POST CLINICAL

PRESENTATION
The Patient
29 M
Full Code
NKA
Admitted April 2017
Patient History
Brainstem CVA
2nd degree basilar artery thrombosis
Asthma
G-tube
Chronic emesis
Obesity
Posterior fossa decompression
EVD placement with redo (no bone flap)
Brainstem CVA
Also known as a cerebrovascular
accident or a stroke
Occurs when there is a sudden
death of brain cells because of
the lack of oxygen
This lack of oxygen happens
when blood flow to the brain is
compromised by a blockage or
rupture of an artery to the brain
 2nd Degree Basilar Artery Thrombosis
The basilar artery Can lead to death or long-term
supplies the brain disability if not recanalized
with oxygen rich Recanalization of an artery is the
process of restoring blood flow to
blood the blocked channel
Occurs when a blood
clot forms in the
basilar artery
An infrequent form of
acute stroke
Asthma
A long term inflammatory disease of the
airways of the lungs
The airways swell and produce extra mucus
 G-tube
It is a short and hollow
tube inserted into the
stomach from the
surface of the abdomen
through an opening
called the gastrostomy
site
A G-tube allows access to
deliver nutrition
supplements for people
who need it
G-tube
Keep in standard fowlers position to minimize
risk of aspiration
Have suction equipment at beside to suction
when needed
Observe for signs of aspiration
Auscultate lung sounds after feed
Chronic Emesis
Frequent vomiting
The G-tube water flushes was making the
patient nauseous
The best way was to push them slowly
Obesity
When excess body fat has complied to the
extent that it may have negative health
outcomes
This was because this patient and his family
did not receive education on nutrition
However, now he has lost a lot of weight
because he is primarily getting his nutrition
from the G-tube
Posterior Fossa Decompression
The posterior fossa is a small
space in the skull, found near the
brainstem and cerebellum. The
cerebellum is the part of the brain
responsible for movement,
balance, and coordination. The
brainstem is responsible for
controlling vital body functions,
such as breathing
A posterior fossa decompression is
a surgical procedure to remove the
bone at the back of the skull and
spine to expand the space
EVD placement with redo (no bone flap)
EVD stands for External Ventricular Drain
This device is used in neurosurgery to relieve
elevated intracranial pressure when the flow of
cerebrospinal fluid inside the brain is
obstructed
NURSING CARE PLAN
Impaired Physical Mobility
Impaired Physical Mobility
Impaired physical mobility related to
neuromuscular impairment or cognitive
impairment evidenced by a limited range of
motion
This patient uses an electric wheelchair to
move around
Uses a mechanical lift to move from bed to
chair
Nursing Interventions
Changing positions every 2 hours reduces risk of
tissue injury and skin breakdown
Elevating arms and hands promotes venous return
and prevents edema
Begin active or passive ROM to all extremities to
help minimize muscle atrophy and promote
circulation
Setting goals with the patient and family in activity
participation to promote sense of expectation of
improvement, control and independence
Desired Outcomes
Maintaining or increasing strength and
function of affected or compensatory body
part
Demonstrating behaviours that resemble
resumption of activities
Maintaining skin integrity
 NANDA NURSING
DIAGNOSIS
Risk for Ineffective Coping
Risk for Ineffective Coping
Inability to form a valid appraisal of the
stressors
Inadequate choices of practiced responses
Inability to use available resources
Risk for Ineffective Coping
Risk for Ineffective coping and impaired
adjustment related to loss of normal body
functioning and chronic symptoms.
Patients in their twenties and thirties are not
developmentally prepared to acknowledge and
cope with disability and their own mortality
Assessment Data
Objective Data:
Insomnia
High Illness rate
Physical symptoms:
Chronic fatigue
Overeating or lack of appetite
Subjective Data:
Depression
Inability to ask for help
Inability to make decisions
Uncertainty about choices
Client Outcomes
Short Term
Setting goals with the nurse for coping outcomes
Working together with nurse to find individualized
interventions
Long Term
Patient is able to initiate effecting coping strategies
Patient makes decisions and follows through with
appropriate action
Patient uses available resources and support systems
Patient describes positive results from new behaviours
Nursing Interventions
Providing an atmosphere of acceptance
Providing factual information regarding diagnosis
and prognosis
Arranging situations that encourage autonomy
Exploring previous methods of dealing with life
problems
Encouraging verbalization of feelings, perceptions,
and fears
Encouraging patient to identify own strengths and
abilities
Rationale
Establishing rapport is essential to a therapeutic
relationship and supports the client in self-
reflection. Recognizing problems and sharing
feelings is best brought about in an atmosphere of
warmth and trust.
Factual information serves as a foundation for the
patient to explore feelings and alternative coping
strategies. Stressed clients often misunderstand
facts and require frequent clarification so that
appropriate conclusions can be drawn. Having
valid information can help relieve stress.
Rationale
Situations that encourage autonomy enhances
a sense of control, personal achievement, and
self-esteem.
Present and past coping status assists in
capitalizing on successful methods, identifying
ineffective strategies, and developing new
skills more appropriate to the present situation
Rationale
Open, nonthreatening discussions facilitate
the identification of what is causing and
contributing to the ineffective coping
Identifying strengths and abilities helps
develop appropriate strategies for coping
based on personal strengths and previous
experiences. Improves self-concept and sense
of ability to manage stress.
Evaluation
Assisting in care to the extent of the patients
abilities
Being knowledgeable on their condition
Patient takes advantage of resources and
support systems
Demonstrates ability to verbalize feelings
Patient is showing improved coping behaviours
RELATIONAL INQUIRY
FRAMEWORK
Relational Inquiry
An inquiry that is guided by conscious
participation with clients using a NUMBER
of relational skills including listening, questioning,
empathy, mutuality, reciprocity, self-observation,
reflection and a sensitivity to emotional contexts.
Relational practice encompasses therapeutic
nurse client relationships and relationships among
health care providers.
Relational Inquiry
Interpretations are products of multiple
relational interactions
Enhances nurse-client relationship to promote
health and healing
Observing peoples behaviors and situations
Interplay between intrapersonal, interpersonal,
and contextual
Relational Inquiry
By observing his behaviours with other
hospital staff members it became evident that
he wanted to have a role in his health care
He would instruct nurses on his treatment
protocols to his preferred method
He was hoping to get discharged so he wanted
to have a more independent role in his care
Relational Inquiry
When I was caring for this patient he confided in
me about his difficulty communicating with others
He explained to me that when he speaks, he can
coherently think of the words in his mind, however
when he speaks them out loud it becomes
distorted resulting in a speech impairment
It became evident that this was something very
important to him
By building therapeutic rapport with the patient I
was able to discover what the patients worries and
troubles are
Relational Inquiry
Observing his family members behaviour
showed evidence of them supporting him by
helping to find ways to maintain his quality of
life
They found an alternative therapy to help him
with his speech impairment
In his hospital room he had various devices to
help him with his coordination, agility and ROM
Alternative Therapy - Di Tan Tang
It is used to open orifices and induce diaphoresis, used
for stiffness of the tongue and speech impairment.
Consists of:
Pinella Rhizome potential to contribute to heart
attack, stroke and seizure, possibly unsafe when
used orally
Bitter Orange minor inhibitor of CYP206 moderate
inhibitor CYP3A4, increased serum medication levels,
prolong qt interval
Licorice Root may exacerbate hypokalemia
Grassleaf Sweetflag Rhizome (Calamus) decrease
efficacy of medications with anticholinergic
properties like dimehydrinate, may contain
carcinogen beta-asarone