and incomplete.

• C Protein binding: High. Widely distributed. Rapidly hydrolyzed to salicylate. Half-life: 15-20 min (aspirin); 2- 3 h (salicylate at low dose); more than 20 h (salicylate at high dose)

• GENERIC NAME :ATORVASTATIN • BRAND NAME :LIPITOR • CHEMICAL NAME :Statins / HMG-CoA

reductase inhibitors • DOSE : 20 mg • ROUTE : Oral • FREQUENCY : OD • CLASSIFICATION :Antihyperlipidemics,

HMG CoAreductase inhibitors

Indication Contraindication Side effect Hyperlipidima Hypercholesterola emia Prevention of cardiovascular disease

Active hepatic disease, lactation, pregnancy, unexplained elevated liver function test results, rhabdomyolysis, hypersensitivity.

cold symptoms diarrhea Heartburn joint pain forgetfulness confusion unexplained muscle weakness, tenderness, or pain tiredness loss of appetite upper stomach pain dark-colored urine Jaundice, also known as icterus yellowing of your skin or the

PHARMACODYNAMICS MECHANISM OF ACTION An anti-hyperlipidemic that inhibitsHMG-CoA reductase, the enzyme that catalyzes the early step in cholesterol synthesis.

PHARMACOTHERAPEUTIC THERAPEUTIC EFFECT:

Decreases LDL and VLDL cholesterol and plasma triglyceride levels; increases HDL cholesterol concentration

PHARMACOKINETICS • Poorly absorbed from the GI tract. Protein

binding is > 98%. Metabolizedin the liver. Minimally eliminated inurine. Plasma levels are markedly increased in chronic alcoholic hepaticdisease but are unaffected by renaldisease.

• Half-life: 14 h

• GENERIC NAME : • BRAND NAME :

Dose : • Route : • Frequency : • CLASSIFICATION :

Omeprazole Nexium, Prilosec OTC 20mg IV OD Gastrointestinal agents, antiucler agents, protonpump inhibitors (PPIs).

INDICATIO N

CONTRAINDICATION SIDE EFFECT

Peptic ulcer perforation

– Avoid combination with itraconazole and ketoconazole (decreases efficacy of these drugs). – Monitor combination with warfarin, digoxin, phenytoin. – Do not exceed 20 mg daily in patients with severe hepatic impairment. – Pregnancy: no contra- indication – Breast-feeding: avoid, administer only if clearly need

constipation diarrhoea nausea (feeling sick) vomiting Headache dizziness abdominal pain excessive gas in stomach or bowel dry or sore mouth skin rash, itchy skin.

PHARMACODYNAMICS • MECHANISM OF ACTION

A proton-pump inhibitor that is converted to active metabolites that irreversibly bind to and inhibit hydrogen-potassium adenosine triphosphates, an enzyme on the surface of gastric parietal cells. Inhibits hydrogen ion transport into gastric lumen.

PHARMACOTHERAPEUTIC

• .

Therapeutic action – Antiulcer drug (proton pump inhibitor)

Therapeutic Effect: Increases gastric pH, reducing gastric acid production

PHARMACOKINETICS Well absorbed after oral administration. Protein binding: 97%. Extensively metabolized by the liver by CYP219 and CYP3A4. Primarily excreted in urine. Half-life: 1-1.5 h.

• GENERIC NAME : • BRAND NAME : • Dose : • Route : • Frequency • CLASSIFICATION :

insulin glargine (IN su lin GLAR gine) Lantus, Lantus Solostar Pen 8 U Subcutaneous HS Long Acting Human Insulin and Analogs

INDICATIO N

CONTRAINDICAT ION

SIDE EFFECT NURSES RESPONSIBILITY

Type 1 diabetes mellitus and type 2 diabetes mellitus.

• Diarrhea, • fever, • infection, • thyroid disease, • Vomiting • Hepatic disease, • renal failure, • renal

impairment • Coma, • Hypoglycemia • Hypokalemia • Geriatric, visual

impairment

• Low blood sugar; itching, mild skin rash; or thickening or hollowing of the skin where you injected the medicine.

• weight gain • feeling short of breath • signs of low potassium-

leg cramps, constipation, irregular heartbeats, fluttering in your chest, increased thirst or urination, numbness or tingling, muscle weakness or limp feeling.

• describe the effect of insulin on blood glucose levels

• describe the mild and severe signs and symptoms of hypoglycaemia

• demonstrate competent use of blood glucose monitoring equipment to confirm hypoglycaemia

• if the person with diabetes is unresponsive, ensure their airway is clear and call emergency services.

Pharmacokinetics • Lantus (insulin glargine) is a man-made

form of a hormone (insulin) that is produced in the body. Insulin is a hormone that works by lowering levels of glucose (sugar) in the blood. Insulin glargine is a long-acting insulin that starts to work several hours after injection and keeps working evenly for 24 hours.

• Lantus is used to improve blood sugar control in adults and children with diabetes mellitus.

Pharmacokinetics • Absorption :Insulin glargine is administered via the

subcutaneous route only • Distribution :Endogenous insulin distributes

widely throughout the body • Metabolism :A small portion is inactivated by

peripheral tissues, but the majority is metabolized by the liver and kidneys

• Elimination :Insulin is filtered and reabsorbed by the kidneys; the plasma half-life of human endogenous insulin is approximately 5 to 6 minutes.

• GENERIC NAME : • BRAND NAME : • Dose : • Route : • Frequency : • CLASSIFICATION :

Insulin regular HumuLIN R, NovoLIN R, HumuLIN R According to sliding scale Subcutaneous 6th hourly Anti diabetic

INDICATION CONTRAINDICATIO N

SIDE EFFECT

Type 1 Or Type 2 Diabetes.

• low blood sugar • low amount of

potassium in the blood

• liver problems • kidney disease with

reduction in kidney function

• Allergies: • Insulins • Insulins - Human

• low blood sugar; • swelling in your

hands or feet; • weight gain; or • thickening or

hollowing of the skin where you injected the medicine.

• GENERIC NAME :

• BRAND NAME :

• Dose : • Route : • Frequency : • CLASSIFICATION

Enoxaparin Clexane, Lovenox 0.4U Subcutaneous OD • Anticoagulants, cardiovascular, • Anticoagulants, Hematologic

Indication Contraindication Side effect ➢ Prophylaxis

for Deep Vein Thrombosis

➢ Deep Vein Thrombosis

➢ Prophylaxis for Angina and myocardial infarction

➢ Deep Vein Thrombosis Prophylaxis after surger

• Bleeding • Impaired liver

function • Impaired kidney

function • Percutaneous

coronary revascularisation procedures

• Heparin-Induced Thrombocytopenia

• Bleeding gums • Increased

menstrual flow • Collection of

blood under the skin

• Fever • Bleeding at the

injection site • Irritability • Convulsions • Back pain • Dizziness • Fast heartbeat • Diarrhea

Pharmacotherapeutic : • The effect of this medicine lasts for an

average duration of 12 hours. Pharmacodynamics: Onset of action • The peak effect of this medicine can

be observed in 3 to 5 hours

NON MEDICATION

•Oxygen administration •Physiotherapy for strengthening exercise •Proper positioning •Gait training

Nursing diagnosis

ND 1: Ineffective cerebral tissue perfusion related to interruption of blood flow (ischemic stroke) as evidenced by decreased motor and sensory function Goal:

1.To display no further deterioration / recurrence of deficits 2. To improve motor and sensory function

Assessment Intervention Rational Subjective data: The patient verbalized that ana mofi kara- ik yasar regil Objective data: The patient has decreased motor and sensory perception as evidenced by

Assessed factor’s related to individual situation for decreased cerebral perfusion

Assessment will determine and influence the choice of interventions.

Closely assessed and monitored the neurological status frequently and compared with the baseline.

Assesses trends in level of consciousness (LOC) and potential for increased ICP and is useful in determining location, extent, and progression of damage. May also reveal presence of TIA, which may warn of impending thrombotic CVA.

Not able to feel pain or move her left side of the body, as evidenced by ROM – Left upper and lower extermity – 2/5 Strength – left upper & lower extermity – 1/5

Monitored vital signs T :36.9℃ P :90 b/min R :18 breath/min BP :170/90 mmHg SPO2 : 98%

P: Changes in rate, especially bradycardia, can occur because of the brain damage R:Irregularities can suggest location of cerebral insult or increasing ICP and need for further intervention, including possible respiratory support. BP: Fluctuations in pressure may occur because of cerebral injury in vasomotor area of the brain

Assessed higher functions, including speech, if patient is alert.

- Slurred speech

Changes in cognition and speech content are an indicator of location and degree of cerebral involvement and may indicate deterioration.

Position with head slightly elevated and in neutral position

Reduces arterial pressure by promoting venous drainage and may improve cerebral perfusion

Administered supplemental oxygen as indicated.

Reduces hypoxemia. Hypoxemia can cause cerebral vasodilation and increase pressure or edema formation.

Administered medications as indicated:

• Anticoagulants Inj.Clexane 0.4U sc

• Antiplatelet agents Tab Aspirin 81mg p/o

May be used to improve cerebral blood flow and prevent further clotting when embolism and/or thrombosis is the problem.

Evaluation : 1. Patient had no further deterioration and has

improved motor and sensory function as evidenced by the patient was able to feel pain and move the left side of the body. ROM – Left upper and lower extermity – 4/5 Strength – left upper & lower extermity – 4/5

ND: Impaired Physical Mobility related to weakness as evidenced by decreased muscle strength/control

• GOAL: • To maintain/increase strength and

function of affected or compensatory body part

Assessment Intervention Rational Subjective data: The patient verbalized that “I feel numbness and weakness of the left side of my body” Objective data: The patient has decreased muscle strength as evidenced by impaired coordination and limited range of motion

Assessed the extent of impairment initially and on a regular basis. Classify according to 0–4 scale.

Identifies the strengths and deficiencies that may provide information regarding recovery.

Changed positions at least every 2 hr and possibly more often if placed on the affected side.

Reduces risk of tissue injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown.

Assessment Intervention Rational ROM – Left upper and lower extermity – 2/5 Strength – left upper & lower extermity – 1/5

Elevated the arm and hand

Promotes venous return and helps prevent edema formation

Observed the affected side for color, edema, or other signs of compromised circulation.

Edematous tissue is more easily traumatized and heals more slowly.

Inspected the skin regularly, particularly over bony prominences. Gently massage any reddened areas

Pressure points over bony prominences are most at risk for decreased perfusion. Circulatory stimulation help prevent skin break

Intervention Rational Provided active or passive ROM to all extremities on admission. Encouraged exercises such as squeezing rubber ball, extension of fingers and legs/feet.

Minimizes muscle atrophy, promotes circulation, helps prevent contractures.

Encouraged the patient to assist with movement and exercises using unaffected extremity to support and move weaker side.

Aids in retraining neuronal pathways, enhancing proprioception and motor response. May respond as if affected side is no longer part of body and needs encouragement and active training to “reincorporate” it as a part of own body

Evaluation : • The patient was able to increase the strength and

function of affected body parts as evidenced by ROM –

Left upper extremity 4/5 Left lower extremity

Strength – Left upper extremity 4/5 Left lower extremity

ND: Impaired verbal communication related to impaired cerebral circulation as evidenced by impaired articulation (dysarthria)

GOALS: Establish method of communication in which needs can be expressed.

Assessment Intervention Rational subjective data: The patient verbalized that “I feel difficult to talk” Objective data: The patien was not not able to talk properly as evidenced by slurred speech.

Assessed the extent of dysfunction- slurred speech

Helps determine area and degree of brain involvement and difficulty patient has with any or all steps of the communication process.

Talked slowly and directly to patient. Used yes or no question to begin with

It reduces confusion or anxiety and having to process and respond to large amount of information of information at one time.

Intervention Rational Provided alternative methods of communication such as action, writing, pictures.

Provides communication needs of patient based on individual situation and underlying deficit

Anticipated and provided care according to patients needs

Helps to decrease frustration when depending on others

Speak in normal tones and avoid talking too fast. Give patient ample time to respond. Avoid pressing for a response.

Raising voice may irritate or anger patient. Forcing responses can result in frustration and may cause patient to resort to “automatic” speech

Intervention Rational Encouraged visitors to persist in efforts to communicate with patient: discussing family happenings even if patient is unable to respond appropriately.

It is important for family members to continue talking to patient to reduce patient’s isolation, promote establishment of effective communication, and maintain sense of connectedness with family.

Consulted and reffered the patient to speech therapist.

Assesses individual verbal capabilities and sensory, motor, and cognitive functioning to identify deficits/therapy needs.

Evaluation : • The patient was able to establish

communication in which her needs can be expressed as evidenced by the patient was able to ask her basic needs.

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