I- INTRODUCTION

Cerebrovascular accident (CVA) or stroke is defined as a sudden loss of brain function accompanied by neurological deficit. Strokes are caused by ischemia (oxygen deprivation) resulting from a thrombus, embolus, severe vasospasm, or cerebral hemorrhage. Blood supply to the brain is interrupted causing neurological deficits of sensation, movement, thought memory, or speech. The loss of function can be temporary or permanent. Furthermore, differences in the affected side of the brain have been identified. Clients with left-side CVA tend to have communication deficits of aphasia, or inability to communicate. These clients tend to have communication deficits of aphasia, or inability to communicate. These clients tend to be cautious in behaviour and have intellectual and have intellectual impairments such as memory deficits or loss of problem solving skills. A defect in the right visual field occurs, and hemiplegia occurs on the right side. On the other hand, HPN stage II Hypertension is high blood pressure. Stage 2 is of 160179 systolic and 100-109 diastolic. This is the moderate stage, which needs to be addressed if present and brought down immediately to ensure a proper recovery. Diets rich in fats, cholesterol, sodium, sugar are some of the factors. Added to that is smoking and lack of exercise. What happens in CVA is that too much fat and cholesterol pile up in the blood vessels in the brain and because of these, the pressure will increase inside the blood vessels and eventually the blood vessels will lose its integrity and it will burst. It will eventually cause oxygen deprivation in the brain. At five minutes of oxygen deprivation, the brain cells could die causing loss of function to the affected part.

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Internationally,

according

to

World

Health

Organization

the

frequency

of

Cebrebrovascular accident worldwide found that in 2008, there are 6.15 million people in a year. High blood pressure contributes to more than 12.7 million strokes worldwide. In the Philippines, the morbidity rate is 206.3 cases per 100,000 populations according to Department of Health. Here in Davao City, there are 2,248 people who have been affected by CVA in the year 2011 City Health Office. This case caught the groups interest because even though that Cerebrovascular accident is common cause of illness and death here in the country and globally, our knowledge about the illness is not that extensive that is why we choose to study the said case. On one hand, this case is one of the most unusual cases that weve handled in our ward exposures. Furthermore, the group sought to study and discover the occurrence of CVA, to be able to fully understand the disease process itself.

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II- OBJECTIVES

General Objective Within 3 days of duty in the neuro ward of Southern Philippine Medical Center, we will be able to give safe and effective nursing care by relating and putting to use the knowledge that has been imparted to us from the academe and that we would be able to pick a patient for our case study and conduct a comprehensive case study of the patients condition. Specific Objectives: Cognitive o to be able to define the complete diagnosis of the patient o to conduct and present a cephalocaudal assessment of the patient o to identify the developmental data of the patient o be able to trace the signs, symptoms, etiology and pathophysiology of the condition of our patient o to present a comprehensive prognosis o to able to create efficient nursing care plan based on actual high-risk health needs o discuss the implications of the laboratory results of the patient as well as the surgical procedure done

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o to review and discuss the human anatomy and physiology of the digestive system, focusing primarily on the affected organ and organ systems o to present a genogram that could trace any disease that could be hereditary to the patient which might contribute to his present condition Psychomotor o to select a patient, conduct an interview and obtain data for our case study o to choose and apply the different and related nursing theories that are appropriate to the present health condition of the patient o to present drug studies and discuss the different medications given to the patient and why they were indicated for the patient o to present the patients data, family background, health history and present health condition o to establish a good rapport with the patient to gain their trust and cooperation

Affective o to give recommendations to the group, patient and Ateneo de Davao Universitys School of Nursing o to provide health teachings to the client to achieve optimum wellness as well as other relevant discharge orders.
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III- PATIENTS DATA Code Name: Patient B Age: 57 years old Sex: Male Birthday: May 9, 1955 Birthplace: Manila Address: Central Park Bangkal, Talomo Dist. Davao City Nationality: Filipino Civil Status: Single Occupation: Stylist/Beautician

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Religion: Roman Catholic Educational attainment: High school Graduate Hospital: Southern Philippines Medical Center Date of Admission: November 24, 2012 Time of Admission: 10:00 PM Vital Signs upon Admission: Blood Pressure: 280/140 Pulse: 80 bmp Respiratory Rate: 18 cpm Temperature: 36.5c

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IV- HEALTH HISTORY

Diagnosis: CVA Bleed left Capsulo Ganglionic , HPN II Admitting Physician: Dr. Reco Prospero S. Delos Reyes

I.

Past Health History

According to patients watcher, Pt B experienced motor accident three years ago but he only got a bruise on his left leg. Patient B has no surgery history. He had his
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Immunization but his watcher cannot tell if its complete or not. He has no known allergies in terms of foods and medication according to his watcher. He was diagnosed hypertension when he is still 31 years of age. On the same instance he also had a history of mild stroke happened august last year. Patient B ignore his condition, he dont have maintenance for hypertension. Patient B is fond of eating fatty foods such as humba as verbalized by his watcher.

August of 2011, patient B had his first attack of Mild stroke. He was brought to Davao Doctors Hospital. Upon being diagnosed patient B experienced difficulty in speaking and complaint of having body weakness. After he diagnosed of Mild stroke he again keeps on doing things that worsen his condition.

II.

Present Health History

Last November 24, 2012, patient B attended a party at NCCC with his co beautician. He suddenly lost her balance and fell on the floor. His friends immediately rushed him to the clinic of NCCC but the NCCC clinic refer him to Davao Doctors Hospital to have a thoroughly check up and examination. Three hours Prior to admission patient B experienced sudden onset of decrease in sensorium associated with right sided weakness thus brought to DDH, patient was managed as a
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case of CVA bleed. Patient B was then subsequently transferred to SPMC for further management. No relatives around with poor medical history. With GCS of 11 (E4, V1, M6) with flattened left nasolabial fold, and with Babinski reflex

88

84

40

52

57

59
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LEGEND: Deceased Male Patient B

Deceased Female

DM

Hypertension Point to pt.

Living Male Living Female

FAMILY HEALTH HISTORY The Grandfather and Grand Mother of both sides already died but the watcher dont have idea what is the cause of death. The mother of our Patient 88 of age diagnosed with hypertension. On the other hand his father 86 years of age also diagnosed with hypertension. Our patient is third in the family. The third brother 52 years of age was diagnosed with hypertension. The younger brother 59 years of age was diagnosed with DM they do not know if he has any maintenance medications. SOCIAL HISTORY Patient B occasionally drinks and smoke after the beauty pageant event which he was one of the team as make-up artist. He does not use illegal drugs. He rides jeepney from his house to his different events and bus as transportation going in and out in the city proper. He owned a
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beauty parlor and worked as beautician aside from that he owned small karinderya and he personally cooks the foods. He lives at the Central Park Bangkal, Talomo Dist. Davao City. According to the watcher he lives with his friends together. Sometimes, in his free time he played mah-jong and cards with his fellow friends. According to the watcher Patient B goes somewhere alone when they are not scheduled to have some make-up event. He is Roman Catholic, he attend masses rarely. In the morning, he wakes up early to go to market and cook for his karinderya and during afternoon he visit to his parlor and supervised his beautician. NUTRITIONAL ASSESSMENT Patient B height is 54 and weight is 54kg. and his BMI is 19.46. He does not follow any particular diet. He eats what he wanted to cook. He is fond eating fatty foods. V. DEVELOPMENTAL DATA Eriksons Psychosocial Theory Erikson's stages of psychosocial development as articulated by Erik Erikson explain eight stages through which a healthily developing human should pass from infancy to late adulthood. In each stage the person confronts, and hopefully masters, new challenges. According to Erikson, these developmental stages consist of a series of normative conflicts that every person must handle. The two opposing energies (developmental crisis) must be synthesized in a constructive manner to produce positive expectations for new experiences. If the crisis is unresolved, the person does not develop attitudes that will be helpful in meeting future developmental tasks. The resolution of the task can be complete, partial or unsuccessful, the

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more the success of an individual has at each developmental stage, the healthier the personality of the individual. STAGE AGE CHARACTERISTICS This stage takes place Adulthood 30-65 years old Generativity vs. Stagnation during middle adulthood between the ages of approximately 30 and 65. During this time, adults strive to create or nurture things that will outlast them; often by having children or contributing to positive changes that benefits other people. ACHIEVED JUSTIFICATION Being a stylist, an event manager and a person that manage his own parlor and carenderia at the age of 57, he is considered as a part of the Generativity vs. Stagnation stage of Eriksons Theory. Patient B spends his time wisely by engaging in helpful activities such as organizing fashion and
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modeling events which displays a persons creativity. He was able to raise and manage his own carenderia which contributes to the society and benefits the future generation.

Jean Piagets Cognitive developmental theory Jean Piagets theory views intellectual development as a result of constant interaction between environmental influences and genetically determined attributes. Piagets research focused on four stages of intellectual growth during childhood, with emphasis on how a child learns and adapts what is learned from the adult world. STAGE AGE CHARACTERISTICS ACHIEVED JUSTIFICATION

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 FORMAL 12 years-

This stage begins at age 12 years and lasts to adulthood. The person develops adult logic and is able to reason, from conclusions, plan for the future, think abstractly and build ideas.

Patient B considers the possible outcomes and consequences of his actions. He left his hometown and decided to start a new life in Davao City without hesitations because he knew the reason for making his decision. He was able to find a good job and manage his own business. While he was in the hospital during his recovery, he

OPERATIONAL adulthood

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stated that he is now more careful about the foods that he will eat and decided to have check-ups.

DEVELOPMENTAL TASK THEORY According to Havighurst, learning is basic to life and that people continue to learn throughout life. He described growth and development as occurring during six stages, each associated with six to ten tasks to be learned. The developmental task is one that arises at a certain period in our lives, the successful achievement of which leads to happiness and success with later tasks; while failure leads to unhappiness, social disapproval, and difficulty with later tasks. STAGE Middle Age AGE Ages 4060 CHARACTERISTICS ACHIEVED *Assisting teenage children to become responsible and happy PASSED JUSTIFICATION Patient B treats his younger costylists like his

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adults.

own relative. His friends and costylists call her Mommy. They stated that Patient B was their helping hand and their teacher.

* Achieving adult social and civic responsibility.

PASSED

He was able to carry out his role as an adult and an individual of the society. He participates in baranggay activities, and especially he participates in organizing events such as modeling and contests.

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* Reaching and maintaining satisfactory performance in ones occupational career.

PASSED

He managed his own carenderia and parlor well. His earnings were good and he makes sure that he spends his money wisely.

* Developing adult leisure time activities.

PASSED

He enjoys performing some leisure activities. He goes majong but most of the time he visits his parlor where he chats with his clients and workers, watch TV, listen to music and reads magazine.

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* Relating oneself to ones spouse as a person.

He wasnt able to get married; He doesnt have someone whom he spends his life with aside from his friends and co-workers.

* To accept and adjust to the physiological changes of middle age.

PASSED

He knew that physical and physiologic activity gradually decreases from time to time. Somehow, he accepts that the process of aging and degenerative changes is just but a normal to

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all.

* Adjusting to aging parents.

PASSED

Patient B was able to detach from his parents and has his own house separated from his parents. He accepted that his parents were aging and someday he will have to live his life without them all time.

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VI- PYHSICAL ASSESSMENT General Survey: At 8:00 PM on December 07, 2012, Physical Assessment was done. Patient B was lying on bed awake with watcher on side. Patient B dont have clothes, he only use blanket to cover his body. Patient B is wearing diaper. Patient B is ectomorph in body built. Right side of his body is weak and unable to move voluntarily upon assessment. Language and communication is poor and impaired. Vital Signs: Blood Pressure-140/80 Pulse-82 Respiratory Rate-20

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Temperature- 36.4c Anthropometric Measurement: Weight-53 kilograms Height-54 Neurological Exam: CN I- Patient B, able to identify the smell of alcohol. CN II- Patient B, was not able to see clearly the far objects and stated he is nearsighted. CN III, IV& VI- responsive; equal pupil size; eyes moves smoothly. CN V- + sensation CN VII-+ hearing CN VIII- patient can hear CN IX and CN X- + gag reflex CN XII+ tongue deviation

Neurological assessment: Level of consciousness: patient is only aroused to painful stimuli, and conversation is unclear. Glasgow coma scale:
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Eye opening- score: 4 Best Verbal response- score: 1 Best Motor Response-score: 6 obey commands Orientation- the patient is non-responsive on questions asked.

Communication: Patient has poor communication status. Patient is able to understand spoken words. But response inappropriate. Speech is not clear and voice modulation is very low.

Skin Skin is dry and warm to touch, with a poor skin turgor as evidenced by its springs back slowly to normal state when pinched. With a capillary time of 3 seconds on both fingers and toes. No presence of rashes, lesions, bruises, abrasions and pigmented spots upon inspection. Hair is oily, nails are not trimmed. Head

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Head is normacephalic and is at midline with the abdomen. Hair is brown in color, oily and scantly distributed. No dandruff noted. Lacerations, lesions, masses and tenderness are not noted behind the ears and along the hairline at the neck. Eyes Eyes are symmetrical and almond shape. Eyebrows are evenly distributed with back hair strands, eyebrows symmetrically aligned and equal in movement. Eyelashes are equally distributed and curled slightly outward. Skin of the eyelids is intact; no discharges and discoloration noted; lids close symmetrically while blinking, Anicteric sclera with some visible capillaries noted. Conjuctivas are pale pink in color. No edema or tenderness over lacrimal gland edema or tearing of lacrimal gland not noted. Iris is dark brown in color. No redness anad secretions noted. Pupils are equally rounded. With the use of penlight, pupils are 2mm in diameter upon exposure. Brisk eye response noted. Pupils dilate when looking at distant objects and constrict when looking at nearer objects. Pupils are equal in size, reactive to light and accommodation. Peripheral vision is good for both sides. Patient did not use any corrective aids such as glasses or contact lenses.

Ears He has symmetrical external auricle with same color to facial skin. Top portion of the auricle are aligned to the outer canthus of the eye. No Cerumen discharges noted upon inspection.

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Auricles are mobile, firm and not tender upon palpation, pinnae recoils after it is being folded. No rashes, lesions and lacerations noted around and at the back of both ears. Auditory status is normal as evidenced by patient is aroused to verbal stimuli. Nose Nose is symmetrical and at midline of the face, with uniform color. Nasolabial fold is evident. Nasal septum is intact and found in midline, with pinkish mucosa. Nares are patent. No unusual discharges noted. Mouth Patient has dry and slightly dark lips. Gums are slightly pale in appearance. His tongue is pinkish. Patient can swallow food and masticate.

Neck Trachea is at midline. Head is not uniformly coordinated in movement since the patient cannot move freely, but head can move slowly. Lymph nodes are not palpable. Anterior neck is symmetrical at both sides with no masses noted. No masses also palpated on posterior neck. There was no unusual enlargement. Chest and Lungs The patient has intact chest skin with uniform temperature. Chest is symmetrical. There is an equal chest wall expansion with clear breath sounds, with rhythmic and effortless respiration.

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Chest wall in is intact with no tenderness and masses noted. Breast are equal in size with dark colored areola. Heart Carotid artery has symmetric pulse volumes upon palpation, and no presence of bruit upon auscultation. Patient has regular heart rhythm and rate with no presence of murmurs. Abdomen The abdomen is flabby in appearance, uniform in color and is warm to touch. Abdomen is not distended, no mass noted. Upper extremity Shoulders and arms are symmetrical with no deformity. Right arm is weak, cannot be moved voluntarily and non-reactive to stimuli. Left arm has a normal movement and very reactive to stimuli. Lower Extremity Right leg is unable to move, and non-reactive ti stimuli. Left leg is normal in movement and reactive to stimuli. Both feet are dry, callous noted on the soles of the feet. Nails are not untrimmed and dirty. Male Genitalia Assessment Client wears an adult diaper.

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VII- PATIENTS DIAGNOSIS DEFINITION OF COMPLETE DIAGNOSIS Cerebrovascular accident Stroke or Cerebrovascular accident (CVA) results from sudden interruption of blood supply to the brain, which precipitates neurologic dysfunctions lasting longer than 24 hours. Strokes are either ischemic, cause by partial or complete occlusion of a cerebral blood vessel by cerebral thrombosis or embolism or hemorrhage.

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Source:Lippincott Manual Nursing Practice handbook 3rd Edition Pgs 901-908 A stroke, or cerebrovascular accident (CVA), is the rapid loss of brain functions due to an abnormal perfusion of brain tissue or disturbance in the blood supply to the brain. This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a hemorrhage.As a result, the affected area of the brain cannot function, which might result in an inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or an inability to see one side of the visual field. Source: http://en.wikipedia.org/wiki/Stroke Cerebrovascular accident or stroke is sudden diminution or loss of consciousness, sensation, and voluntary motion caused by rupture or obstruction of a blood vessel of the brain. Source:Merriam-Webster medical dictionary new edition by Roger W. Pease, Jr., Ph.D.

Bleed Capsuloganglionic Bleed Capsuloganglionic also known as the Capsuloganglionic Hemorrhage is the hemorrhage into the basal ganglia and internal and external capsule of the brain. Source: Dorland's illustrated medical dictionary - Volume 1914 - Page 422

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 Bleed Capsuloganglionic refers to the hemorrhage that occurs in the internal capsule of the brain and the basal ganglia that usually marked by paralysis of the opposite limb, sensory disturbance of half of the body and hemianopsia. Source: Pathophysiology of Health Care Professionals 3rd Edition pages 561-566. Bleed Capsuloganglionic (Capsuloganglionic hemorrhage)

HYPERTENSION STAGE II
Hypertension Stage II is more severe hypertension, stage 2 hypertension is a systolic

pressure of 160 mm Hg or higher or a diastolic pressure of 100 mm Hg or higher. Source: Brunner and Suddharts textbook of Medical Surgical Nursing Pgs 685 Hypertension Stage IIalso known as Late High Blood Pressure or Severe high blood pressure. A systolic blood pressure value of >160 or a diastolic blood pressure value of>100. Stage 2 Hypertension is a serious form of high blood pressure, and requires immediate treatment. Source: http://highbloodpressure.about.com/od/glossary/g/s2_glos.htm Hypertension stage IIis also known as the severe hypertension where the mean arterial pressure often rises to as high as 150 to 170 mm Hg, with diastolic pressures as high as 130 to 150 mm Hg and diastolic arterial p ressures sometimes as great as 250 mmHg. Source: Guytons Textbook of MEDICAL PHYSIOLOGY 7th Edition by Arthur C. Guyton M.D Pg 266
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CVA Bleed Left Capsuloganglionic Hypertension II is a stroke that causes bleeding into the left capsuloganglionic area due to a chronic severe hypertension; There is a rupture of a blood vessel and hemorrhage into the brain tissue resulting in swelling of the brain, compression of the brain contents or spasm of the adjacent blood vessels.

VIII- ANATOMY AND PHYSIOLOGY The Human Nervous System The nervous system is one of the bodys principal control and integrating centers. In humans, the nervous system serves three board functions: sensory, integrative, and motor. First, it senses certain changes within the body and in the outside environment; this is its sensory function. Second, it interprets the changes; this is the integrative function. Third, it responds to the interpretation by initiating action in the form of muscular contractions or glandular secretions; this is its motor function.

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Through sensation, integration, and response, the nervous system represents the bodys most rapid means of maintaining homeostasis. Its split-second reactions, carried out by nerve impulses, can normally make the adjustments necessary to keep the body functioning efficiently.

A.) Central Nervous System (CNS) The central nervous system is effectively the center of the nervous system, the part of it that processes the information received from the peripheral nervous system. The CNS consists of the brain and spinal cord. It is responsible for receiving and interpreting signals from the PNS and also sends out signals to it, either consciously or unconsciously

The Nerve Cell

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Nerve cells, called neurons, are responsible for conducting nerve impulses from one part of the body to another. Neurons have two kinds of cytoplasmic processes: dendrites and axons. Dendrites are usually highly branched, thick extensions of the cytoplasm of the cell body. Their function is to conduct nerve impulses toward the cell body. On the end of these dendrites lie the axon terminals, which plug into a cell where the electrical signal from a nerve cell to the target cell can be made. This plug (axon terminal) connects into a receptor on the target cell and can transmit information between cells.

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Axon, is usually a single long, thin process that is highly specialized and conducts nerve impulses away from the cell body to another neuron or muscular or glandular tissue.

Classification of Neurons: 1.) Afferent Neurons transmit impulses from receptors in the skin, sense organs, muscles, joints, and viscera to the CNS. 2.) Efferent Neurons convey impulses from the brain and spinal cord to effectors, which may be either muscles or glands, and from high to lower centers of the CNS. 3.) Interneurons carry impulses from sensory neurons to motor neurons and are located in the brain and spinal cord. Spinal Cord

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The spinal cord begins as a continuation of the medulla oblongata and terminates at about the second lumbar vertebra. It is protected by the vertebral canal, meninges, cerebrospinal fluid, and vertebral ligaments. 31 pairs of spinal nerves rise along the spinal cord. These are mixed nerves because each contain both sensory and motor axons. However, within the spinal column, all the sensory axons pass into the dorsal root ganglion where their cell bodies are located and then on into the spinal cord itself all the motor axons pass into the ventral roots before uniting with the sensory axons to form the mixed nerves A major function of the spinal cord is to convey sensory nerve impulses from the periphery to the brain and to conduct motor impulses from the brain to the periphery. Another, is to serve as a reflex center. It serves as a minor reflex center. Brain The brain receives sensory input from the spinal cord as well as from its own nerves (ex. Olfactory and Optic nerves). It devotes most of its volume (and computational power) to processing its various sensory inputs and initiating appropriate and coordinated- motor outputs. White Matter and Gray Matter Both the spinal cord and the brain consist of: White Matter bundles of axons each coated with a sheath of myelin
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Gray Matter masses of the cell bodies and dendrites each covered with synapses.

In the spinal cord, the white matter is at the surface, they gray matter inside. The Meninges Both the spinal cord and brain are covered in three continuous sheets of connective tissue, the meninges. From outside in, these are the Dura mater pressed against the bondy surface of the interior of the vertebrae and the cranium Arachnoid Pia Mater

The region between the arachnoid and pia mater is filled with cerebrospinal fluid (CSF) a.) Brain Stem 1.) Medulla Oblongata The medulla contains all ascending and descending tracts that communicate between the spinal cord and various parts of the brain. These tracts constitute the white matter of the medulla.

Rhythmically stimulate the intercostals muscles and diaphragm making breathing possible

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Regulate heartbeat Regulate the diameter of arterioles thus adjusting blood flow

2.) Pons The pons seems to serve as a relay station carrying signals from various parts of the cerebral cortex to the cerebellum. Nerve impulses coming from the eyes, ears, and touch receptors are sent on the cerebellum. The pons also participates in the reflexes that regulate breathing. The reticular formation is a region running though the middle of the brain stem ( and on into the midbrain). It receives sensory input (eg. Sound) from higher in the brain and passes these back up to the thalamus. The reticular formation is involved in sleep, arousal (and vomiting) 3.) Midbrain The midbrain (mesencephalon) occupies only a small region in humans (it is relatively much larger in lower vertebrates). We shall look at three features:

The reticular formation: collects inpur from higher brain centers and passes it on to motor neurons.

The substantia nigra: helps smooth out body movements; The ventral tegmental area (VTA): packed with dopamin-releasing nurons that:

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o Are actuvated by nicotinic acetylcholine receptors and o Whose projections synapse deep within the forebrain. The VTA seems to be involved in pleasure: nicotine, amphetamines and cocaine bind to and activate its dopamine-releasing neurons and this may account for their addictive qualities.

b.) Diencephalon 1.) Thalamus All sensory input (except for olfaction) passes through these paired structures on the way up to the somatic-sensory regions of the cerebral cortex and then returns to them from there. Signals from the cerebellum pass through them on the way to the motor areas of the cerebral cortex. 2.) Hypothalamus The seat of the autonomic nervous system. Damage to the hypothalamus is quickly fatal as the normal homeostasis of body temperature, blood chemistry, etc. goes out of control. c.) Cerebellum

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The cerebellum consists of two deeply-convoluted hemispheres. Although it represents only 10% of the weight of the brain, it contains as many neurons as all the rest of the brain combined. Its most clearly-understood function is to coordinate body movements. People with damage to their cerebellum are able to perceive the world as before and to contract their muscles, but their motions are jerky and uncoordinated. It appears to be a center for learning motor skills (implicit memory). Laboratory studies have demonstrated both long-term potentiation (LTP) and long-term depression (LTD) in the cerebellum

The Cerebral Hemispheres

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Each hemisphere of the cerebrum is subdivided into four lobes visible from the outside: 1.) Frontal lobe conscious thought; damage can result in mood changes 2.) Parietal lobe plays important roles in integrating sensory information from various senses, and in the manipulation of objects; portions of the parietal love are involved with visuospatial processing 3.) Occipital lobe sense of sight; lesions can produce hallucinations 4.) Temporal lobe senses of smell and sound, as well as processing of complex stimuli like face and scenes.

B.) Peripheral Nervous System (PNS) The peripheral nervous system branches outside of the central nervous system and is comprised of nerves and neurons that transmit information to and from the brain. The peripheral nervous system is further divided into two parts called the somatic nervous system and the autonomic nervous system.

a.) The Sensory-Somatic Nervous System The sensory somatic nervous system consists of: 12 pairs of cranial nerves and
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31 pairs of spinal nerves

The Spinal Nerves All of the spinal nerves are mixed;that is, they contain both sensory and motor neurons. All our conscious awareness of the external environment and all our motor activity to cope with it operate through the sensory-somatic division of the PNS. b.) The Autonomic Nervous System

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The autonomic nervous system consists of sensory neurons and motor neurons that run between the central nervous system (especially the hypothalamus and medulla oblongata) and various internal organs such as the : Heart Lungs Viscera Glands (Both endocrine and exocrine)

It is responsible for monitoring conditions in the internal environment and bringing about appropriate changes in them. The contraction of both smooth muscle and cardiac muscle is controlled by motor neurons of the autonomic system.

The actions of the autonomic nervous system are largely involuntary (in contrast to those of the sensory-somatic system). It also differs from the sensory-somatic system in using two groups of motor neurons to stimulate the effectors instead of one.

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The first, the preganglionic neurons, arise in the CNS and run to a ganglion in the body. Here they synapse with

Postganglionic neurons, which run to the effector organ (cardiac muscle, smooth muscle, or a gland)

The autonomic nervous system has two subdivisions, the Sympathetic Nervous System Parasympathetic Nervous System

The Sympathetic system activates and prepares the body for vigorous muscular activity. Stress. And emergencies. While the Parasympatheticsystem lowers activity, operates during normal situations, permits digestion, and conservation of energy. Major Blood Vessels of the Brain

Normal function of the brains control centers is dependent upon adequate supply of oxygen and nutrients through a dense network of blood vessels. Blood is supplied to the brain,

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face, and scalp via two major sets of vessels: the right and left common carotid arteries and the right and left vertebral arteries. The common carotid arteries have two divisions. The external carotid arteries supply the face and scalp with blood. The internal carotid arteries supply blood to the anterior three-fifths of cerebrum, except for parts of the temporal and occipital lobes. The vertebrobasilar arteries supply the posterior two-fifths of the cerebrum, part of the cerebellum, and the brain stem. Any decrease in the flow of blood through one of the internal carotid arteries brings about some impairment in the function of the frontal lobes. This impairment may result in numbness, weakness, or paralysis on the side of the body opposite to the obstruction of the artery. Occlusion of one of the vertebral arteries can cause many serious consequences, ranging from blindness to paralysis. Circle of Willis

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At the base of the brain, the carotid and vertebrobasilar arteries form a circle of communicating arteries known as the circle of Willis. From this circle otheir arteries the anterior cerebral artery (ACA), the middle cerebral artery (MCA), the posterior cerebral artery (PCA) arise and travel to all parts of the brain. Posterior Inferior Cerebellar Arteries (PICA), which branch from the vertebral arteries, are not shown. Because the carotid and vertebrobasilar arteries form a circle, if one of the main arteries is occluded, the distal smaller arteries that it supplies can receive blood from the other arteries (collateral circulation). Anterior Cerebral Artery

The anterior cerebral artery extends upward and forward from the internal carotid artery. It supplies the frontal lobes, the parts of the brain that control logical thought, personality, and voluntary movement, especially the legs. Stroke in the anterior cerebral artery results in opposite leg weakness. If both anterior cerebral territories are affected, profound mental symptoms may result (akinetic mutism) Middle Cerebral Artery

The middle cerebral artery is the largest branch of the internal carotid. The artery supplies a portion of the frontal love and the lateral surface of the temporal and parietal lobes, including the primary motor and sensory areas of the face, throat, hand and arm in the dominant hemisphere, the areas of speech. The middle cerebral artery is the artery most often occluded in stroke. Posterior Cerebral Artery
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The posterior cerebral arteries stem in most individuals from the basilar artery but sometimes originate from the ipsilateral internal carotid artery. The posterior arteries supply the temporal and occipital lobes of the left cerebral hemisphere and the right hemisphere. When infarction occurs in the territory of the posterior cerebral artery, it is usually secondary to embolism from lower segments of the vertebral basilar system or heart. Lenticulostriate Arteries

Small, deep penetrating arteries known as the lenticulostriate arteries branch form the middle cerebral artery. Occlusions of these vessels or penetrating brancjes of the circle of Willis or vertebral or basilar arteries are referred to as lacunar strokes. The cells distal to the occlusion die, but since these areas are very small often only minor deficits are seen. When the infarction is critically located, however, more severe manifestations may develop, including paralysis and sensory loss. Within a few months of the infarction, the necrotic brain cells are reabsorbed by macrophage activity, leaving a very small cavity.

Renin-Angiotensin-Aldosterone System
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The renin-angiotensin-aldosterone system (RAAS) plays an important role in regulating blood volume and systemic vascular resistance, which together influence cardiac output and arterial pressure. As the name implies, there are three important components to this system: 1) renin, 2) angiotensin, and 3) aldosterone. Renin, which is primarily released by the kidneys, stimulates the formation of angiotensin in blood and tissues, which in turn stimulates the release of aldosterone from the adrenal cortex. Renin is a proteolytic enzyme that is released into the circulation primarily by the kidneys. Its release is stimulated by: sympathetic nerve activation (acting via 1-adrenoceptors) renal artery hypotension (caused by systemic hypotension or renal artery stenosis) decreased sodium delivery to the distal tubules of the kidney.

Juxtaglomerular (JG) cells associated with the afferent arteriole entering the renal glomerulus are the primary site of renin storage and release in the body. A reduction in afferent arteriole pressure causes the release of renin from the JG cells, whereas increased pressure inhibits renin release. Beta1-adrenoceptors located on the JG cells respond to sympathetic nerve stimulation by releasing renin. Specialized cells (macula densa) of distal tubules lie adjacent to the JG cells of the afferent arteriole. The macula densa senses the amount of sodium and chloride ion in the tubular fluid. When NaCl is elevated in the tubular fluid, renin release is inhibited. In contrast, a reduction in tubular NaCl stimulates renin release by the JG cells. There is evidence that prostaglandins (PGE2 and PGI2) stimulate renin release in response to reduced NaCl transport across the macula densa. When afferent arteriole pressure is reduced, glomerular filtration

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decreases, and this reduces NaCl in the distal tubule. This serves as an important mechanism contributing to the release of renin when there is afferent arteriole hypotension. When renin is released into the blood, it acts upon a circulating substrate, angiotensinogen, that undergoes proteolytic cleavage to form the decapeptide angiotensin I. Vascular endothelium, particularly in the lungs, has an enzyme, angiotensin converting enzyme (ACE), that cleaves off two amino acids to form the octapeptide, angiotensin II (AII), although many other tissues in the body (heart, brain, vascular) also can form AII.

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AII has several very important functions: 1. Constricts resistance vessels (via AII [AT1] receptors) thereby increasing systemic vascular resistance and arterial pressure 2. Acts on the adrenal cortex to release aldosterone, which in turn acts on the kidneys to increase sodium and fluid retention 3. Stimulates the release of vasopressin (antidiuretic hormone, ADH) from the posterior pituitary, which increases fluid retention by the kidneys 4. 5. Stimulates thirst centers within the brain Facilitates norepinephrine release from sympathetic nerve endings and inhibits norepinephrine re-uptake by nerve endings, thereby enhancing sympathetic adrenergic function 6. Stimulates cardiac hypertrophy and vascular hypertrophy

The renin-angiotensin-aldosterone pathway is regulated not only by the mechanisms that stimulate renin release, but it is also modulated by natriuretic peptides (ANP and BNP) released by the heart. These natriuretic peptides acts as an important counter-regulatory system. Therapeutic manipulation of this pathway is very important in treating hypertension and heart failure. ACE inhibitors, AII receptor blockers and aldosterone receptor blockers, for example, are used to decrease arterial pressure, ventricular afterload, blood volume and hence ventricular preload, as well as inhibit and reverse cardiac and vascular hypertrophy.

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IX- ETIOLOGY

Etiology is the study of the cause or origin of a disease. Studying the etiology of the patients condition helps us find the factors with which produce or predispose toward a certain disease or disorder. Predisposing Presence Factors Age Present Justification Patient B is 57 years old. Rationale The chances of having a stroke go up with age. Twothirds of all strokes happen to people who are over age 65. Stroke risk doubles every 10 years past age 55. The risk of stroke increases with age, each ten years double the stroke risk after the age of 55. At least 66 percent of all people with stroke were aged 65 or more.

Source: https://www.myhealth.va.gov/mhvportal-web/ShowBinary/BEA Gender Present Patient B is Male. %20Repository/pdf/Stroke_Risk_Check.pdf Stroke is more common in men than women. Almost one in four men and nearly one in five women can expect to have a stroke if they live
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to their 85th year.

Source: http://www.stroke.org/site/PageServer? Hereditary Present Patient B Mom and Dad have Hypertensio n. pagename=RISK A very great number of association studies have been performed in order to examine the possible implication of candidate genes due to their known or supposed functions, but very few genetic variants have been associated with an increased risk of CVA, this increase being modest moreover. Quite recently an approach combining genetic linkage analysis and a haplotypic association study has allowed the localisation and identification of a new gene, phosphodiesterase 4D, implicated in ischaemic CVA, and the localisation on chromosome 7 of a gene implicated in the occurrence of cerebral aneurysms, thus raising new hopes in this multifactorial form. Although actual risk varies, people with a family history of stroke is at risk for stroke themselves.

Source: http://www.ncbi.nlm.nih.gov/pubmed/14694787
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Race

Absent

Patient B is an Asian, a Filipino.

Black and Hispanic Americans have a higher risk than people of other races. Compared with whites, young black Americans, both women and men have a risk of 2 to 3 times more likely to make a stroke and die from this cause. People of Asian and African-Caribbean ethinicity.11 The prevalence of stroke is 40-70% higher among African-Caribbean and South Asian men than in the general population.

Source: http://www.doctortipster.com/3062stroke-cva-causes-risk-factors-symptoms-andtreatment.html#ixzz2F8ZZ7z6l Prior stroke attack Present Patient B had a past history of stroke last November 24, 2012 Transient Ischemic Attacks, also called TIAs or ministrokes, are brief episodes of stroke symptoms that usually last for only a few minutes. Symptoms may include weakness, numbness, speech changes, and blindness. Unlike stroke, TIAs do not result in permanent brain damage. More than one- third of all people who experience TIAs will go on to have a stroke. If already had a stroke, it may be up to
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10 times more likely to have another.

Source: https://www.myhealth.va.gov/mhvportal-web/ShowBinary/BEA %20Repository/pdf/Stroke_Risk_Check.pdf

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Precipitating Presence Factors Hypertension Present Justification Patient B BP upon admission is 280/170mmHg Rationale Uncontrolled high blood pressure increases a person's stroke risk by four to six times. Over time, hypertension leads to atherosclerosis and hardening of the large arteries. This, in turn, can lead to blockage of small blood vessels in the brain. High blood pressure can also lead to weakening of the blood vessels in the brain, causing them to balloon and burst. The risk of stroke is directly related to how high the blood pressure is.

Source: Kozier and Erbs Fundamentals of nursing, 8th edition 2008 by: Berman, Aubrey, Synder, Shirlee, Kozier, Barbara & Erb, Diabetes Mellitus Present Patient B sugar level shows and his taking RI during admission. Source: Kozier and Erbs Fundamentals of nursing, 8th edition 2008 by: Berman, Aubrey, Synder, Shirlee, Kozier, Barbara & Erb, Elevated bad blood cholesterol levels (LDL) Present Patient B level of cholesterol. Glenora Patients with diabetes often have unhealthy cholesterol levels including high LDL
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Glenora Individuals with insulin resistance or diabetes in combination with one or more of these risk factors are more likely to fall victim to heart disease or stroke.

cholesterol, and high triglycerides. This triad of

X- SYMPTOMATOLOGY The symtomatology of the patients condition is made to determine the presence or absence of the signs and symptoms common to a disease.

Present/ Symptoms Absent Unilateral Limb weakness Present Patient B experienced paralysis Affected side exhibits in his right side since the numbness and weakness. affected area is in his left brain. Muscles are contracted and tense, so movement is difficulty. The side of the body opposite of the cerebral infarct is affected because as fibers cross over right after
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Rationale

Justification

passing the brain. Source: Tortora and Derrickson, 9th edition. Difficulty in speech or comprehending Present Patient B during interview has Damage to one or more of

difficulty in enunciating words. the language areas of the brain. Many times, the cause of the brain injury is a stroke. A stroke occurs when blood is unable to reach a part of the brain. Brain cells die when they do not receive their normal supply of blood, which carries oxygen and important nutrients. Source: http://www.strokecenter.org/ patients/caregiver-andpatient-resources/aphasiainformation/

Difficulty in seeing in one or both eyes

Present

Patient B affected body area is in his right, patient B cannot see clearly/ blurred vision in his right eye.

Blindness in half of the visual field or both eyes is a common occurrence with CVA. It happens because of
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the disruption of optic nerve. Source: Tortora and Derrickson, 9th edition. Loss of body coordination, loss of balance Present Patient B cannot walk properly, It will happen because of the he used wheelchair. damage of cerebellum. Cerebellum is the one responsible for the initiation and control of movements of extremities in the brain stem. Source: Williams and Hopper 2007 Severe headache Present Patient experienced headache sometimes as he stated. It occurs due to increased intracranial pressure. Headache may be associated with the displacement of pain-sensitive blood vessels and cranial structures when blood enters the area surrounding the brain. Source: Williams and Hopper 2007 Nausea and Vomiting Present Patient experienced nausea and vomiting as he stated. Symptoms From Blockage in the Basilar Artery. The other
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major site of trouble, the basilar artery, is formed at the base of the skull from the vertebral arteries, which run up along the spine and join at the back of the head. When stroke or TIAs occur here, both hemispheres of the brain may be affected so that symptoms occur on both sides of the body. Source: http://health.nytimes.com/he alth/guides/disease/stroke/pr int.html drowsiness Present Stroke could have damaged the parts of the brain involved in sleep/wake cycles. Source: http://www.caring.gov/ Unequal pupil size Present Due to increased in intracranial pressure or
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damage in cranial nerves III, IV and VI. Source: http://www.nlm.nih.gov/medl ineplus/ency/article/003314. htm

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XI- PATHOPHYSIOLOGY Predisposing Factors: Age (+) Race (-) Ow h Hereditary (+) Gender (+) Prior stroke attack (+) Precipitating Factors: High Blood Pressure (+) Diabetes Mellitus (+) Cigarette Smoking (+) High Fat High Sodium Diet (+) Physical Inactivity (-) Elevated bad blood cholesterol levels/LDL (+) Obesity (-) Alcoholism (+)

Decreased stretching ability of blood vessels

Increased Fluid Volume

Increased blood viscosity

Increased Blood Pressure Vasospasm limits blood flow Rupture of blood vessels Clot formation o Severe Headache o Nausea o Vomiting Blood release into the brain tissue Decreased blood flow Bleeding of blood vessels

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Bleed in the left Swelling of the brain capsuloganglionic area

Ischemia

Pressure in the brain tissue

o Weakness o Drowsiness o Unequal pupil size

No space for expansion; compression of brain tissue

Impaired nutrition and oxygenation of the brain

Difficulty seeing in one or both eyes

Difficultly speech or comprehending o Loss of body coordination o Loss of balance Brain tissue necrosis accurs at the affected area

Decreased cerebral perfusion

Unilateral limb weakness Cerebrovascular accident/ Stroke

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IF TREATED: Return to normal perfusion Improved Function

IF NOT TREATED: Continued inadequate blood flow Further tissue compression Severe paralysis Respiratory arrest

Treatment: Medication Physical therapy/Rehabilitation Lifestyle modification

GOOD PROGNOSIS

BAD PROGNOSIS

DEATH

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NARRATIVE PATHOPHYSIOLOGY Cerebrovascular accident also known as stroke is a sudden impairment of cerebral circulation in one or more blood vessels. The predisposing factors that affect the disease are age, gender, genetics, chronic hypertension and prior stroke. Furthermore, it is precipitated by high blood pressure, diabetes mellitus, low HDL, high blood cholesterol, Cigarette smoking, Alcoholism, Physical inactivity and obesity. In the case of our patient, the predisposing factors that affect the disease are hereditary, gender, and prior stroke attack. On the other hand the predisposing factors are focused on hypertension, diabetes mellitus, alcoholism, cigarette smoking and elevated LDL or high blood cholesterol level. These factors led to the inability of the blood vessels to stretch and increase the blood viscosity. To compensate for this flow of blood, theres an increase in blood pressure. Just like in the case of our patient, his high blood pressure in particular led to the rupture and bleeding of his blood vessel which causes severe headache. These headaches are often followed by nausea and vomiting. As a result, blood release around the cells. In our patients case, the bleeding occurred in the capsuloganglionic area. This area is one of the most common sites of hypertensive bleeds. The release of blood leads to the swelling of the brain. The swelling causes pressure in the brain tissues. Since the skull doesnt allow room for expansion, the tissues are compressed and this compression leads to lack of nutrition and oxygen to the brain. This leads to the inability of the brain to store glucose and oxygen. Therefore, Brain tissue necrosis happens which leads to decrease cerebral perfusion, which then leads to cerebrovascuar accident. Furthermore, as blood is released, it irritates the blood vessels and meninges because blood is a noxious agent. Another effect of the bleeding is the constriction of the blood vessel; this is to limit blood loss. As a result to the vasospasm, blood
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is limited and clotting follow. Apparently, this leads to the decrease flow of oxygenated blood in the brain. This is when cerebrovascular accident occurs. This then shows unilateral limb weakness, difficulty in speech or comprehending, difficulty in seeing in one or both eyes, loss of body coordination and loss of balance. If treatment such as proper medication is followed and rehabilitation is done, then there would be a return of normal perfusion and appropriate blood flow is restored. Also, physical therapies and rehabilitations help prevent further complications. If not treated, there would be inadequate blood flow and further tissue compression. This leads to more severe paralysis and respiratory arrest later on may lead to death.

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XII- DOCTORS ORDER Date/Time 11/24/12 Doctors Order Please admit under white service to IMCU level 3 Rationale The patient is to be admitted to Intermediate Medical Care Unit level 3 for further monitoring and proper Secure consent to care management. Client or guardians signed consent necessary for medical care and procedures. This is to avoid any unauthorized procedure and to protect the
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Remarks DONE

DONE

health team from any legal issues. Insert NGT FR 14 (keep end closed) If patient has difficulty eating or drinking after 48 hours, alternate feeding routes are used, such as tube OTF of 1800 Kcal/day 6 divided feedings. feeding. If patient has difficulty eating or drinking after 48 hours, alternate feeding routes are used, such as tube V/S q hourly feeding. Monitoring of DONE
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DONE FR 16 given

DONE

vital signs every hour is done to serve as a baseline data for further interventions and to monitor any unusualities the patient may Dx: exemplify. Complete blood count CBC, Platelet Count with platelet count is ordered to check the hematologic status of the patient regarding the cause of CVA hematologic
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DONE

status of the patient and for signs of Blood Typing thrombosis. Blood typing: Blood typing is a method to tell what specific type of blood you have. What type you have depends on whether or not there are certain proteins, called antigens, on your red blood cells. Prothrombin time with INR, APTT
Prothrombin

DONE

DONE

time (PT) is a blood test that

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measures how long it takes blood to clot. A prothrombin time test can be used to check for bleeding problems. PT is also used to check whether medicine to prevent blood clots is working.

INR

(international normalized ratio) stands for a way of standardizing the results of

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prothrombin time tests, no matter the testing method.

Cranial CT scan plaindone

Cranial Computed Tomography Scan done to rule out evidence of hemorrhagic

DONE Left Capsuloganglionic Bleed in 20cc

Chest X-ray PosteriorAnterior view

stroke. Chest X-Ray done to rule out cardiac origin as the source of

DONE

ECG 12 leads with long lead II

1.

embolus. ECG- 12 Leads done to assess dysfunctional

DONE

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heart rate due to impaired autonomic control from the brain caused by infarct. Specifically, it is to rule out atrial serum creatinine, sodium, potassium 2. fibrillation. Creatine test done to assess severity of loss of creatine which would adversely affect the communicatio n between the peripheral and central nervous system with the muscles.
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DONE

3.Sodium testing is used to detect abnormal concentrations of sodium. It may be ordered to determine if a disease or condition involving the brain, lungs, liver, heart, kidney, thyroid, or adrenal glands is causing or being exacerbated by a sodium deficiency or

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excess.

4.

Potassium testing is used to detect concentrations that are too high (hyperkalemia) or too low

FBS, lipid profile

1.

(hypokalemia) FBS done to measure glucose levels in the blood. Severe hyperglycemia can lead to poor outcomes and reduced perfusion of the brain should

NOT DONE

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thrombolysis occur.

2.

Lipid Profile done to assess the cholesterol blood level in the client in order to assess for the possibility of plaque development in the arteries which may cause CVA.

CBG now

1.

To monitor fluctuation of glucose levels. Capillary blood glucose testing is used as a

DONE

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monitoring tool giving a guide to blood glucose levels at a specific moment in time. This is done because hyperglycaemi c levels are associated with worsening stroke condition. Consume Nicardipine drip: Nicardipine 10mg + 90cc D5W to run @ 5mg/kg/hr q15mins until MAP of 1102.

Nicardipine injections are used for shortterm treatment of blood pressure when oral medications are not

DONE

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120 is achieved as side drip.

possible or desirable. Paired with D5W for fluid replacement and parenteral access of medications and for the BP not to decrease abruptly and for it to be regulated

D5W 500cc to run at KVO rate (main line)

3.

properly. Isotonic solution indicated for rehydration, keeps the body from using up protein and muscle mass by giving it carbohydrates

DONE

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and can decrease sodium and potassium levels.For fluid replacement and parenteral access of medications Medications: Mannitol 20% 150cc q6 as bolus
4.

. Mannitol reduces an increase in intracranial pressure, improves cerebral metabolism and oxygenation in patients after

DONE

Citicoline 1gram IVTT

5.

brain injury. Citicoline is a naturally

DONE

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q12

occurring brain chemical that is important for brain function. It is given to improve impaired functioning of the brain for victims with cerebral vascular

Senna Conc. 2 tabs OD @HS

6.

accidents. Promotes incorporation of water into stool resulting in softer fecal mass and relieving

DONE

Refer to Neurosurgery

7.

constipation. Refered to Neurosurgery

DONE

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for STAT evaluation and co-mgt

to assess condition and possible treatment for

Moderate high back rest

8.

the patient. Patients head is elevated to reduce cerebral edema by improving venous

DONE

Complete Bed Rest w/o Bathroom Privilege

9.

drainage. CVA patients have body weakness and have to recuperate and prevent from any possible injuries that

DONE

Retain Foley catheter F16 attached to urobag

10.

may occur. Foley Catheter is attached due to the order of complete bed

DONE

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rest w/o bathroom I&0 q shift 11. privilege. Monitoring the intake and output of patient allows the nurse to compare the amount of fluid the patient takes in Refer accordingly 12. and out. To report any unusualities that may develop into 11/24/12 GCS 9-10 E3-4 V1 M5 Patient seen & examined Isocoric Aphasic. Spontaneous purposeful Neurosurgery notes: 13. complications Neurosurgery assessed and evaluated the medical condition of the patient to provide
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DONE

DONE

movements

appropriate care and

CT Scan Left Capsuloganglionic Bleed in 20cc History reviewed 14.

treatment. Assessed for any related conditions or factors that may have

DONE

(-)midline shift affected the Scan verified 15. patient. Reviewed scan results to evaluate condition of CO-manage patient 16. the patient. Further continue management and treatments Shift IVF to PNSS 1L @ 140cc/hr while on mannitol 17. to patient. Mannitol will crystallize with D5W thats why it is shifted to NOT DONE DONE DONE

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PNSS an isotonic table salt used to give IV fluids to the patients shifting from salt and water Atorvastatin 80mg 1Tab OD 18. deprivation. Atorvastatin is an oral drug that lowers the level of cholesterol in the blood. It his given to stroke patients to prevent the continued formation of Increase Citicoline to 1g IVTT q8 19. plaques. Citicoline is a naturally occurring brain chemical that DONE DONE

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is important for brain function. It is given to improve impaired functioning of the brain for victims with cerebral vascular Neuro Aid 4 caps TID
20.

accidents. NeuroAiD is a natural oral treatment dedicated to stroke recovery and s troke

DONE

Cerebrolysin 1 amp IVTT q8

21.

rehabilitation. Treatment of disturbances of concentration and memory

DONE

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and sequels of stroke (ischaemic and Will refer to service consultant 22. haemorrhagic) To report any unusualities that may develop into Thank you for this referral 23. complications Your welcome! DONE

11-25-12 2:00 AM

1 Citicoline 1 gm IVTT q8 Shift IVF to PNSS 1L@100cc/hr

24.

Same rationale as mentioned

NOT DONE

25.

above. PNSS an isotonic table salt used to give IV fluids to the patients shifting from salt and water

NOT DONE

May continue

26.

deprivation. Other

DONE
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other meds ordered by neuro surgery

medications are still to be continued to aid health promotion and should be given on time as needed.

Dx: FBS, Lipid profile, CKMB, Trop I APTT, PT with INR

27.

Same with diagnostic rationale above

NOT DONE

28.

Same with diagnostic rationale above

An indicator of

DONE

Urinalysis

NOT DONE

health and disease, it is helpful in the detection of renal or metabolic

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disorders. It is an aid in diagnosing and following the course of treatment in diseases of the kidney and urinary system. Increase mannitol to 150cc q6 hrs x 5 days then reassess Start Omeprazole 40mg 1 Cap OD Irbesartan 300mg 1 Tab now then OD in AM
1. To relieve

DONE

hypertension and to reduce intracranial or intraocular pressure Treatment of active duodenal ulcer. Treatment of hypertension alone or in combination
84 | P a g e

DONE

DONE

with other antihypertensi ves. Amlodipine 10mg 1 Tab now then OD at HS Paracetamol 1 tab q 4hrs PRN for Temp greater than or equal to 37 degrees celscius CBG monitoring q6 pre-meals (511-5-11) 4. To monitor fluctuation of glucose levels. Capillary blood glucose testing is used as a monitoring
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Management of hypertension

DONE

3.

Decreases fever by a hypothalamic effect leading to sweating an d vasodilation

DONE

DONE

tool giving a guide to blood glucose levels at a specific moment in time. This is done because hyperglycaemi c levels are associated with worsening stroke RI 10 u SQ q6
5.

condition. Insulin is prescribed for because there is an episode of an increase

DONE

Standing Order 5 u IVTT for CBG >140g/dl

6.

in blood sugar. Insulin is prescribed for because there is an episode of an increase

DONE

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in blood sugar. Standing order D50W 25cc IVTT for CBG< or = to 80mg/dl_ D50W 50cc IVTT for CBG< or = 70mg/dl Repeat CBG q 15 mins until >100mg/dl 7. Same with diagnostic rationale above ordered for close monitoring of sugar level. monitor electrolytes in normal levels Aggressive TSB 9. 8. Assess if there are electrolyte imbalances present. TSB done to reduce fever. DONE DONE DONE NOT DONE

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maintain Systolic BP= 140-160

10.

Maintaining BP will ensure safety on not having severe hypertention and reduce risk of hypotension due to drugs

DONE

Refer accordingly

11.

administered. To report any unusualities that may develop into

6:00 AM Cxr: LV cardiomegaly considered unremarkable pulmonary findings

Transfer patient to ICU2 L3

12.

complications Patient to be transferred to intensive care unit 2 level 3 for close monitoring and provide proper treatment.

DONE

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Continue all meds

To maintain the pharmacologic al effect of medications as indicated.

DONE

Attach all labs to chart

All labs done by patient referred to NOD and

NOT DONE

Refer accordingly

attach to chart. To report any unusualities that may develop into

11-26-12 3:00 AM

Telephone Order of Dr. Mantos to Charmaine Miranda R.N:

1.

complications Management of moderate to severe hypertension. Paired with

DONE

BP: 170/100 mmHg Start Hydrolazine drip with D5W

D5W for fluid replacement and parenteral

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500cc + 4 amps Hydralazine to run at 5 ugtts/min with increments of 5 ugtts/min every 20 mins with maximum dose of 30 ugtts/min Maintain MAP 2. at 110 mmHg

access of medications and for the BP not to decrease abruptly and for it to be regulated properly.

Mean arterial pressure is considered to be the perfusion pressure seen by organs in

DONE

1:40 PM GCS 10 E3 M6 V1

Diagnostic: To secure Cranial CT

1.

the body. CT Scan: Rationale of Diagnostics

ABG & Blood Typing

90 | P a g e

Aphasic

scan

stated earlier

DONE

follow up chest xray result ABG USD of KUB + Prostate secure Blood typing ABG: Blood gases are drawn to determine acid-base imbalances. Chest X-ray Rationale of Diagnostics stated earlier

USD of the

KUB + Prostate: Ultrasound may be used to diagnose the

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presence of urinary obstruction, ki dney stones and also to assess the blood flow into the kidneys. And any changes or enlargement of the prostate gland.

Blood typing: Rationale of Diagnostics stated earlier

Continue meds

To maintain the pharmacologic al effect of

DONE

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medications as indicated. Metroprolol 100mg PO BID

Treatment of

DONE

hemodynamica lly stable acute myocardial infarction, angina pectoris,

Captopril 25 mg SubLingual if SBP>180mm Hg Kalium Durule 1TAB PO Days TID

hypertenstion. Treatment of hypertension

DONE

Prevention and

DONE

correction of potassium deficiency

IVF PNSS 120cc/hr

Same rationale as mentioned

DONE

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above DONE

I&O monitoring Continue CBG monitoring q6

Same rationale as mentioned above Same rationale as mentioned above

DONE

4:00 PM

Refer Neurosurgery notes

Soft diet is ordered to start

DONE

GCS 9-10 E3-4 V1 M5 Receptive Aplasia

May have gelatin diet & sips of water PO Progress to oatmeal then porridge once tolerated

normalization diet and exercise swallowing. Soft diet is ordered to start normalization diet and exercise DONE

Suggest NGT removal once tolerated

swallowing. NGT removal is ordered once patient can eat and well

NOT DONE

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tolerated without Cont Hydrolazine Cont meds problems. Same rationale as mentioned above To maintain the pharmacologic al effect of medications as indicated. 10:00 AM Refer DONE DONE DONE

For compliance to meds

Same rationale as mentioned above

Turn patient side to side

CVA puts the client in a bedridden position and thus prone to the development

DONE

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of bedsores. To prevent formation of bed sores, change of positioning of at least every two hours is done to relieve pressure from staying in one Moderate High Back Rest area. Patients head is elevated to reduce cerebral edema by improving venous Refer to DSWD, for family tracing drainage. To trace location of family and contact for informations. Refer
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DONE

DONE

accordingly 2:00 PM Rounds w/ Dr. Del Rosario Hold Hydralazine Maintained BP or desired level is assured of preventing Cont General liquids Amlodipine BID Cont. other meds hypertension. General liquids help in rehydration. Same rationale as mentioned above To maintain the pharmacologic al effect of medications as Cont. trail feeding indicated. Trail feeding done for progression diet to be tolerated and
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DONE

DONE

DONE

DONE

DONE

enhance swallowing reflex to prevent aspiration. Refer

140/100 mmHg

IM Neuro

Same diagnostic

DONE

70 bpm

For repeat cranial CT

rationale as mentioned above Same diagnostic rationale as mentioned DONE

20 cpm

scan May remove NGT

37 C

E4 V2 M6

GCS 12

Cont. meds

above To maintain the pharmacologic al effect of medications as

DONE

Cont. CBG

indicated. Same

DONE
98 | P a g e

monitoring

diagnostic rationale as mentioned above

11/28/12 10:30 AM

Suggest to transfer patient under neurosurgery Service if ok with IM May transfer patient to Neuro L3 Will co manage pt Refer Patient to be transferred to neurosurgery ward for

DONE

further assessment, monitoring and treatment.

DONE

DONE

11:00 AM

Trans out to neuro ward

Same diagnostic rationale as

DONE

Meds.

mentioned above

Amlodipine
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10mg 1 Tab BID Metroprolol 100mg 1 Tab BID Same diagnostic rationale as mentioned Kalium Durule TID x 3 days above Same diagnostic rationale as mentioned Irbesartan 300mg 1 Tab OD above Same diagnostic rationale as mentioned Mannitol 100cc IVTT q8 hrs above Same diagnostic rationale as mentioned Citicoline 500mg 2 caps TID above Same diagnostic rationale as
100 | P a g e

DONE

DONE

DONE

DONE

DONE

mentioned Senna Concentrate 2 tabs OD @ HS above Same diagnostic rationale as mentioned Atrovastatin 80mg 1 Tab OD @ HS above Same diagnostic rationale as mentioned 11/29/12 Cont. meds above To maintain the pharmacologic al effect of medications as Progression diet indicated. For the stomach to adjust and assess if diet can be tolerated to reduce risk of DONE DONE DONE DONE

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Refer

aspiration. To report any unusualities that may develop into

11/30/12

Cont. meds

complications To maintain the pharmacologic al effect of medications as

DONE

Refer

indicated. To report any unusualities that may develop into

12/1/12

Mannitol to 50cc IVTT x 3 doses

complications Same diagnostic rationale as mentioned

DONE

Resume Foley catheter

above Distention in the bladder/ incontinence resulting to

DONE

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reattachment of Foley Full Body bath 1. Catheter. For hygienic purposes to reduce risk of Refer infection To report any unusualities that may develop into complications 10:00 AM Cleared from neurosurgery MGH neurosurgerywise May be discharged from the ward and may go home. IM neuro for final disposition Refer To report any unusualities that may
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DONE

develop into 12/2/12 DIET: Low Salt Low Fat, Low Caffeine diet complications Low salt is advised to prevent hypertension and constriction of blood vessels. Low fat diet advised to prevent further formation of plaques leading to arthrosclerosis. Home meds: Same diagnostic Senna Concentrate 2 Tabs OD @ HS Atorvastatin Same To Comply
104 | P a g e

DONE

To Comply

rationale as mentioned above

40mg 1 Tab OD @ HS

diagnostic rationale as mentioned above

Irbesortan 300mg 1 Tab OD

Same diagnostic rationale as mentioned above

To Comply

Amlodipine 10mg 1 Tab BID

Same diagnostic rationale as mentioned above

To Comply

Citicoline 500mg 1 Tab TID x 1 month

Same diagnostic rationale as mentioned above

To Comply

Metroprolol 100mg 1 Tab

Same diagnostic

To Comply

105 | P a g e

BID

rationale as mentioned above

Follow up check up after 1 week

Check-up must be done to reassess and evaluate condition for improvement or

To Comply

12/3/12

MGH still in

reoccurrence. Still waiting for billing

DONE

Cont meds

process. Medications are to be continued to aid health promotion.

DONE

106 | P a g e

107 | P a g e

XIII- DIAGNOSTIC AND LABORATORY TEST

Date and Time

RBC Count Diagnostic Test/ 4.20-6.10 Normal Range Hemoglobin 135-175

Date and Time received: 11-25-12 07:33 AM

Date/Time Reported: 11-25-12 08:35 AM Date/Time released: 11-25-12 17:23 PM Hematocrit 0.40-0.52 WBC Count 5.0-10.0

5. Assess the puncture 3.53x10^6/uL -Used to determine site for signs and Result Purpose Clinical Significance Nursing Responsibility L anemia and symptoms of bleeding hemorrhage. Below the Normal or bruising of the skin. -This test may also be Range R: It is essential for used test to help diagnose thethe nurse to apply Hemoglobin 1. Explain and/or monitor any pressure by using 96.0 g/L measures the amount procedure and purpose number of diseases sterile gauze at the L of hemoglobin in of the test to the that the blood and is affect a good patient. site. production or lifespan measure of the blood's Below the Normal R: To gain cooperation of the red blood cells. ability to carry oxygen Range from the patient. 6. Assess the client for throughout the body. thepatient presence of any -used to determine if 2. Tell the that physiologic factors patient need blood no fasting is required. that may affect the transfusion. R: Food intake before laboratory results. the test has no colossal R: Physiologic factors effect on the result. may alter the results. 8.34x10^3/uL -used to determine the Within the normal 3. Assess the hydration presence of other range 7. Immediately notify -measured on a person status of the client. diseases that affect the physician if to determine the extent R: because hydration WBCs such as abnormal 0.29 of anemia. may alter results. results are allergies, leukemia or noted. L Below the Normal immune disorders. R:that To provide -the test to show Range 4. Ensure the -test is used to test the immediate care to the anemia or present of blood is not taken from monitor/function of patient. polycythemia. the hand or arm that bone marrow. has an intravenous line. 8. Observe and record any factorwith that may R: Hemodilution increase or intravenous fluids decrease causes aWBC false count. decrease in the value
108 | P a g e

Date/Time Received: 11-25-12 05:02

Differential Count Neutrophil 55-75 85 H -Help us detect the level of neutrophils in the body. -Tests are performed for routine health screenings or if a disease or toxicity is suspected. Above the normal Range

Date/Time Reported: 11-25-12 08:24 Date/Time Released: 11-25-12 Lymphocytes 20-35

13 L

-test measures the number of lymphocytes (a type of white blood cell) in blood - It is used to evaluate and manage disorders of the blood or the immune system.

Below the Normal Range

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Monocytes 2-10

-test measures the amount of monocytes in blood. -This test is used to evaluate and manage blood disorders, certain problems with the immune system, and cancers, including monocytic leukemia - This test may also be used to evaluate for the risk of complications after a heart attack.

Within the Normal Range

Eosinophil 1-8

0 L

-The test that counts the number of eosinophils. - It is used to evaluate and manage allergic conditions, blood and infectious diseases as well as certain infections.

Below the normal range

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Basophil 0-1

-Test measures the amount of basophils in blood. -This test is used to help evaluate and manage treatments including certain allergic disorders, blood disorders, neoplastic disorders, and infections caused by parasites.

Within the normal range

Within the normal range Platelet Count 150-400 243x10^3/uL -A platelet count may be used to screen for or diagnose various diseases and conditions that affect the number of platelets in the blood. High platelet count can lead to excessive, dangerous blood clotting if left untreated. Low platelet count called thrombocytopenia refers to an abnormally low number of platelets, the particles in blood that help with clotting,
111 | P a g e

MCH ( Mean Corpuscular Hemoglobin ) 25.70-32.20

27.3 pg

-Test that is carried out to diagnose the average amount of hemoglobin in the red blood cells.

Within Normal Range

Within Normal Range MCHC ( Mean Corpuscular Hemoglobin Concentration ) 32.30-36.50 -Used to test the level of hemoglobin in the blood. -a test that is carried out to test a person for anemia.

32.9 g/d

112 | P a g e

Date Released: 11-25-12 Date Reported: 11-25-12 Date Released: 11-25-12

BLOOD CHEMISTRY Importance why we need to know our blood type: -The blood that should be transfused to you should match the blood type you have - to avoid mismatch in emergency cases.

-Clean the needle site with alcohol. AB -Put the needle into the vein. More than one needle stick may be needed. -Attach a tube to the needle to fill it with blood. -Remove the band from your arm when enough blood is collected. -Put a gauze pad or cotton ball over the needle site as the needle is removed. Positive

Blood Type

Blood Type Rh

-Each blood type is also grouped by its Rhesus factor, or Rh factor. Blood is either Rh positive (Rh+) or Rh negative (Rh-)

-Put pressure to the site and then a bandage. -patient may feel nothing or may feel a quick sting or pinch. W

113 | P a g e

Potassium 3.5-5.5

3.36 mmoL/L L

-To evaluate clinical signs of potassium excess or potassium depletion. -to monitor renal function, acid base balance, and glucose metabolism

Below normal Range

Within normal Range -To evaluate fluid electrolyte and acidbase balance and related neuromuscular, renal and adrenal functions. -testing is used to detect abnormal concentrations of sodium, termed hyponatremia, and hypernatremia.

Sodium 136.00-155.00

139.50 mmoL/L

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Creatinine 53.00-115.00

314.30 mmoL/L H

-Measures the level of creatinine in the blood and urine . -used to diagnose impaired kidney function and to determine renal (kidney) damage.

Above the normal range

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XIV- DRUG STUDY

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Generic Name Amlodipine Besylate Brand Name Classification Indications Dosage Action (Norvasc) cardiovascular agent; calcium channel blocker; antihypertensive agent -Treatment of essential hypertension and angina 10mg 1 tab BID Inhibits calcium ions from entering the slow channels or select voltagesensitive areas of vascular smooth muscle and myocardium Side Effects Adverse Effects during depolarization. Rash, headache, dizziness and nausea CNS: Lightheadedness, fatigue, lethargy CV: Peripheral edema, arhythmias Dermatologic: Flushing Interactions Contraindications GI: Abdominal discomfort 1. Drug-drug: possible increased serum levels and toxicity of 1. 2. 3. 4. 5. Nursing Responsibilities 2. 6. 1. cyclosporine if taken concurrently. Allergy to amlodipine Hepatic or renal impairment Sick sinus syndrome Heart block Sick sinus syndrome Lactation Orient self with the 10 rights of giving medication before administering drug to the patient. Assess patient for history of allergy to amlodipine, impaired hepatic or renal function, sick sinus syndrome, heart block, or CHF. 3. 4. Physical assessment such as the skin lesion, color and edema. Assess for adverse drug reactions; report irregular heartbeat, swelling of the hands and feet, shortness of breath, pronounced dizziness, and constipation. 5. 6. Monitor patients blood pressure, pulse rate and cardiac rhythm frequently. Monitor for S&S of dose-related peripheral or facial edema that may not be accompanied by weight gain; rarely, severe 117 edema |Page may cause discontinuation of drug. 7. Instruct patient to take drug with meals if abdominal discomfort

118 | P a g e

Generic Name:

metoprolol succinate/ metoprolol tartate Brand name: Classification: Toprol-XL, Apo-Metoprolol, Betaloc , Lopressor, Norometoprol Cardiovascular system drugs, antihypertensive, pregnancy risk category C Indication: 1. 2. 3. Dosage: Action: Hyperthension Early intervention in acute MI Agina pectoris

100 mg/tab ; BID Unknown. A selective beta blocker that selectively blocks beta receptors; decreases cardiac output, peripheral resistance, and cardiac oxygen consumption, and depresses rennin secretion.

Contraindication:

1.

Contraindicated in patients hypersensitive to drug or other beta blockers

2.

Contraindicated in patients with sinus bradycardia, greater than first-degree heart block, cardiogenic shock, or overt cardiac failure when used to treat hypertension or agina. When used to treat MI, drug is contraindicated in patients with heart rate less than 45 beats/min, greater than first-degree heart block, PR interval of 0.24 second or longer with first-degree heart block, systolic blood pressure less than 100 mmHg or moderate to severe cardiac failure.

3.

Use cautiously in patients with heart failure, diabetes, or respiratory or hepatic disease.

Side effects: Adverse Effects:

Fatigue, dizziness, hypotension. CNS: depression CV: bradycardia, heart failure, AV block GI: nausea, diarrhea Respiratory: dyspnea
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120 | P a g e

Generic Name

Potassium Chloride Brand Name Classification Kalium Durule electrolytic and water balance agent

Indications

Utilized for treatment of hypokalemia; To prevent and treat potassium deficit secondary to diuretic or corticosteroid therapy. Also indicated when potassium is depleted by severe vomiting, diarrhea; intestinal drainage, fistulas, or malabsorption; prolonged diuresis, diabetic acidosis. Effective in the treatment of hypokalemic alkalosis (chloride, not the gluconate).

Dosage Action

100meq; 1 tab TID Principal intracellular cation; essential for maintenance of intracellular isotonicity, transmission of nerve impulses, contraction of cardiac, skeletal, and smooth muscles, maintenance of normal kidney function, and for enzyme activity. Plays a prominent role in both formation and correction of imbalances in acidbase metabolism.

Side Effects

Rash, GI bleeding, GI obstruction, GI ulceration, ECG (peaking of T waves, loss of P waves depression of ST segment, prolongation of QTc interval)

Adverse Effects

GI: Nausea, vomiting, diarrhea, abdominal distension. Body Whole: Pain, mental confusion, irritability, listlessness, paresthesias of extremities, muscle weakness and heaviness of limbs, difficulty in swallowing, flaccid paralysis. Urogenital: Oliguria, anuria. Hematologic: Hyperkalemia. Respiratory: Respiratory distress.
121 | P a g e

CV: Hypotension, bradycardia; cardiac depression, arrhythmias, or

Generic Name

Irbesartan Brand Name Classification Indications Avapro Angiotensin II receptor antagonist (ARB), Antihypertensive Treatment of hypertension as monotherapy or in combination with other antihypertensives. Slowing of the progression of kidney disease in Dosage Action patients with hypertension and type 2 diabetes 300mg 1 Tab; OD Selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle and adrenal gland; this action blocks the vasoconstriction effect of the renin-angiotensin system as well as the release of aldosterone, leading to decreased blood pressure. Side Effects Adverse Effects Headache, dizziness, syncope, muscle weakness Hypotension, orthostatic hypotension Rash, inflammation, urticaria, pruritus, alopecia, dry skin Diarrhea, abdominal pain, nausea, constipation, dry mouth, dental pain URI symptoms, cough, sinus disorders Interactions Contraindications Cancer in preclinical studies, back pain, fever, gout, fatigue 28. Drug-drug: use caution with drugs metabolized by CYP2C9; 29. anticipated effects may altered Contraindicated with hypersensitivity to irbesartan, pregnancy (use during the second or third trimester can cause injury or even death to the fetus), lactation. Nursing Responsibilities 32. 33. 34. 35. 36. 30. 31. Use cautiously with hepatic or renal dysfunction, hypovolemia. Orient self with the 10 rights of giving medication before administering drug to the patient Assess patient for hypersensitivity to irbesartan, hepatic or renal dysfunction and hypovolemia. Physical assessment, assess the skin color, any lesions and turgor. Administer without regard to meals. Monitor VS specially the BP. Monitor patient I/O.
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123 | P a g e

Generic Name:

Brand name: Classification: Indication:

mannitol Osmitrol, Sahar mannitol 20% solution for IV Osmotic Diuretic; Pregnancy risk category 1. Test dose for marked oliguria or suspected inadequate renal function 2. 3. 4. 5. Oliguria To prevent oligurioa or acute renal failure To reduce intraocular or intracranial pressure Diuretics in drug intoxication

Dosage: Action:

6. Irrigating solution during transurethral resection of prostate gland 100cc Increases osmotic pressure of glumerular filtrate, inhibiting tubular reabsorption of water electrolytes; drug elevates plasma osmolality, increasing water flow into extracellular fluid. Route Onset Peak Duration I.V. 30-60 mins Unknown 3-8hr Diarrhea CNS: dizziness, headache, blurred vision, seizures CV: hypotension, hypertension, edema, tachycardia, chest pain Dermatologic: urticaria, skin necrosis with infiltration GI: nausea, anorexia, dry mouth, thirst GU: dieresis, urine retention Hematologic: fluid and electrolyte imbalances, hyponatremia Respiratory: pulmonary congestion, rhinitis Drug-drug 1. Litium: may increase urinary excretion of lithium. Monitor litium level closely Contraindicated in patients hypersensitive to drug Contraindicated with anuria due to severe renal disease Use cautiously with pulmonary congestion, active intracranial bleeding, dehydration, renal disease, congestive heart failure, pregnancy, lactation. Assess hypersensitivity of patient with the drug
124 | P a g e

Side effects: Adverse Effects:

Interactions:

Contraindication:

2. 3. 4.

Nursing Responsibilities:

1. 1.

Assess patient if he/she experienced severe or long-term kidney

Generic Name

Brand Name Classification Indications

Citicoline Nicholin, Somazine, 5-Cytidine diphosphate choline Neurotonics, Nootropics 1. Parkinsons disease 2. 3. 4. 5. 6. 7. 8. 9. Head injury Cerebral vascular disease Alzheimers disease Cerebral surgery or acute cerebral disturbance Disturbance of consciousness following brain surgery Patients with acute, severe & progressive disturbance of consciousness Administration with hemostatics Intracranial pressure relieving drugs or use measures to keep body temp low.

Dosage Action

500mg 2 caps TID 1. Citicoline seems

to

increase

brain

chemical

called

phosphatidylcholine. This brain chemical is important for brain function. Citicoline might also decrease brain tissue damage when the brain is injured.It is usually known that phospholipid, especially lecithin, decreases following decline in brain activity with cerebral trauma. Citicoline, which is a co-enzyme, accelerates the biosynthesis of lecithin in the body. 2. This medication enhances the action of the brain stem ciliary body especially the ascending ciliary body activating system, which is closely related to consciousness, but does not exert effort on the extrapyramidal system. Citicoline increases cerebral blood flow and oxygen consumption of the brain and improves cerebral circulation and metabolism.
125 | P a g e

3.

Scientific research demonstrates that Citicoline consumption promotes brain metabolism by enhancing the synthesis of acetyl-

126 | P a g e

Generic Name

Brand Name Classification Indications Dosage Action

Senna Concentrate Senokot 187 mg Tablet/ granules Laxative For the relief of functional constipation through peristaltic stimulation. 2 tabs OD @ HS Senokot preparations contain glycosides (the natural principles of senna) which, upon ingestion, exert no action in the stomach or small intestine. In the colon, according to current theory, enzymatic action converts the inactive glycosides into active aglycones which act specifically in the large bowel through the auerbachs plexus to stimulate peristalsis. This medication may cause diarrhea, nausea, vomiting, rectal irritation, stomach cramps or bloating. If these effects continue or become bothersome, inform your doctor. Gastrointestinal Disorders: Common: Abdominal pain. Uncommon: Feces discoloration, nausea, rectal hemorrhage, vomiting. Immune System Disorders: Uncommon: Urticaria. Very Rare: Anaphylactic or anaphylactoid reaction. Renal and Urinary Disorders: Uncommon: Chromaturia. Reproductive System and Breast Disorders: Uncommon: Breast milk discoloration. Skin and Subcutaneous Tissue Disorders: Uncommon: Erythematous rash, maculopapular rash, perianal irritation. 14. No known drug interactions. 15. Do not use when abdominal pain, nausea, vomiting, or other symptoms of appendicitis are present, acute abdominal diseae, intestinal hemorrhage, or obstruction , or persistent diarrhea. 16. 17. 18. 19. 20. Store at temperature not exceeding 30 degrees Celsius. Orient self with the 10 rights of giving medication before administering drug to the patient Assess hypersensitivity if senna concentrates. Advised that patient may experience common side effect such as diarrhea, nausea and vomiting.
127 | P a g e

Side Effects

Adverse Effects

Interactions Contraindications

Nursing Responsibilities

Notify physicianif experience: rectal bleeding, rapid heart rate, weakness, dizziness, fainting, sweating, skin rash, unrelieved

128 | P a g e

Generic Name

Atorvastatin calcium Brand Name Classification Lipitor Antihyperlipidemic HMG-CoA reductase inhibitor

Indications

Adjunct to diet to reduce LDL cholesterol, total cholesterol, apolipoprotein B, and triglyceride levels and to increase HDL cholesterol levels in patients with primary hyoercholesterolemia (heterozygous level familial and nonfamilial) primary and mied lipidemia (Fredrickson types IIa and IIb); adjunct to diet to reduce triglyceride (Fredrickson type IV); dysbetalypoproteinemia (Fredrickson type III) in patients who dont respond adequately to diet. Alone or as an adjunct to lipid-lowering treatments such as LDL apheresis to reduce total and LDL cholesterol in patients with homozygous familial hypercholesterolemia. Heterozygous familial hypercholesterolemia. To lower cholesterol To stabilize plaque and prevent strokes through anti-inflammatory and other mechanisms 40mg 1 tab OD @ HS Reduces plasma cholesterol and lipoprotein levels by inhibiting HMGCoA reductase and cholesterol synthesis in the liver and by increasing the number of LDL receptors on liver cells to enhance LDL uptake and breakdown.

Dosage Action

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Side Effects

Allergic reaction, facial or generalized edema, flulike symptoms, infection, lymphadenopathy, weight gain

130 | P a g e

Generic Name

Nicardipine Hydrochloride Brand Name Classification Indications Cardene, Cardene SR Calcium channel blockers; antianginal; antihypertensive Nicardipine is used with or without other medications to treat high blood pressure (hypertension). Lowering high blood pressure helps prevent strokes, heart attacks, and kidney problems. Nicardipine is called a calcium channel blocker. It works by relaxing blood vessels so blood can flow more easily.Nicardipine is also used to prevent certain types of chest pain(angina). It may help to increase your ability to exercise and decrease the frequency of angina attacks. This medication must be taken regularly to be effective. It should not be used to treat attacks of chest pain when they occur. Use other medications (such as sublingual nitroglycerin) to relieve attacks of chest pain as directed by Dosage Action your doctor. Consult your doctor or pharmacist for details. 10mg These medications block the movement of calcium into the smooth muscle cells surrounding the arteries of the body. Since calcium promotes contraction of muscle, blocking calcium entry into the muscle cells relaxes the arterial muscles and causes the arteries to become larger. This lowers blood pressure, which reduces the work that the heart must do to pump blood to the body. Reducing the work of the heart lessens the heart muscle's demand for oxygen and thereby helps prevent angina (heart pain) in patients with coronary artery disease. Unlike verapamil or diltiazem, nicardipine has little effect on heart Side Effects muscle or on electrical conduction within the heart. Side effects include swelling of the feet (edema), dizziness,headaches, flushing, palpitations, and nausea. Fainting, over growth of the gums, and rash also may occur. It may increase heart rate due to a drop in blood pressure. Nicardipine sometimes causes an increase in the frequency and duration of angina. The reason for this side effect is not clearly understood. Excessively low blood pressure can occur in rare instances, especially during initiation of treatment or following Adverse Effects adjustments of dosage. CV: hypotension, arrhythmias, asytole
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Generic Name

Brand Name Classification Indications Dosage Action

Neuro Aid Capsule MLC 601; MOleac M03BX - Other centrally acting agents ; Used as muscle relaxants. It helps support neurological, motor and cognitive functions resulting in a better quality of life. 4 capsule TID NeuroAiD has been proved to stimulates the secretion of BDNF. The in vitro and in vivo results show that NeuroAiD makes cell more resistant against glutamate aggression, increases neurite outgrowth and connectivity as well as reduces the infarct volume, therefore results in better neurological functions.[3] May cause increase thirsty and dry mouth vomiting, nausea, and mild headaches 64. Research on drug interactions with aspirin as an antiplatelet agent were conducted and revealed no severe side effect. Yet today, no other interaction researches have been recorded so far. Not allowed for use in pregnancy, lactating mothers and children below 18. Orient self with the 10 rights of giving medication before administering drug to the patient 67. 68. 69. 70. 71. 72. 73. Note for the age and condition of the patient. Advised that patient may experience common side effects such as thirsty and dry mouth. Advised to report immediately if experienced headches, nausea and vomiting. Advised to increased oral fluid to lessen the dryness experienced. Monitor Patients VS. Checked the GCS. Checked the motor response and reflex. http://www.neuroaid.com.sg/neuroaid-leaflet.html http://www.wisegeek.com/what-is-neuroaid.htm neuroaid.html
133 | P a g e

Side Effects Adverse Effects Interactions

Contraindications Nursing Responsibilities

65. 66.

Source

74. 75.

76.

http://www.neuroaid.com/en/medical-professional/what-is-

134 | P a g e

Generic Name

Cerebrolysin Brand Name Ebewe; Bulgaria Classification C04A - PERIPHERAL VASODILATORS ; Used as peripheral vasodilators. Indications 1. Complex therapy of endogenous depression (in combination with psychotherapy and antidepressants) 2. 3. 4. Post-apopletic complications Chronic cerebrovascular disorders Brain and spinal cord injuries (craniocerebral trauma, post operative trauma, concussion, cerebral contusion,) 5. 6. 7. 8. Dosage Action Alzheimer disease Ischemic stokes (treatment the complications) Mental retardation Senile dementia 2152mg/ml/amp is a nootropic drug which contains low molecular biologically active neruropeptides, which penetrate through blood-brain barrier and act directly on the nerve cells. The drug possesses a multimodal organo-specific effect on the brain, provides metabolic regulation, neuroprotection, functional neuromodulation, and neurotrophic activity as well. Cerebrolysin improves the efficiency of aerobic energy metabolism in the brain, improves the intracellular protein synthesis in the developing and aging Side Effects brain. heat, sweating, dizziness, tachycardia or fibrillation. agitation, hypertension, hypotension, lethargy, tremors, depression, apathy, dizziness, headache, shortness of breath, diarrhea, nausea) were identified during clinical trials and occurred equally in patients, receiving Cerebrolysin , and patients taking placebo. |Page Adverse Effects1. Digestive system: loss of appetite, indigestion, diarrhea,135 constipation, nausea and vomiting.

Generic Name:

Paracetamol (acetaminophen) Brand name: abenol, acephen,aceta,actamin, aminofen, tempra, valorin, panadol, feverall, Biogesic Classification: Cardiovascular system drugs; Nonopioid analgesics and antipyretics, Pregnancy risk category B Indication: Dosage: Action: 1. Mild pain or fever

500mg IVTT q6 hours Unknown. Thought to produce analgesia by blocking pain impulse by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat-regulating center. Route Onset Peak Duration P.O./ P.R. Unknown -2 hours 3-4hr 1. Many OTC and prescription products contain acetaminophen, be aware of this when calculating total daily dose. 2. Use liquids form for children and patients who have difficulty swallowing 3. In children, do not exceed five doses in 24 hours

Contraindication:

Side effects: Adverse Effects:

jaundice, rash Hematologic: hemolytic anemia, neutropenia, leucopenia, pancytopenia Hepatic: jaundice

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Metabolic: hypoglycemia Skin: rash, urticaria Drug interactions: Drug-drug: 1. Barbiturates, carbamazepine, hydantoins, rifampin, sulfinpyrazone: high doses or long-term use of these drugs may reduce therapeutic effects and enhance hepatotoxic effects of acetaminophen Drug-food: caffine: may enhance analgesic effects of acetaminophen. Drug-lifestyle: alcohol use: may increase risk of hepatic damage Nursing Responsibilities: 2. 3. 4. Assess vital signs Identify indications for therapy and expected outcomes. Document presence of fever. Rate pain, noting type, onset, location, duration and intensity. 5. Do not take for more than 5 days for pain in children or for more than 3 days for fever without consulting the doctor. 6. 7. 8. In children, dont exceed five doses in 24 hours. Report pallor, weakness and palpitations. Advise client to take only as directed and with food or milk to minimize GI upset 9. Many OTC and prescription products contain paracetamol; be aware of this when calculating total daily dose. 10. Review with parents the difference between the concentrated dropper dose formulation and teaspoon dose formulation. 11. Any unexplained pain or fever that persists longer than 3-5 days requires medical evaluation

137 | P a g e

Sources:

12. 13.

http://www.drugs.com/paracetamol.html. 2009 Nursing2006 drug handbook. 26th edition. Lippincott Williams & Wilkins. Page 351-353

14.

http://www.mims.com/USA/drug/info/paracetamol/. 2011

Generic Name:

Omeprazole :Losec Classification: Indication: Prilosec gastrointestinal agent; proton pump inhibitor 15. Duodenal and gastric ulcer. Gastroesophageal reflux disease including severe erosive esophagitis (4 to 8 wk treatment). Long-term treatment of pathologic hypersecretory conditions such as Zollinger-Ellison syndrome, multiple endocrine adenomas, and systemic mastocytosis. In combination with clarithromycin to treat duodenal ulcers associated with Helicobacter pylori. Dosage: Action: 40 mg capsules An antisecretory compound that is a gastric acid pump inhibitor. Suppresses gastric acid secretion by inhibiting the H+, K+-ATPase enzyme system [the
138 | P a g e

acid (proton H+) pump] in the parietal cells. Contraindication: 16. Long-term use for gastroesophageal reflux disease, duodenal ulcers; lactation. Side effects: Asthenia, vertigo, insomnia, anxiety, paresthesias, dream abnormalities, inflammation, dry skin, pruritus Adverse Effects: CNS:Headache, dizziness, fatigue. GI:Diarrhea, abdominal pain, nausea, mild transient increases in liver function tests. Urogenital:Hematuria, proteinuria. Skin:Rash. Drug interactions: Drug-drug: increased serum levels and potential increase in toxicity of benzodiazephines, phenytoin, warfarin. Decreased absorption with sucralfate, give these drugs at least 30 min apart. Nursing Responsibilities: 17. 18. 19. 20. 21. 22. 23. Assess for hypersensitivity to omeprazole. Physical assessment: skin (lesions and color) Monitor I/O, it affect the urinary output. Checked VS. abnormal results in RR. Take medications with food Do not crush or chew the capsule Caution patient to avoid alcohol, salicylates, ibuprofen; may cause GI irritation 24. Patient may experience anorexia; small frequent meals may help to maintain adequate nutrition. 25. Report severe headache, unresolved severe diarrhea, or changes in respiratory status.

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Sources:

26.

Nursing2006 drug handbook. 26th edition. Lippincott Williams & Wilkins. Page 881-882

27.

http://www.mims.com/USA/drug/info/omeprazole/. 2011

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Generic Name

Brand Name Classification Indications Dosage Action

Hydralazine Hydrochloride Alphapress, Apresoline, Novo-Hyzalin, Supres Cardiovascular System Drug, Antihypertensive, Pregnancy risk category C Essential hypertension (orally, alone or with other antihypertensives), severe essential hypertension (parenterally to lower blood pressure quickly) 5mEq IVTT PRN for diastolic blood pressure over 110mmHg Unknown. A direct-acting vasodilator that relaxes arterial smooth muscle. Route P.O. I.V. I.M. Onset 20-30 min 5-20 min 10-30 min Peak 1-2 hours 10-80 min 1 hour Duration 2-4 hours 2-6 hours 2-6 hours

Side Effects

Headache, tachycardia, angina pectoris, palpitations, nausea, vomiting, diarrhea, anorexia, neurotopenia, leucopenia,, agranulocytopenia, agranulocytosis, thromobocytopenia with or without purpura CNS: peripheral neuritis, headache, dizziness; CV: orthostatic hypotension, tachycardia, edema, angina pectoris, palpitations; EENT: nasal congestion GI: nausea, vomiting, diarrhea, constipation, anorexia Hemotologic: neurotopenia, leucopenia, agranulocytopenia, agranulocytosis, thromobocytopenia with or without purpura Skin: rash Drug-drug: 16. 17. 18. 19. Diazoxide, MAO inhibitors: May cause severe hypotension. Use together cautiously. Diuretics, other hypotensive drugs: May cause excessive hypotension. Dosage adjustment may be needed. Indomethacin: May decrease effects of hydralazine. Monitor blood pressure. Metoprolol, propanolol: May increase levels and effects of beta blockers. Monitor patient closely and there is a need to adjust the dosage. Contraindicated in patients sensitive to the drug, heart disease.

Adverse Effects

Interactions

Contraindications

20. 21.

Those with coronary artery disease or mitral valvular rheumatic

141 | P a g e

Generic Name

Brand Name Classification Indications

Insulin (Regular) Humulin R, Novolin R, Regular Insulin, Pork Regular Iletin II, Regular Purified Pork Insulin, Velosulin, Velosulin BR, Velosulin Human hormone and synthetic substitute; antidiabetic agent; insulin Emergency treatment of diabetic ketoacidosis or coma, to initiate therapy in patient with insulin-dependent diabetes mellitus, and in combination with intermediate-acting or long-acting insulin to provide better control of blood glucose concentrations in the diabetic patient. Used IV to stimulate growth hormone secretion (glucose counter regulatory hormone) to evaluate pituitary growth hormone reserve in patient with known or suspected growth hormone deficiency. Other uses include promotion of intracellular shift of potassium in treatment of hyperkalemia (IV) and induction of hypoglycemic shock as therapy in psychiatry. 100 units/mL Short-acting, clear, colorless solution of exogenous unmodified insulin extracted from beta cells in pork pancreas or synthesized by recombinant DNA technology (human). Enhances transmembrane passage of glucose across cell membranes of most body cells and by unknown mechanism may itself enter the cell to activate selected intermediary metabolic processes. Promotes conversion of glucose to glycogen. Rash Hives Itching Swelling of the mouth or throat Wheezing or other difficulty breathing BodyWhole:Most adverse effects are related to hypoglycemia; ana-phylaxis (rare), hyperinsulinemia [Profuse sweating, hunger, headache, nausea, tremulousness, tremors, palpitation, tachycardia, weakness, fatigue, nystagmus, circumoral pallor; numb mouth, tongue, and other paresthesias; visual disturbances (diplopia, blurred vision, mydriasis), staring expression, confusion, personality changes, ataxia, incoherent speech, apprehension, irritability, inability to concentrate, personality changes, uncontrolled Babinski reflex, coma. (Urine glucose tests will be
142 | P a g e

Dosage Action

Side Effects

Adverse Effects

yawning, loss of consciousness, delirium, hypothermia, convulsions, negatives).

XV- NURSING THEORIES

Sister Callista Roys Adaptation theory Adaptation theory of Sister Callista Roy views a person as an adaptive system with coping processes. She described the person as a whole comprised of parts which functions as a unity for some purposes. In relation to our patient, we think that our patient needs to adapt to the changes related to his disease and that it is a need to undergo into some modification when it comes to his health because we, as a part of the medical team desires to give the best possible care to our patients. As a student nurse, the interventions we perform ultimately elicit a response from our patients. It is on how we render service to our clients and how we treat them individually and on the nature and extent of the nursing intervention. Our patients may or may not actually adapt according to our expectations. This theory assumes that a person should be aware about his or herself and the environment he is into. The patient should be the one to identify his capabilities and needs in the human adaptive system. He should be able to select appropriate approaches for her and implement it as well as to evaluate whether it had helped him in his daily living. Nurses serve as a guide in helping the patients in this cycle which we call the nursing process starting from assessing what is the major problem up to evaluating the outcome. The patient should adapt to the 4 adaptive modes which includes the physiologicphysical, self- concept group identity, role function and interdependence. In the physiologic143 | P a g e

physical, being physically fit is not always consider as healthy and therefore in the case of our client, we must remind him that by eating the right kind of food that are not contraindicated by his physician. The last adaptive mode is interdependence, which includes the giving and receiving of love form his family, also having rest and towards to society and have the core values through effective relations and communications with his significant other.

Faye Glenn G. Abdellahs TWENTY ONE NURSING PROBLEMS "Nursing is based on an art and science that mould the attitudes, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help people, sick or well, cope with their health needs." - Abdellah This theory helps us student nurse utilize problems from our patient. It helps Decides the appropriate course of action to take in terms of relevant nursing principles, providing continuous care of the individuals total needs helps the individual to become more self directing in attaining or maintaining a healthy state of mind & body and helping the individual to adjust to his limitations and emotional problems. It helps our patient especially in healthy lifestyle since our patient really needs a healthy lifestyle due to his disease which is chronic kidney disease.

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This theory is about nursing care for whole individual with the help of the 21 typology Abdellah made: Abdellahs Typology of 21 Nursing Problems are as follows:

1. To promote good hygiene and physical comfort 2. To promote optimal activity, exercise, rest, and sleep 3. To promote safety through prevention of accidents, injury, or other trauma and through the prevention of the spread of infection 4. To maintain good body mechanics and prevent and correct deformities 5. To facilitate the maintenance of a supply of oxygen to all body cells 6. To facilitate the maintenance of nutrition of all body cells 7. To facilitate the maintenance of elimination 8. To facilitate the maintenance of fluid and electrolyte balance 9. To recognize the physiologic responses of the body to disease conditions 10. To facilitate the maintenance of regulatory mechanisms and functions 11. To facilitate the maintenance of sensory function 12. To identify and accept positive and negative expressions, feelings, and reactions 13. To identify and accept the interrelatedness of emotions and organic illness 14. To facilitate the maintenance of effective verbal and nonverbal communication 15. To promote the development of productive interpersonal relationships 16. To facilitate progress toward achievement of personal spiritual goals 17. To create and maintain a therapeutic environment
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18. To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs 19. To accept the optimum possible goals in light of physical and emotional limitations 20. To use community resources as an aid in resolving problems arising from illness 21. To understand the role of social problems as influencing factors in the cause of illness

Abdellah described nursing as a service to individual, to families and therefore to the society. She acknowledged the influence of Henderson and expanded Hendersons 14 needs into her own 21 problems that she believed would serve as a knowledge base for nursing. In her nursing practice, she strongly believed and supported the idea that nursing research would be the key factor in helping nursing to advance and grow into a true respectable profession. It was through her research that what is now known and seen as nursing diagnosis was developed. Abdellah stated that people have physical, emotional and sociological needs and that these needs are overt needs which consist largely of physical needs which are covert in nature such as emotional, social and interpersonal needs which are often perceived incorrectly. Abdellah averred that the patient is the justification for the existence of nursing. The individuals (families) are the recipients of nursing care and health or achieving it is the purpose of nursing. Abdellah defined man, health, environment/society and nursing. And of nursing she stated that Nursing is a service to individuals, families and therefore to society. The goal of nursing according to her is the physical, emotional, intellectual, social and spiritual functioning of the client which pertains to holistic care.

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Virginia Hendersons 14 Basic Human Needs Virginia Henderson's 14 Basic Human Needs Theory emphasizes the importance of patient independence that the patient will continue to progress after being released from the hospital. Henderson described the role of the nurse as substitutive, which is doing tasks for the patient; supplementary, which is helping the patient do the tasks; or complementary, which is working with the patient to do tasks. All of these roles are to help the patient become as independent as possible.

Since our patient is admitted at the hospital and is for treatment, it is our duty as nurses to do tasks for him, to help him and to work with him in order to attain his independence as possible towards maintaining his health. It is also our responsibility to take care of our patient while he is still at the hospital so that he, later on, will be able to take care of himself independently. This is why health teachings are very important because the care that we give to our patient is not limited only at the hospital but our patient can also practice our way of care even at home. But before giving care to our patient, we nurses should know by heart the primary needs that humans have. With this, we will be able to plan carefully and accordingly on the interventions to be done to our patient. This is why Hendersons theory is considered as the basis for nursing care. Henderson categorized nursing activities into fourteen components based on human needs. The fourteen components of Henderson's concept are as follows: 1. 1. Breathe normally. Eat and drink adequately. It is necessary for us to breathe because if we stop breathing we eventually die. To eat and drink adequately is for our body to maintain balance or keep working. We need to eat food that contains nutrients necessary for survival including water, which is very needed by our body. It regulates heat, cleanses the body and provides fluid for the body. 2. Eliminate body wastes.
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3.

Eliminate by all avenues of elimination. Our body then absorbs the nutrients and what is left are unnecessary materials or toxics that must be taken out of the body and this is process by elimination of urine or feces.

4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

Move and maintain desirable postures. For our body to function normally we must maintain desirable body positions. Sleep and Rest Our body can function 24 hours a day but if prolonged we eventually die. We need to rest to regain strength, to grow and to develop. Select suitable clothes-dress and undress. Select suitable clothing. We must select suitable clothing prior to temperature of the environment to maintain normal body temperature. Maintain body temperature within normal range by adjusting clothing and modifying environment. Maintain body temperature within normal range. If body temperature declines or increases, both are risky. Keep the body clean and well groomed and protect the integument. Keeping the body clean lessens the risk of attaining infection or disease. Avoid dangers in the environment and avoid injuring others. To avoid dangers in the environment we must be extra very careful to our actions Communicate with others in expressing emotions, needs, fears, or opinions Communicate with others makes life much easier and comfortable through increasing social health. Worship according to one's faith We humans have different believes, have different Gods but what is common to us is that we believe in God whom we believe is the giver of our lives and is the source of our strength and intellectual thinking.

20. 21. 22. 23.

Work in such a way that there is a sense of accomplishment We work or do something to keep us alive, something that makes us happy and complete. Play or participate in various forms of recreation. Play or participate in various forms of recreation. To aid our lives with better standards of living we usually play significant roles in various forms of recreation.
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24. 25.

Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities Basic needs are essential for survival and to daily life activities and experiences

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XVI- NURSING CARE PLAN Patients Name: Patient B Gender: Male Diagnosis: Cerebrovascular bleed capsuloganglionic hypertension II Ward: Neuro

DATE

CUES

NEEDS

NURSING DIAGNOSIS WITH RATIONALE

OBJECTIVE OF CARE

NURSING INTERVENTIONS WITH RATIONALE

EVALUATIO

December 6, 2012

SUBJECTIVE:

3-11 Shift Subjective: 3 PM Wala mn koy kauban diri pag mtulog nako, buntag na sila mubalik.

SelfPerception SelfConcept Pattern

Anxiety related to absence of a family member/ support group.

Absence of a family member during illness/ hospitalization of an individual may cause depression and

After 8 hour span of care, patient will appear relaxed and anxiety will be lessened as evidenced by verbalization of relief of anxiety.

1.

Establish rapport to the client and family. Establishing rapport to the client and family will enable the nurse to gain the confidence and cooperation of the client.

December 6 2012

11 PM

2.

Listen actively to the patient. Patient will feel comforted.

GOAL MET

After 8 hour Speak in brief statements and use span of care, simple words. patient was ab This allows the patient to understand what to verbalize a 3.
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Objective:

anxiety due to the feeling of being alone.

you are saying. Simple words are applicable for a child.

>Restlessness/anx iety

>Lack of pleasure in activities

Nurses Pocket Guide by Doenges, Moorhouse and Murr

relief of anxie Maayo na ln naa si nanay n watcher dra s 4. Give patient a little advice and pleasing pikas, naay mubantay sa ideas. akoa. Mubalik This will help stimulate the patient to be bitaw si bayo relaxed. ugma sayo sa buntag. 5.

Advice the patient to play or divert attention to hobbies. >Patient appe This will help the patient forget about his to be relaxed current feelings. comfortable 6. Teach the patient about relaxation techniques, such as guided imagery. This soothes the mindset of the patient and will help him relax.

7. Tell the patient verbalize feelings. This helps patient to relax mentally and physically.

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8. Encourage social interactions. Social interactions lessen anxiety and loneliness.

9. Advice the watcher to be with the patient as much as possible. This helps reduces loneliness and anxiety.

1.

Advice the watcher to seek for a spiritual advice/help. Spiritual advice can strengthen ones faith and reduces anxiety.

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Date, Time and Shift D E C E M B E R 07, 2 0 1 2 4:00 PM

Cue
Objective: 1. Slur red spee ch 2. Diff icult y in expr essi ng idea s and feeli ngs

Needs/ Patterns
P E R C E P T U A L C O G N I T I V E P A T T E R N

Nursing Diagnosis
Impaired verbal communication related to cognitive function secondary to cerebrovascular accident

Objective

Nursing Intervention

Nursing Evaluation

Within 6 hours of nursing interventions, the patient will be able to establish method of communication in which needs can be expressed as evidenced by using resources appropriately to express needs.

1.

Assess type/degree of dysfunction R: Helps determine area and degree of brain involvement and difficulty patient has with any or all steps of the communication process. Differentiate aphasia from dysarthria R: Choice of interventions depends on type of impairment. Listen for errors in conversation and provide feedback R: Patient may lose ability to monitor verbal output and be unaware that communication is not sensible. Ask patient to follow simple commands (e.g., Shut your eyes, Point to the door); repeat simple words/ sentences R: Test for receptive aphasia

GOAL MET! 12/07/12 10:00 PM After 6 hours of nursing interventions, the patient was able to use other resources as a means of communication as evidenced by the patient using a pen to express his needs using his left hand.

2.

3.

4.

5.

Have patient produce simple sounds, e.g., Sh, Cat. R: Identifies dysarthria, because motor
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components of speech (tongue, lip movement, breath control) can affect articulation and may/may not be accompanied by expressive aphasia. 6. Ask patient to write name and/or a short sentence. If unable to write, have patient read a short sentence. R: Tests for writing disability (agraphia) and deficits in reading comprehension (alexia), which are also part of receptive and expressive aphasia. Provide alternative methods of communication, e.g., writing or felt board, pictures. Provide visual clues gestures, pictures, needs list, demonstration). R: Provides for communication of needs/desires based on individual situation/underlying deficit. Anticipate and provide for patients needs.

7.

8.

R: Helpful in decreasing frustration

when dependent on others and unable to communication desires. 9. Talk directly to patient, speaking slowly and distinctly. Use yes/no questions to begin with, progressing in complexity as patient responds. R: Reduces confusion/anxiety at having to process and respond to 172 | P a g e

large amount of information at one time 10. Speak in normal tones and avoid talking too fast. Give patient ample time to respond. Talk without pressing for a response.

R: Patient is not necessarily hearing

impaired, and raising voice may irritate or anger patient. 11. Encourage SO/visitors to persist in efforts to communicate with patient, e.g., reading mail, discussing family happenings even if patient is unable to respond appropriately. R: It is important for family members to continue talking to patient to reduce patients isolation, promote establishment of effective communication, and maintain sense of connectedness with family. Advise the patient to consult with speech therapist. R: Assesses individual verbal capabilities and sensory, motor, and cognitive functioning to identify deficits/therapy needs.

12.

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DATE

CUES

NEEDS

NURSING DIAGNOSIS WITH RATIONALE

OBJECTIVE OF CARE

NURSING INTERVENTIONS WITH RATIONALE

EVALUATIO

December 6, 2 December 6, 2012 OBJECTIVE: Activity Exercise Pattern Impaired physical mobility related to neuromuscular involvement: weakness, paresthesia, as evidenced by impaired coordination, limited range of motion, decreased muscle strength secondary to CVA. A stroke is an upper motor neuron lesion and results in Short term: After 8 hours of nursing care the patient will be have improved physical mobility as evidenced by: 1. Establish rapport to the client and family. Establishing rapport to the client and family will enable the nurse to gain the confidence and cooperation of the client. 2.

11 PM

3-11 Shift

3 PM

Subjective: Maglisod na man siya maglihok karon kay dili na niya kaya ang iyahang lawas. As verbalizedby the watcher.

GOAL MET

Objective: > Generalized weakness >With pale skin >With fatigability

Reassess ability to carry out ADLs After the span (e.g., feeding, dressing, grooming, care, the patien bathing and ambulating) on regular was able to: 1. Verbalization basis. of understanding To determine the aspect of ADL of situation or risk that is difficult to the patient. factors and 1. Maintai individual 3. Change position at least every two position treatment regimen hours and more often if placed on function and safety the affected side. and skin measures. integrit Reduces risk of tissue ischemia and evidenc 2. Maintain bedsores. by abse position of of foot Position in prone position once or function and skin 4. and
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>Paralysis

control over motor movements. Because the upper motor control on one side of the body may reflect damage to the upper motor neurons on the opposite side of the brain thus resulting to impairment in physical mobility.

integrity as twice a day if client can tolerate. evidenced by Helps maintain functional hip absence of extension contractures, foot drop, and so forth. 5. Position extremities in functional position; use footboard. Maintain 3. Maintain or neutral position of head. improve strength and function of affected and/ or compensatory part. 6. Prevents contractures or foot drop and facilitates use when function returns. Observe affected side for color, edema, or other signs of compromised circulation. Edematous tissue is more easily traumatized and heals more slowly. 7. Inspect skin regularly, particularly over bony prominences. Gently massage any reddened area. Pressure points over bony prominences are most at risk for decreased perfusion. 8. Assist in maintaining sitting balance. Aids in retaining neuronal pathways,
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bedsore

2.

Verbali underst ng of treatme regimen safety measur

1.

Maintai strength in functional

Nurses Pocket Guide by Doenges, Moorhouse and Murr

enhancing proprioception and motor response. 9. Set goals with client for increasing participation in activities, exercises or position changes. Promotes sense of expectation of progress and provides some sense of independence. 10. Encourage patient to assist with movement and exercises using unaffected side to support or to move weaker side. May respond as if affected side is no longer part of the body and needs encouragement to reincorporate it as a part of own body. 11. Consult with physical therapist regarding active, resistive exercises and client ambulation, Individualization program can developed to meet particular needs with deficits in balance, coordination and strength.

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DATE D E C E M B E R

CUES Subjectiv e:

NURSING DIAGNOSIS Ineffective Cerebral tissue

NEED S A C T I V I T Y E

RATIONALE

OBJECTIVES OF CARE After 2 days of

NURSING INTERVENTIONS 1. Determine factors related to individual situation/cause for coma/decreased cerebral perfusion. R: Influences choice of interventions.

Intake of Fat and sodium; Cigarette smoking; Alcoholism, Imbalanced nutrition

Nursing Intervention, the client will be able to:

Nastrok e siya as verbalize d by the patients watcher

perfusion r/t interruption of blood flow secondary to hemorrhage

Demonstrate increased perfusion as individually appropriate such

2. Monitor/document neurological status frequently and compare with baseline. R: Assesses trends in level of consciousness (LOC) and potential for increased ICP and is useful in determining location, extent, and

7 Objective 2 0 1 2 Speech abnormal ity noted @ Changes 5:00 PM in motor response; extremity weakness ; paralysis :

X E R C I S E Intravascular pressure P A T T E R N Scarring of vessel resistance to flow Vasoconstritio n

as warm skin, strong pulse present/VS within normal range.

progression/resolution of CNS damage. 3. Monitored vital signs. R: Fluctuations in pressure may occur because of cerebral pressure/injury in vasomotor area of the brain.

Muscle strength

183 |Pag e 4. Evaluate pupils, noting

size, shape, equality, light

XVII- DISCHARGE PLANNING (M.E.T.H.O.D.) Medications 1. Discuss to the significant others all the given home medications such as the brand name, dosage, contraindications and the purpose of giving such medication. 2. 3. 4. 5. 6. 7. 8. 9. 10. Metropolol 100mg 1 tab BID 6am-6pm Citicoline (NerveCare) 50mg 1 tab TID 6am-1pm-6pm Amlodipine 10 mg 1 tab 6am Irbesartan 30 mg 1 tab OD 6am Atorvastatin 40mg 1 tab OD @ HS 9pm Senna Concentrate 2 tabs OD @ HS 9pm Encourage client to comply with the medications prescribed by the physician. Inform them about the possible side effects that may occur. Encourage patient to take his medications with food or take medicines before meal if/or needed by medication. Exercise 1. Instruct to have aerobic exercise should focus on large muscle group conditioning such as walking, this exercises build endurance, increase independence and decrease

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cardiovascular disease, according to the American Heart Association. Aerobic activity should be performed three to seven days a week, for 20 to 60 minutes. 2. 3. Instruct to have adequate rest. Encourage client to continue deep breathing exercises to promote circulation of blood and relaxation Treatment 1. Educate significant other about the importance of drug compliance for the patients condition. 2. Encourage significant other to accept or consider medical advice for the treatment of the patients condition. Hygiene 1. 2. 3. Educate to perform hand washing before and after meals. Encourage to brush teeth at least three times a day and change brush every three months. Instruct the significant others to maintain a clean and relaxing environment to prevent patient from acquiring infection and promote healthy environment. Out patient 1. 2. Advice patient to visit or have a follow up check-up on his schedule day. Instruct significant other to keep periodic appointments with the health care providers for palliative treatment.
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Diet 1. Instruct to eat foods high in fiber also helps lower your cholesterol and reduce your risk of further strokes. Incorporate at least five fruits and vegetables into your diet each day, and switch from white bread products to whole grain or whole wheat. 2. 3. Sodium intake should be limited to no more than 1,500 g per day. Limiting or avoiding foods that are high in trans-fats, saturated fats and cholesterol may help you lower your cholesterol levels. In a 2,000-calorie meal plan, eat no more than 6 oz. of lean meat, poultry or fish per day. Choose lean cuts of meat, and remove all visible fat and skin. Broil your meats and pour visible fat off pan-fried foods. Do not use partially hydrogenated oils, use low-fat or fat-free dairy products, and limit sugary foods and drinks.

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XVIII- PROGNOSIS

Criteria

Poor (1)

Fair (2)

Good (3)

Justification

Onset of illness

During the onset of attack, the patient didnt mind the symptoms he felt until he lost consciousness and was brought to the assigned doctor of the event.

Duration of illness

The duration of the illness was not too long since the client was immediately rushed to the hospital after he was assessed by the doctor

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Precipitating Factors and Predisposing Factors X

Among the predisposing and precipitating factors presented which contribute to CVA, 6 of them are present in the patient which are age, sex, hereditary, hypertension, increased cholesterol (ldl) and alcohol drinking.

Environmental Factor

He lives in Bangkal, Davao City. His friends reported that he lives in a house by himself, which has adequate space, and that the environment is peaceful.

Willingness to take medications/ treatment X

The patient accepts the need to follow treatment regimen for his recovery. He is greatly willing to take his medications and subject himself to the prescribed treatments.

Age

The patient is 57 years old. Stroke is considered a disease that generally attacks elderly persons; And the chance of having a stroke more than doubles for each 10 years of life after the age of 55.
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The patient gets enough emotional support Emotional Support X from his friends. He is well supported by them and always there to comply with the treatment of the patient; They regularly visit him in the hospital.

RATING: Good: 2.4 3.0 Fair: 1.7 2.3 Poor: 1.0 1.6 COMPUTATION: Good: 4 x 3 = 12 Fair: 1 x 2 = 2 Poor: 2 x 1 = 2 Total: 16/7 = 2.29 = Fair

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XIX- RECOMMENDATION To our Client The potency of the drugs, treatments procedures and therapies given does not rely only to the health care team, rather, it requires a significant participation on the part of the patient. His willingness and readiness to understand the purposes of those treatments would be very helpful for the health care team to provide him of necessary medical and nursing interventions. It would also be helpful that he verbalize his feelings openly to his friends regarding his concerns to his condition.

To the Student Nurses We, the student nurses, are also responsible in providing the basic information of his disease and its management. Since he has no family in here, in Davao city or anywhere near it, we should also educate his close friends. In the clinical area, we do not just perform nursing procedures and administer medications, but , we should serve as health educators. Also, when performing basic nursing skills in the area, we should be certain and confident enough in providing treatment to the patient. This case study would also be very helpful on the part of the student nurses who may handle the same case/disease. The knowledge that we obtained from this case study could also serve as a basis for the health teachings to the patient.

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To the Ateneo de Davao University School of Nursing We would like to recommend the School of Nursing to maintain its high quality of education. May the high spirits of the clinical instructors be a beacon of morale to the student nurses, and continue to help, guide, and teach us of the dos and donts of the clinical area. The School of Nursing should continue to mold the students to be effective in their skills as well as their knowledge and attitude towards the clients.

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XX- REFERENCES Book: 1. Estes, M. E. Z. (2010). Health assessment & physical examination. 4th edition. Developmental Assessment, 4, 89-119. 2. Kozier and Erbs Fundamentals of nursing, 8th edition 2008 by: Berman, Aubrey, Synder, Shirlee, Kozier, Barbara & Erb, Glenora 3. 4. 5. 6. 7. 8. Tortora and Derrickson, 9th edition. Nurses Pocket Guide 4th Edition by Marilyn Doenges and Mary Frances Moorhouse myDr, 2001. Copyright: myDr, UBM Medica Australia, 2000-2011. Theoretical Foundation of Nursing 1st edition by Joy N. Bautista Nursing2006 drug handbook. 26th edition. Lippincott Williams & Wilkins. Nursing2009 student drug handbook. 10th edition. Lippincott Williams & Wilkins. Internet:
9. 10. 11. 12.

http://www.drugs.com/ www.myhealth.va.gov/ www.stroke.org www.ncbi.nlm.nih.gov

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13.

www.heart.org

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