I.

Introduction
Health of the people is really the foundation upon which all the happiness and all their powers as a state depends -Anonymous-

Aneurysms in the brain occur when there is a weakened area in the wall of a blood vessel. An aneurysm may be present from birth (congenital) or it may develop later in life, such as after a blood vessel is injured. There are many different types of aneurysms. A berry aneurysm can vary in size from a few millimeters to over a centimeter. Giant berry aneurysms can reach well over 2 centimeters. These are more common in adults. Multiple berry aneurysms are inherited more often than other types of aneurysms. Other types of cerebral aneurysm involve widening of an entire blood vessel, or they may appear as a "ballooning out" of part of a blood vessel. Such aneurysms can occur in any blood vessel that supplies the brain. Atherosclerosis, trauma, and infection, which can injure the blood vessel wall, can cause cerebral aneurysms. About 5% of the population has some type of aneurysm in the brain, but only a small number of these aneurysms cause symptoms or rupture. Risk factors include a family history of cerebral aneurysms, and certain medical problems such as polycystic kidney disease, coarctation of the aorta, and high blood pressure. High blood Pressure can cause the rupture of the aneurysm because of the increase pressure and may lead to subarachnoid hemorrhage, is bleeding into the subarachnoid space the area between the arachnoid membrane and the pia mater surrounding the brain. This may occur spontaneously, usually from a ruptured cerebral aneurysm, or may result from head injury. The classic symptom of subarachnoid hemorrhage is headache .This headache often pulsates towards the occiput . About one-third of sufferers have no symptoms apart from the characteristic headache, and about one in ten people who seek medical care with this symptom are later diagnosed with a subarachnoid hemorrhage.[Vomiting may be present, and 1 in 14 have seizures. Confusion, decreased level of consciousness or coma may be present, as may neck stiffness and other signs of meningism. Neck stiffness usually presents six hours after initial onset of SAH. Isolated dilation of a pupil and loss of the pupillary light reflex may reflect brain herniation as a result of rising intracranial pressure. Intraocular hemorrhage may occur in response to the raised pressure, subhyaloid and vitreous hemorrhage may be visible on fundoscopy. This is known as Terson syndrome and is more common in more severe SAH.

Nerve abnormalities, affected eye looking downward and outward and inability to lift the eyelid on the same side, or palsy may indicate bleeding from the posterior communicating artery. Seizures are more common if the hemorrhage is from an aneurysm; it is otherwise difficult to predict the site and origin of the hemorrhage from the symptoms. SAH in a person known to have seizures is often diagnostic of an arteriovenous malformation. As a result of the bleeding, the body releases large amounts of adrenaline and similar hormones. This leads to a sharp increase in the blood pressure; the heart comes under substantial strain, and accumulation of fluid in the lungs, cardiac arrhythmias, electrocardiographic changes and cardiac arrest may occur rapidly after the onset of hemorrhage. Subarachnoid hemorrhage may also occur in people who have suffered a head injury. Symptoms may include headache, decreased level of consciousness and hemi paresis . SAH is a frequent occurrence in traumatic brain injury, and carries a poor prognosis if it is associated with deterioration in the level of consciousness. Subarachnoid hemorrhage can also lead to stroke because of the ruptured of the aneurism. A stroke, previously known medically as a cerebrovascular accident (CVA), is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage, or a hemorrhage. As a result, the affected area of the brain is unable to function, which might result in an inability, inability to understand or formulate speech, or an inability to see one side of the visual field. The function deficits caused by the stroke depend on the size and specific areas of the brain affected. Paralysis of affected limbs and subsequent development of spasticity in those limbs can occur if motor areas are affected. Balance mechanisms are impaired if the cerebellum or its related structures are involved. Language deficits occur if language area is involved. Current Trends Subarachnoid Haemorrhage More Commonly Caused by Environmental Factors Than Genes, Study Finds ScienceDaily (Sep. 20, 2010) The Nordic twin study investigating the heritability of subarachnoid haemorrhage (SAH) suggests that the role of genetic factors underlying the development of SAH is less than previously believed. The prevalence of subarachnoid haemorrhage (SAH) is almost three times as high in Finland and Japan as among other nationalities. In Finland, some 1,000 cases are diagnosed every year, with almost half of the cases ending in death. SAH predominantly affects the working age population. Haemorrhage occurs when an aneurysm, a balloon-like bulge in the wall of the cerebral artery, ruptures. Cerebral aneurysms and haemorrhages from ruptured aneurysms have been studied extensively in Finland. Tl Hospital of Helsinki University

Central Hospital (HUCH) in Finland is one of the best-known centres for the neurosurgical treatment of SAH in the world. During the past few decades, the genetic makeup has been regarded as playing a significant role in the development of SAH. Contrary to this belief, however, a twin study recently published in the journal Stroke showed that environmental factors account for most of the susceptibility to develop SAH Conducted in Finland, Sweden and Denmark, the study is the largest population level twin study in the world. "This information is important for the families of SAH patients and for doctors," says Miikka Korja, head of the research team and neurosurgeon at the HUCH Neurosurgery Department. "On an average, close family members of SAH patients have a low risk of developing SAH, and this risk may be further reduced by modifying lifestyle and environmental factors. This means that instead of screening the close family members of SAH patients, the focus of preventive treatment may now be increasingly shifted to the efficient management of hypertension and smoking cessation intervention. This is what we do with other cardiovascular diseases as well." The Nordic study combined data on almost 80,000 pairs of twins over several decades. All in all, the follow-up time of all of the twin pairs corresponds to a staggering 6 million person-years. The researchers nevertheless emphasize that there are rare cases of families among whose members SAH is significantly more common than in the overall population. In these cases genetic factors are the principal cause underlying the development of the disease. The challenge is to identify these rare families and provide accurate genetic counselling and preventive treatment.

Drinking Coffee, Having Sex Are Triggers That Raise Rupture Risks for Brain Aneurysm, Study Finds ScienceDaily (May 5, 2011) From drinking coffee to having sex to blowing your nose, you could temporarily raise your risk of rupturing a brain aneurysm -- and suffering a stroke, according to a study published in Stroke: Journal of the American Heart Association. Dutch researchers identified eight main triggers that appear to increase the risk of intracranial aneurysm (IA), a weakness in the wall of a brain blood vessel that often causes it to balloon. If it ruptures, it can result in a subarachnoid hemorrhage which is a stroke caused by bleeding at the base of the brain. An estimated 2 percent of the general population have IAs, but few rupture. Calculating population attributable risk -- the fraction of subarachnoid hemorrhages that can be attributed to a particular trigger factor -- the researchers identified the eight factors and their contribution to the risk as:
y y y y

Coffee consumption (10.6 percent) Vigorous physical exercise (7.9 percent) Nose blowing (5.4 percent) Sexual intercourse (4.3 percent)

y y y y

Straining to defecate (3.6 percent) Cola consumption (3.5 percent) Being startled (2.7 percent) Being angry (1.3 percent) "All of the triggers induce a sudden and short increase in blood pressure, which seems a possible common cause for aneurysmal rupture," said Monique H.M. Vlak, M.D., lead author of the study and a neurologist at the University Medical Center in Utrecht, the Netherlands. Risk was higher shortly after drinking alcohol, but decreased quickly, researchers said. "Subarachnoid hemorrhage caused by the rupture of an intracranial aneurysm is a devastating event that often affects young adults," Vlak said. "These trigger factors we found are superimposed on known risk factors, including female gender, age and hypertension." Few people with IAs have symptoms before such a rupture, such as vomiting, vision problems, loss of consciousness, and especially severe headaches. Many have none. With the increasing use of neuroimaging techniques, more incidental aneurysms are being detected, researchers said. The researchers sought to identify potential triggers and their level of risk. They asked 250 patients with aneurysmal subarachnoid hemorrhage to complete a questionnaire about exposure to 30 potential trigger factors in the period shortly before their event and their usual frequency and intensity of exposure to these triggers. They then assessed relative risk using a casecrossover design that determines if a specific event was triggered by something that happened just before it. Although physical activity had triggering potential, researchers don't advise refraining from it because it's also an important factor in lowering risk of other cardiovascular diseases. "Reducing caffeine consumption or treating constipated patients with unruptured IAs with laxatives may lower the risk of subarachnoid hemorrhage," Vlak said. "Whether prescribing antihypertensive drugs to patients with unruptured IAs is beneficial in terms of preventing aneurysmal rupture still needs to be further investigated." The findings were limited by the retrospective design of the study and the average three weeks between subarachnoid hemorrhage and completion of the questionnaire, researchers said. Moreover, specifically asking for exposure in a particular time frame may have been limited by recall bias and including patients in a relatively good clinical condition could have led to survival bias. A. Reason for Choosing Such Case for Presentation The group chose this topic for their case study because the group still wanted to explore more on this condition. Since subarachnoid hemorrhage may lead to stroke, stroke is one of the most common conditions the Filipino people usually suffer; a broadened knowledge would imply better nursing management and care for those patients. The group wants to learn the underlying facts and techniques to make this topic appear easy. The reason of us choosing this case study was partly because the group was intrigued on the way how the patient is experiencing his manifested signs and symptoms. The curiosity of the

group regarding on how the head and other parts of it interact ,to be responsible for this condition, led them to study more. The group was also have been assigned with this patient making sure that he is in good health and comfortable as the group was with him they were also able to establish rapport with the patient and his family. The group also wanted to familiarize themselves on this condition because it affects many people. This means that they have greater chances of handling patients similar with this condition. They want to be equipped with the proper information about it so that the group may be able to render the best care we can offer to their future patients. B. Objectives y Student-Nurse Centered: At the end of the case study, the student nurses will be able to:

General Objective: Gain knowledge and deeper understanding of the disease process itself (subarachnoid hemorrhage), and be able to provide the best nursing care for the client, and impart health teachings regarding the clients condition in maintaining an optimum level of functioning.

Specific Objectives: 1. Recognize the current trends and statistics regarding the disease condition. 2. Identify the demographic data of the patient. 3. Identify the patients lifestyle, diet, ADLs, socio-economic and cultural factors and environmental factors that may have contributed to the development of the present condition. 4. Outline the family health-illness history of the patient, history of past illnesses and history of present illnesses. 5. Perform a thorough cephalo-caudal physical assessment including cranial nerve assessment. 6. Make a list of the indications, analyze and interpret the diagnostic and laboratory procedures ordered to the patient. 7. Illustrate a complete anatomy and physiology, inclusive of visual aids, of all the systems affected by the patients present condition. 8. Illustrate a comprehensive schematic diagram on how the patients present condition. 9. Discuss a comprehensive synthesis and definition of the disease and a thorough definition. 10. Recognize the modifiable and non-modifiable factors that contribute to the development of the disease condition.

11. Make a list of the signs and symptoms associated with the present condition of the patient, inclusive of their corresponding rationales. 12. List the indications and take note of the patients response on the treatment regimen indicated. 13. Prepare NCPs for the actual and foreseeable problems of the patient. 14. Present the actual SOAPIERs used during the actual hospital duty. 15. Present the clients daily progress chart from the day of patients admission up to the last day of the student nurses hospital visit. 16. Present a concise discharge planning. 17. Impart knowledge to colleagues in providing care for clients experiencing the same disease condition. Patient-centered: At the end of the case study, the pts including his SO will be able to: 1. Increase their knowledge and understanding in the disease process including the risk factors involved. 2. Identify different interventions given the disease condition. 3. Acquire knowledge on the importance of compliance to treatment regimen. 4. Demonstrate compliance on the treatment management. 5. Identify different measures to prevent further aggravation of condition. 6. Participate in the plan of care.

II. NURSING ASSESSMENT A. Personal History 1. Demographic Data This is the case of Mang Dugz, 69 years old, male, natural-born Filipino and affiliated to the Roman Catholic Church. He is the youngest among 5 siblings. He lives in Brgy. Babo Pangulo, Porac, Pampanga. He was born on May 18, 1942 at a government hospital in Pampanga. He was admitted to a secondary hospital in Pampanga with a cheif complaint of weakness and having a mild stroke.

2. Family Health Illness History PATERNAL

Asthma BPN

MATERNAL
CVA

VA

X COPD

HTN

HTN LEGEND:

- MALE

CVA

CVA

CVA

CVA

CVA Mang Dugz - FEMALE

- DECEASED

EXPLANATION OF THE GENOGRAM: Mang Dugz, who is diagnosed to have subarachnoid hemorrhage secondary to ruptured AV malformation right internal carotid PCA, is the youngest in a family of five children. His three brothers, and one sister have all died because of having cerebrovascular accidents. His mother and father both had hypertension. Mang Dugzs father is the third among five children. His fathers eldest brother died of an unknown etiology. His female siblings have no known disease. His youngest sibling died of a vehicular accident. With Mang Dugzs maternal side, his mother is the eldest in their family. The second among the siblings of Mang Dugzs mother has no known diseases while her third sibling had COPD and the youngest was murdered. Mang Dugzs grandfather died with asthma; while his deceased grandmother was diagnosed with pneumonia. On the other hand, Mang Dugzs grandfather on his mother side died due to old age; while her grandmother died of Cerebrovascular accident. a

C. History of Past Illness Mang Dugz had no previous hospitalization. According to him, he had not been hospitalized before due to any major illness. He said that simple fever, cough and colds are easily cured by using over-the-counter drugs resulting to self-medication. His only concern for his health was that he has hypertension but took no medical management in taking care of such. He claims that one of contributing factors for this occurrence is due to his high fat and salt diet. He said thats the kind of food he usually eats.

D. History of Present Illness Mang Dugz was admitted at a secondary hospital in Pampanga last June 23, 2011 at 4:00 in the afternoon due to having an episode of a mild stroke and collapsing. It was in the afternoon when the client was with his grandson, when he said that he wanted to sleep. It was at that time that he had experienced a mild stroke and had fainted. The next thing the client knew, he was being attended to by a physician at the emergency room. Based from the significant others story, while Mang Dugz was unconcscious, his respirations were no longer present or either declining, and she had thought that shed lose him already. Luckily, the timing was just right and the physician was able to revive the client. However, after a couple of days, because of the physical demands the client needed, the hospital that he was brought to could no longer suffice his needs, so he was then referred to the known provincial hospital for better care. Some of the contributing factors to the occurrence of this illness are the facts that the client drinks alcohol occasionally, was a smoker until he reached the age of 50 when he decided

to stop, he usually eats foods that are high in sodium and fats and also because the illness had run in the family.

E. Physical Examination June 25, 2011 (copied from the chart) BP: 210/100 mmHg; HR: 108bpm; no pallor, pink palpebral conjunctiva, aicteric sclera, (+) CLAD; with nuchal rigidity, (-) babinski June 27 & 28, 2011 General Condition Conscious and coherent, appears weak but can perform activities such as sitting with the help of the SO with slight facial grimaces and discomfort, with slurred speech

INTEGUMENT a. Skin: Brown skin but appears to be dry, uniform in complexion on exposed areas, with good skin turgor. b. Nails: Smooth in texture, convex curved, intact tissues around nails, no clubbing, normal capillary refill (<3 sec.) HEAD AND FACE: a. Hair: Gray in color, short, dry, evenly distributed, patches of hair loss is noted. b. Skull and Face: Smooth skull contour, round, without nodules noted; symmetrical facial features; facial movements (able to smile, frown, and raise eyebrows and shows teeth). c. Eye structure and visual acuity: Eyebrows symmetrically aligned, evenly distributed; eyelashes evenly distributed, curled slightly outward; eyelids have intact skin, lids closes symmetrically, no lesions or nodules found. d. Ears and Hearing:

Auricles symmetrical, aligned with outer canthus of eye; ear canals seen with dry cerumen; ears are mobile and firm; pinna recoils after it is folded; able to hear whispered words at the back of his ears, able to hear the tick of the watch. e. Nose and Sinuses: Nose is proportional, uniform in color, no lesions and discharges, non-tender; nasal septum is intact in the midline; Non-tender facial sinuses. f. Mouth and Oropharynx: Lips slightly pale in color, proportional with the face, slightly rough in texture due to the dryness; moist buccal mucosa with no signs of bleeding; tongue is pink, moves freely, with no signs of swelling and ulceration; palates and uvula are light pink in color; uvula is positioned in midline of soft palate; oropharynx and tonsils are pink in color. NECK: Neck is uniform in color, coordinated with movement, no enlargement of the lymph nodes upon palpation; trachea is on the midline of the neck; able to turn head from left to right and vice versa; upward and downward with slight difficulty; thyroid gland not visible upon inspection, absence of bruit upon auscultation of the thyroid gland, jugular vein not distended. THORAX AND LUNGS: Full and symmetric chest expansion upon inspection; with absence in increased rate (bpm) and shallow breathing. No lesions, deformities, masses, and tenderness noted. Difficulty of breathing. HEART: Pulse rate is within normal range; no extra heart sounds were noted upon auscultation. ABDOMEN Skin on the abdomen is uniform in color, sagging, without epigastric tenderness. UPPER AND LOWER EXTREMITIES Arms and legs are symmetrical in shape, size, and color; there are no deformities, tenderness, lesions, or swelling noted; with limited range of motion; with the same temperature upon palpation of both upper and lower extremities. Edema on right hand from dislocation of IV cannula.

Neurologic Vital Signs (Glasgow Coma Scale) Eye Response

1. 2. 3. 4.

No eye opening. Eye opening to pain. Eye opening to verbal command. Eyes open spontaneously.

Verbal Response 1. 2. 3. 4. 5. No verbal response Incomprehensible sounds. Inappropriate words. Confused Orientated

Motor Response 1. 2. 3. 4. 5. 6. No motor response. Extension to pain. Flexion to pain. Withdrawal from pain. Localizing pain. Obeys Commands.

GCS = 12/15.

Cranial Nerves Cranial Nerve Type and Function Type: Sensory Function: Smell Assessment Procedure Ask Mang Dugz to close eyes and identify different mild aromas such as perfume. Expected Result Mang Dugz must be able to identify the scent of an object when asked to smell it. Mang Dugz must be able to see object clearly at a Actual Result

1. Olfactory

Mang Dugz was able to identify the different odors presented.

2. Optic

Type: Sensory Function: Vision

Ask Mang Dugz to read a reading material and ask her to identify the objects at a given

Mang Dugz was able to read and identify the objects clearly.

distance of 14 inches. 3. Occulomotor Type: Motor Function: Pupil Constriction Ask Mang Dugz to look straight at an object then using a penlight, and approaching from the side, shine a light on the pupil. Observe the constriction of the eye then do the procedure on the other eye. Holding the penlight at a distance of 1 ft, ask Mang Dugz to look at a fixed position facing you and follow the movement of the penlight with the eyes only, move the penlight slowly to the six cardinal, starting from the center of the eye. While Mang Dugz looks upward, lightly touch lateral sclera of the eye to elicit blink reflex. To test

given distance.

Pupils should constrict once light passes through. Eyes must follow the direction of pen.

Both of Mang Dugz eyes constricted once light passed through it.

4. Trochlear

Type: Motor Function: Eye Movement

Eyes must follow the movement of the object without difficulty.

Mang Dugz was able to follow he direction of the off penlight without difficulty.

5. Trigeminal

Type: Motor Function: Eye Movements

Must b able to move jaw and mouth. Eyes should blink when wiped with cotton.

Mang Dugz was able to elicit a blink reflex upon wisp of a cotton ball. He was also able to identify the

light sensation, have Mang Dugz close eyes. Wipe a wisp of cotton over Mang Dugzs forehead and para-nasal sinuses, To test deep sensation, use alternating blunt and shape ends of a safety pin over the same area. Mang Dugz moves the jaw up and down and side by side. 6. Abducens Type: Motor Function: Lateral eye movement Assess direction of penlight Eyes must follow the direction of movement of the pen.

difference between sharp and dull sensations. Mang Dugz was also able to elicit movement of her jaw without difficulty.

Mang Dugz was able to follow the direction of the penlight laterally without difficulty. Mang Dugz was able to perform this test with ease.

7. Facial

Type: Sensory

Ask Mang Dugz to smile, raise her Function: sense eyebrows, frown, of taste on the puff cheeks and anterior of the close eyes tightly. tongue and facial Ask Mang Dugz expression. to identify various taste placed on tip and sides of tongue: sugar (sweet), salt (sour), and coffee (bitter); identify area of taste.

Mang Dugz must be able to smile, frown, purse lips, and close eyes without difficulty; he must also be able to identify the taste of food.

8. Vestibulocochlear

Type: Sensory Function: Hearing and Balance

Have Mang Dugz occlude one ear. Out of Mang Dugz sight; place a tickling watch 1-2 inch from the unoccluded ear. Ask what Mang Dugz can hear. Repeat with the other ear. Apply taste on the posterior tongue for identification. Ask Mang Dugz to move tongue from side to side and up and down.

Must be able to hear the tick of the watch.

Mang Dugz was able to hear the sound of the ticking watch on both ears upon assessment.

9. Glossopharyngeal

Type: Sensory and Motor Function: Pharyngeal movement and swallowing or taste on the posterior 1/3 of the tongue.

Must exhibit swallowing and must move tongue in different directions without difficulty. Must identify the taste of food. Must be able to speak clearly and swallow without difficulty.

Mang Dugz was able to show her ability to swallow, move tongue from side to side, and identify the different tastes of food.

10. Vagus

Type: Sensory and motor Function: Sensation of swallowing and speaking

Mang Dugz will drink water for swallowing and assess Mang Dugzs speech for hoarseness.

Mang Dugz was able to drink/ swallow water with slight difficulty and spoke in a soft, hoarse voice. Mang Dugz was able to perform the test without difficulty.

11. Accessory

Type: Motor Function: Movement of shoulder muscles

Ask Mang Dugz to shrug shoulders against resistance from your hands and repeat for the other side.

Move head side to side and move shoulders without any difficulty upon resistance.

12. Hypoglossal

Type: Motor Function: Movement of tongue and strength of the tongue

Ask Mang Dugz to protrude tongue at midline then move it side to side.

Tongue should move without difficulty and must be able to protrude it.

Mang Dugz was able to perform the test with ease

F. Diagnostic and Laboratory Procedures Date ordered Date results in Normal Values (Units used in the hospital)

Diagnostics /Laboratory Procedures

Indications or Purposes

Results

Analysis and Interpretation

Hemoglobin

Date ordered: 06-26-11 Date results in: 06-26-11

To evaluate blood loss, Anemia, and response to therapy. It is an important component of red blood cells that carries oxygen and carbon dioxide to and from tissues.

146 g/L

125-175g/L

The result showed a normal in Hgb which indicates that there is sufficient oxygen going to the body organs.

0.38 It measures the concentration of RBC within the blood volume and is expressed as a percentage. It is also a useful tool in evaluating dehydration and hypervolemia.

0.40-0.52

Hematocrit

Date ordered: 06-26-11 Date results in: 06-26-11

The result showed a normal Hct which indicates that there is a normal number of RBC.

WBC

Date ordered: 06-26-11 Date results in: 06-26-11

It detects for the presence of infection and the ability of the body to fight 9.9 x 10 9/L 5-10 x 109/L infection or microorganism that invade the body.

This indicates that the body as compensatory mechanism tries to increase WBC in order to fight invading microorganism and tries to help in tissue repair.

Lymphocytes

Date ordered: 06-26-11 Date results in: 06-26-11

It detects for the presence of infection and the ability of the body to fight infection or microorganism that invade the body.

0.10

0.20-0.35

Based on the result of the patient, the lymphocyte level is low this could predispose the patient to infection, since lymphocytes are responsible for the bodys immune response.

Monocytes

Date ordered: 06-26-11 Date results in: 06-26-11

It detects for the presence of infection and the ability of the body to fight infection or microorganism that invade the body.

0.3

0.02-0.06

Based on the result of the patient, the monocytes level is within the normal level this indicates that the monocytes have the capability phagocytize bacteria, dead cells, and any debris within the tissues. Based on the result of the patient, the basophils level is increased indicates that the body as compensatory mechanism, since they are the first to enter the infected tissue, so they would multiply in order to fight the invaded organism or to help in repair of damage tissue. The platelet count of the patient is low which indicates that the patient is risk for bleeding or injury.

Neutrophils

Date ordered: 06-26-11 Date results in: 06-26-11

It detects for the presence of infection and the ability of the body to fight infection or microorganism that invade the body.

0.87 0.45-0.65

Platelets

Date ordered: 06-26-11 Date results in: 06-26-11

This determines if the patient risk for bleeding and to determine the coagulating property of platelets

97 x 109/L

140-550 x 109/L

Prior: y y y y y Note current drug therapy before procedure. Check the physicians order. Identify the client. Prepare the needed materials. Explain the procedure, its purpose and how it is done.

Tell the patients SO that no fasting is required. Inform the patients SO that the test may require blood specimen and might bring a little pain to the punctured site. y Wash hands. During: y y y y y y After: y Collect approximately 5 to 7 ml of venous blood in a lavender-top tube; however, only 0.5 ml is required when using capillary tubes. Avoid hemolysis. List on the laboratory slip any drugs that may affect test results. Maintain aseptic technique.

Apply pressure or a pressure dressing to the venipuncture site to prevent bleeding.

Potassium (K)

Date ordered: 06-26-11 Date results in: 06-26-11

This diagnostic procedure is to detect presence of electrolyte imbalance specifically determining the level of Potassium in the blood. It is used to detect hypokalemia or hyperkalemia.

3.74 mmol/L

3.5-5.5 mmol/L

Based on the result, it shows that the potassium level of the patient is within normal range AEB potassium level of 3.74. there is no signs of potassium imbalance.

Nursing Responsibilites: PRIOR 1. 2. 3. 4. Explain to the patient that this test determines potassium content of the blood. Tell the patient that no special diet is required. Tell the patient, this test requires blood sample for it to be done. Tell patient that may feel discomfort from the needle puncture and the pressure of tourniquet. 5. Prepare all the materials needed.

DURING 1. 2. 3. 4. Instruct the patient to avoid opening and closing the hand after tourniquet is applied. Collect approximately 5-7mL of venous blood and put it in a red top tube. Avoid hemolysis. Indicate in the laboratory slip any drugs that may affect test results.

After 1. 2. 3. 4. 5. Apply pressure to the venipuncture site. Evaluate patient with increased or decreased potassium levels for cardiac arrhythmias If hematoma develop at the venipuncture site apply warm soaks. Monitor patient taking digoxin and diuretics for hypokalemia. Document the results.

Sodium (Na)

To detect presence of electrolyte Date ordered: imbalance in the This 06-26-11 blood. laboratory Date can results in: procedure 06-26-11 detect if there is hyponatremia or hypernatremia

141.8 mmol/L

135-145 mmol/L

Based on the result, it indicates that the level of sodium in the body especially in the blood, are within normal range which indicate absence of Na+ electrolyte imbalance AEB Na+ level of 141. 8 mmol/L.

Nursing Responsibilites: PRIOR Explain to the patient that this test determines sodium content of the blood. Tell the patient that no special diet is required. Tell the patient, this test requires blood sample for it to be done. Tell patient that may feel discomfort from the needle puncture and the pressure of tourniquet. 5. Prepare all the materials needed. DURING 1. 2. 3. 4. After Instruct the patient to avoid opening and closing the hand after tourniquet is applied. Collect approximately 5-7mL of venous blood and put it in a red top tube. Avoid hemolysis. Indicate in the laboratory slip any drugs that may affect test results. 1. 2. 3. 4.

1. Apply pressure to the venipuncture site. 2. If hematoma develop at the venipuncture site apply warm soaks. 3. Document the results.

Creatinine

Date ordered: 06-26-11 Date results in: 06-26-11

This laboratory procedure is used to measure the amount of creatinine in the blood and the renal excretory function.

55.8 mmol/L

58-100 mmol/L

Based on the result, the amount of creatinine in the blood is within the normal range which indicates that there is no presence of muscle wasting or protein breakdown.

Nursing Responsibilities: PRIOR 1. Explain to the patient the procedure and its importance to the treatment regimen. 2. Tell the patient that no special diet is required.

3. Tell the patient, this test requires blood sample for it to be done. 4. Tell patient that may feel discomfort from the needle puncture and the pressure of tourniquet. 5. Prepare all the materials needed. DURING 1. Instruct the patient to avoid opening and closing the hand after tourniquet is applied. 2. Collect approximately 5-7mL of venous blood and put it in a blue top tube. 3. Avoid hemolysis. 4. Rotate venipuncture site. 5. Record time of the procedure. AFTER 1. Apply pressure to the venipuncture site. 2. If hematoma develop at the venipuncture site apply warm soaks. 3. Document the results.

Total cholesterol

Date ordered: 06-26-11 Date results in: 06-26-11

This laboratory procedure is used to measure the amount of cholesterol in the body. It is indicated for the patient in order to rule if there is presence of risk of Coronary artery disease.

3.72 mmol/L

3.45 6.35 mmol/L

Based on the result, the amount of .

Nursing Responsibilities: PRIOR Explain to the patient the procedure and its importance to the treatment regimen. Tell the patient that no special diet is required. Tell the patient, this test requires blood sample for it to be done. Tell patient that may feel discomfort from the needle puncture and the pressure of tourniquet. 5. Prepare all the materials needed. DURING 1. Instruct the patient to avoid opening and closing the hand after tourniquet is applied. 2. Collect approximately 5-7mL of venous blood and put it in a blue top tube. 3. Avoid hemolysis. 4. Rotate venipuncture site. 5. Record time of the procedure. AFTER 1. Apply pressure to the venipuncture site. 2. If hematoma develop at the venipuncture site apply warm soaks. 3. Document the results. 1. 2. 3. 4.

III. ANATOMY AND PHYSIOLOGY Central Nervous System Overview The central nervous system consists the brain and spinal cord.
y

of

The brain plays a central role in the control of most bodily functions, including awareness, movements, sensations, thoughts, speech, and memory. Some reflex movements occur via spinal cord pathways without participation of brain structures.

can the

The spinal cord is connected to a section of the brain called the brainstem and runs through the spinal canal. Cranial nerves exit the brainstem. Nerve roots exit the spinal cord to both sides of the body. The spinal cord carries signals (messages) back and forth between the brain and the peripheral nerves. Cerebrospinal fluid surrounds the brain and the spinal cord and also circulates within the cavities (called ventricles) of the central nervous system. Theleptomeninges surround the brain and the spinal cord. The cerebrospinal fluid circulates between 2 meningeal layers called the pia matter and the arachnoid (or pia-arachnoid membranes). The outer, thicker layer serves the role of a protective shield and is called the dura matter. The basic unit of the central nervous system is the neuron (nerve cell). Billions of neurons allow the different parts of the body to communicate with each other via the brain and the spinal cord. A fatty material called myelin coats nerve cells to insulate them and to allow nerves to communicate quickly. The Brain The Cerebrum The cerebrum is the largest part of the brain and controls voluntary actions, speech, senses, thought, memory.

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The surface of the cerebral cortex has grooves or infoldings (called sulci), the largest of which are termed fissures. Some fissures separate lobes. The convolutions of the cortex give it a wormy appearance. Each convolution is delimited by two sulci and is also called a gyrus (gyri in plural). The cerebrum is divided into two halves, known as the right and left hemispheres. A mass of fibers called the corpus callosum links the hemispheres. The right hemisphere controls voluntary limb movements on the left side of the body, and the left hemisphere controls voluntary limb movements on the right side of the body. Almost every person has one dominant hemisphere. Each hemisphere is divided into four lobes, or areas, which are interconnected.
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The frontal lobes are located in the front of the brain and are responsible for voluntary movement and, via their connections with other lobes, participate in the execution of sequential tasks; speech output; organizational skills; and certain aspects of behavior, mood, and memory.

The parietal lobes are located behind the frontal lobes and in front of theoccipital lobes. They process sensory information such as temperature, pain,taste, and touch. In addition, the processing includes information about numbers, attentiveness to the position of ones body parts, the space around ones body, and one's relationship to this space.

The temporal lobes are located on each side of the brain. They process memory and auditory (hearing) information and speech and language functions.

The occipital lobes are located at the back of the brain. They receive and process visual information. The cortex, also called gray matter, is the most external layer of the brain and predominantly contains neuronal bodies (the part of the neurons where the DNA-containing cell nucleus is located). The gray matter participates actively in the storage and processing of information. An isolated clump of nerve cell bodies in the gray matter is termed a nucleus (to be differentiated from a cell nucleus). The cells in the gray matter extend their projections, called axons, to other areas of the brain. Fibers that leave the cortex to conduct impulses toward other areas are termedefferent fibers, and fibers that approach the cortex from other areas of the nervous system are termed afferent (nerves or pathways). Fibers that go from the motor cortex to the brainstem (for example, the pons) or the spinal cord receive a name that generally reflects the connections (that is, corticopontine tract for the former and corticospinal tract for the latter). Axons are surrounded

in their course outside the gray matter by myelin, which has a glistening whitish appearance and thus gives rise to the term white matter. Cortical areas receive their names according to their general function or lobe name. If in charge of motor function, the area is called the motor cortex. If in charge of sensory function, the area is called a sensory or somesthetic cortex. The calcarine or visual cortex is located in the occipital lobe (also termed occipital cortex) and receives visual input. The auditory cortex, localized in the temporal lobe, processes sounds or verbal input. Knowledge of the anatomical projection of fibers of the different tracts and the relative representation of body regions in the cortex often enables doctors to correctly locate an injury and its relative size, sometimes with great precision. Central Structures of the Brain The central structures of the brain include the thalamus, hypothalamus, andpituitary gland. The hippocampus is located in the temporal lobe but participates in the processing of memory and emotions and is interconnected with central structures. Other structures are the basal ganglia, which are made up of gray matter and include the amygdala (localized in the temporal lobe), the caudate nucleus, and the lenticular nucleus (putamen and globus pallidus). Because the caudate and putamen are structurally similar, neuropathologists have coined for them the collective term striatum.
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The thalamus integrates and relays sensory information to the cortex of the parietal, temporal, and occipital lobes. The thalamus is located in the lower central part of the brain (that is, upper part of the brainstem) and is located medially to the basal ganglia. The brain hemispheres lie on the thalamus. Other roles of the thalamus include motor and memory control.

The hypothalamus, located below the thalamus, regulates automatic functions such as appetite, thirst, and body temperature. It also secretes hormones that stimulate or suppress the release of hormones (for example, growth hormones) in the pituitary gland.

The pituitary gland is located at the base of the brain. The pituitary gland produces hormones that control many functions of other endocrine glands. It regulates the production of many hormones that have a role in growth,metabolism, sexual response, fluid and mineral balance, and the stress response.

The ventricles are cerebrospinal fluid-filled cavities in the interior of the cerebral hemispheres.

For more information, see Anatomy of the Endocrine System.

The Base of the Brain The base of the brain contains the cerebellum and the brainstem. These structures serve complex functions. Below is a simplified version of these roles:
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Traditionally, the cerebellum has been known to control equilibrium and coordination and contributes to the generation of muscle tone. It has more recently become evident, however, that the cerebellum plays more diverse roles such as participating in some types of memory and exerting a complex influence on musical and mathematical skills.

The brainstem connects the brain with the spinal cord. It includes the midbrain, the pons, and the medulla oblongata. It is a compact structure in which multiple pathways traverse from the brain to the spinal cord and vice versa. For instance, nerves that arise from cranial nerve nuclei are involved with eye movements and exit the brainstem at several levels. Damage to the brainstem can therefore affect a number of bodily functions. For instance, if the corticospinal tract is injured, a loss of motor function (paralysis) occurs, and it may be accompanied by other neurologic deficits, such as eye movement abnormalities, which are reflective of injury to cranial nerves or their pathways in the brainstem.
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The midbrain is located below the hypothalamus. Some cranial nerves that are also responsible for eye muscle control exit the midbrain.

The pons serves as a bridge between the midbrain and the medullaoblongata. The pons also contains the nuclei and fibers of nerves that serve eye muscle control, facial muscle strength, and other functions.

The medulla oblongata is the lowest part of the brainstem and is interconnected with the cervical spinal cord. The medulla oblongata also helps control involuntary actions, including vital processes, such as heart rate, blood pressure, and respiration, and it carries the corticospinal (that is, motor function) tract toward the spinal cord.

The Spinal Cord The spinal cord is an extension of the brain and is surrounded by the vertebral bodies that form the spinal column. The central structures of the spinal cord are made up of gray matter (nerve cell bodies), and the external or surrounding tissues are made up of white matter. Within the spinal cord are 30 segments that belong to 4 sections (cervical, thoracic, lumbar,sacral), based on their location:
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Eight cervical segments: These transmit signals from or to areas of the head, neck, shoulders, arms, and hands. Twelve thoracic segments: These transmit signals from or to part of the arms and the anterior and posterior chest and abdominal areas. Five lumbar segments: These transmit signals from or to the legs and feet and some pelvic organs. Five sacral segments: These transmit signals from or the lower back and buttocks, pelvic organs and genital areas, and some areas in the legs and feet. A coccygeal remnant is located at the bottom of the spinal cord. Peripheral Nervous System

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Nerve fibers that exit the brainstem and spinal cord become part of the peripheral nervous system. Cranial nerves exit the brainstem and function as peripheral nervous system mediators of many functions, including eye movements, facial strength and sensation, hearing, and taste. The optic nerve is considered a cranial nerve but it is generally affected in a disease of the central nervous system known as multiple sclerosis, and, for this and other reasons, it is thought to represent an extension of the central nervous system apparatus that controls vision. In fact, doctors can diagnose inflammation of the head of the optic nerve by using anophthalmoscope, as if the person's eyes were a window into the central nervous system. Nerve roots leave the spinal cord to the exit point between two vertebrae and are named according to the spinal cord segment from which they arise (a cervical eight nerve root arises from cervical spinal cord segment eight). Nerve roots are located anterior with relation to the cord if efferent (for example, carrying input toward limbs) or posterior if afferent (for example, to spinal cord).

Fibers that carry motor input to limbs and fibers that bring sensory information from the limbs to the spinal cord grow together to form a mixed (motor and sensory) peripheral nerve. Some lumbar and all sacral nerve roots take a long route downward in the spinal canal before they exit in a bundle that resembles a horse's tail, hence its name, cauda equina. The spinal cord is also covered, like the brain, by the pia matter and the arachnoid membranes. The cerebrospinal fluid circulates around the pia and below the outer arachnoid, and this space is also termed the subarachnoid space. The roots of the cauda equina and the rootlets that make up the nerve roots from higher segments are bathed in cerebrospinal fluid. The dura surrounds the pia-arachnoid of the spinal cord, as it does for the brain. The neuroanatomical basis for multiple brain functions is oversimplified in the above summary. A good example is the neuroanatomical substrate for memory function. Damage to multiple areas of the brain can affect memory. These include structures such as the frontal and temporal lobes, the thalamus, the cerebellum, the putamen, mamillary bodies and fornix, and a convolution above the corpus callosum known as the cingulate gyrus. These structures are variably involved in complex processes such as the storing, processing, or retrieval of memorie Cardiovascular System The heart and circulatory system (also called the cardiovascular system) make up the network that delivers blood to the body's tissues. With each heartbeat, blood is sent throughout our bodies, carrying oxygen and nutrients to all of our cells. Every day, the approximately 10 pints (5 liters) of blood in your body travel many times through about 60,000 miles (96,560 kilometers) of blood vessels that branch and cross, linking the cells of our organs and body parts. From the hard-working heart, to our thickest arteries, to capillaries so thin that they can only be seen through a microscope, the cardiovascular system is our body's lifeline. The circulatory system is composed of the heart and blood vessels, including arteries, veins, and capillaries. Our bodies actually have two circulatory systems: The pulmonary circulationis a short loop from the heart to the lungs and back again, and the systemic circulation (the system we usually think of as our circulatory system) sends blood from the heart to all the other parts of our bodies and back again.

The Heart The heart is the key organ in the circulatory system. As a hollow, muscular pump, its main function is to propel blood throughout the body. It usually beats from 60 to 100 times per minute, but can go much faster when it needs to. It beats about 100,000 times a day, more than 30 million times per year, and about 2.5 billion times in a 70-year lifetime. The heart gets messages from the body tell it when to pump more or less blood depending on a person's needs. When we're sleeping, it pumps just enough to provide for lower amounts of oxygen needed by our bodies at rest. When we're exercising or frightened, the heart pumps faster to get more oxygen to our bodies. that

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The heart has four chambers that are enclosed by thick, muscular walls. It lies between the lungs and just to the left of the middle of the chest cavity. The bottom part of the heart is divided into two chambers called the right and left ventricles, which pump blood out of the heart. A wall called the interventricular septumdivides the ventricles. The upper part of the heart is made up of the other two chambers of the heart, called the right and left atria. The right and left atria receive the blood entering the heart. A wall called the interatrial septum divides the atria, and they're separated from the ventricles by the atrioventricular valves. The tricuspid valve separates the right atrium from the right ventricle, and the mitral valve separates the left atrium and the left ventricle. Two other heart valves separate the ventricles and the large blood vessels that carry blood leaving the heart. These valves are called the pulmonic valve, which separates the right ventricle from the pulmonary artery leading to the lungs, and the aortic valve, which separates the left ventricle from the aorta, the body's largest blood vessel.

The Role of Blood Vessels Blood vessels carrying blood away from the heart are called arteries. They are the thickest blood vessels, with muscular walls that contract to keep the blood moving away from the heart and through the body. In the systemic circulation, oxygen-rich blood is pumped from the

heart into the aorta. This huge artery curves up and back from the left ventricle, then heads down in front of the spinal column into the abdomen. Two coronary arteries branch off at the beginning of the aorta and divide into a network of smaller arteries that provide oxygen and nourishment to the muscles of the heart. Unlike the aorta, the body's other main artery, the pulmonary artery, carries oxygenpoor blood. From the right ventricle, the pulmonary artery divides into right and left branches, on the way to the lungs where blood picks up oxygen. Arterial walls have three layers:
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The endothelium is on the inside and provides a smooth lining for blood to flow over as it moves through the artery. The media is the middle part of the artery, made up of a layer of muscle and elastic tissue. The adventitia is the tough covering that protects the outside of the artery.

As they get farther from the heart, the arteries branch out intoarterioles, which are smaller and less flexible. Blood vessels that carry blood back to the heart are called veins. They are not as muscular as arteries, but they contain valves that prevent blood from flowing backward. Veins have the same three layers that arteries do, but they are thinner and less flexible. The two largest veins are the superior and inferior vena cavae. The terms superior and inferior do not mean that one vein is better than the other, but that they are located above (superior) and below (inferior) the heart. A network of tiny capillaries connects the arteries and veins. Even though they're tiny, the capillaries are one of the most important parts of the circulatory system because it is through them that nutrients and oxygen are delivered to the cells. In addition, waste products such as carbon dioxide are also removed by the capillaries.

What Do the Heart and Circulatory System Do? The circulatory system works closely with other systems in our bodies. It supplies oxygen and nutrients to our bodies by working with the respiratory system. At the same time, the circulatory system helps carry waste and carbon dioxide out of the body. Hormones produced by the endocrine system are also transported through the blood in our circulatory system. As the body's chemical messengers, hormones transfer information and instructions from one set of cells to another. Did you ever wonder about the process behind your beating heart? A healthy heart makes a "lub-dub" sound with each beat. Here's what happens to make that sound: One complete heartbeat makes up a cardiac cycle, which consists of two phases. In the first phase, the ventricles contract (this is called systole, sending blood into the pulmonary and systemic circulation. To prevent the flow of blood backwards into the atria during systole, the atrioventricular valves close, creating the first ("lub") sound. When the ventricles finish contracting, the aortic and pulmonic valves close to prevent blood from flowing back into the ventricles. This is what creates the second sound (the "dub"). Then the ventricles relax (this is called diastole, and fill with blood from the atria, which makes up the second phase of the cardiac cycle. A unique electrical system in the heart causes it to beat in its regular rhythm. The sinoatrial or SA node, a small area of tissue in the wall of the right atrium, sends out an electrical signal to start the contracting of the heart muscle. These electrical impulses cause the atria to contract first; they then travel down to the atrioventricular or AV node, which acts as a kind of relay station. From here the electrical signal travels through the right and left ventricles, causing them to contract and force blood out into the major arteries. In the systemic circulation, blood travels out of the left ventricle, to the aorta, to every organ and tissue in the body, and then back to the right atrium. The arteries, capillaries, and veins of the systemic circulatory system are the channels through which this long journey takes place. Once in the arteries, blood flows to smaller arterioles and then to capillaries.

While in the capillaries, the bloodstream delivers oxygen and nutrients to the body's cells and picks up waste materials. Blood then goes back through the capillaries into venules, and then to larger veins until it reaches the vena cavae. Blood from the head and arms returns to the heart through the superior vena cava, and blood from the lower parts of the body returns through the inferior vena cava. Both vena cavae deliver this oxygen-depleted blood into the right atrium. From here the blood exits to fill the right ventricle, ready to be pumped into the pulmonary circulation for more oxygen. In the pulmonary circulation, blood low in oxygen but high in carbon dioxide is pumped out the right ventricle into the pulmonary artery, which branches off in two directions. The right branch goes to the right lung, and vice versa. In the lungs, the branches divide further into capillaries. Blood flows more slowly through these tiny vessels, allowing time for gases to be exchanged between the capillary walls and the millions of alveoli, the tiny air sacs in the lung. During the process called oxygenation, oxygen is taken up by the bloodstream. Oxygen locks onto a molecule called hemoglobin in the red blood cells. The newly oxygenated blood leaves the lungs through the pulmonary veins and heads back to the heart. It enters the heart in the left atrium, then fills the left ventricle so it can be pumped into the systemic circulation.

V. THE PATIENT AND HIS CARE A. Medical Management a. IVF

Medical Management/ Treatment

Date Ordered Date Started Date Changed

General description

Indications or Purposes

Clients reaction and/or response to the treatment

IVF PNSS 1L + 1 AMP of LYSMIX X 30-31 gtts/min

Date Ordered & Started: 06-25-11

In isotonic solution it has exactly the same water concentration as the cell, there will be no net movement of water across the cell membrane.

This is indicated to the patient in order to be hydrated at all time. The incorporation of lysmix could be the source of vitamins needed for the patient to have optimal nutrition.

The patient have good skin turgor. No dryness of skin, no presence of lesions and No signs of infiltration or bleeding on the IV site.

NURSING RESPONSIBILITIES: PRIOR: 1. 2. 3. 4. 5.

Explain the procedure Check the doctors order Prepare all the materials needed Clean the site of insertion Practice aseptic technique

DURING: 1. Prime the IV tubing 2. Insert the cannula on the large veins, wait for the backflow of blood before removing the needle, then secure the cannula with tape, while securing it apply pressure while connecting the tube. 3. Regulate IV 4. Maintain patent tubing

AFTER: 1. Document the procedure and the time IV is given 2. Put IV tag in the IVF with the time started and time expected to be consumed.

b. Drugs Date ordered Date taken / given Date change / discontinue Date ordered: 06-25-11 to 0628- 11 Date Perfromed: 06-25-11 to 0628-11 Date ordered: 06-25-11 to 0628- 11 Date performed: 06-25-11 to 0628- 11 Date ordered: 06-25-11 to 0628- 11 Date performed: 06-25-11 to 0628- 11 Date ordered: 06-25-11 to 0628- 11 Date Route of Administration, Dosage and Frequency of Administration Clients response to the medication with actual side effect The patients blood pressure have decreased from 170/80 to 150/100.

Name of Drugs Generic Name Brand Name

Indications or purposes

Generic Name: Mannitol Brand Name: Osmitrol

The drug is indicated to the 100 cc IV q 6 patient in order to hours lower the blood pressure. Neurotonic. This drug is indicated to the patient in order to increase blood flow to the brain to have sufficient or adequate cerebral perfusion.

Generic Name: Cytidine Diphosphate Brand Name: Citicholine

1g IV q 12

The patient had no sighs of altered level of consciousness.

Generic Name: Captropril Brand Name: Catapress

25mg/tab 1 tab BID

Antihypertensive. patients This is indicated to The pressure the patient in order blood to lower down the have decreased. blood pressure.

Generic Name: Nimodipine Brand Name: Nimotop

Nimodipine 30mg/tab 2 tabs q (Nimotop) is a dihydropyridine 4 hours calcium channel

The patient have manifested decreased in blood pressure.

performed: 06-25-11 to 0628- 11

blocker originally developed for the treatment of high blood pressure. It is not frequently used for this indication, but has shown good results in preventing a major complication of subarachnoid hemorrhage (a form of cerebral hemorrhage) termed vasospasm; this is now the main use of nimodipine. Antihypertensive. Since the patient have increased blood pressure because of ineffective cerebral perfusion related to impaired gas exchange . Calcium channel blocker, antihypertensive. Since the patient have increased blood pressure because of ineffective cerebral perfusion related to impaired gas exchange.

Generic Name: Losartan Band Name: Cozaar

Date ordered: 06-27-11 Date performed: 06-27-11

100 mg/tab 1 tab OD

The patient have manifested decreased in blood pressure.

Generic Name: Amlodipine Brand Name: Norvasc

Date ordered: 06-27-11 Date performed: 06-27-11

5mg/tab 1 tab OD

The patient have manifested decreased in blood pressure.

Nursing Responsibilities:

Mannitol PRIOR 1. Check doctors order. 2. Verify the Client. 3. Wash hands before handling the medication. 4. Assess patient V/S prior to administration. 5. Prepare the medication as needed. DURING 1. Administer as indicated in the doctors order. 2. Administer medication cautiously and slowly. 3. If IVF clean the insertion point with cotton balls. 4. Gradually inject the drug in to the port. 5. Observed aseptic technique. AFTER 1. 2. 3. 4. 5. Advice patients SO to report any signs of reaction. Wash hands after administration of medication. Observe clients reaction. Document time and date the medication is administered. Monitor vital signs especially Blood pressure after administering the drug.

Cytidine diphosphate PRIOR 1. Check doctors order. 2. Verify the Client. 3. Wash hands before handling the medication. 4. Assess patient V/S prior to administration. 5. Prepare the medication as needed. DURING 1. Administer as indicated in the doctors order. 2. Administer medication cautiously and slowly. 3. If IVF clean the insertion point with cotton balls. 4. Gradually inject the drug in to the port. 5. Observed aseptic technique. AFTER 1. Advice patients SO to report any signs of reaction.

2. Wash hands after administration of medication. 3. Observe clients reaction and Document. Captopril PRIOR 1. Check doctors order. 2. Verify the Client. 3. Wash hands before handling the medication. 4. Assess patient V/S prior to administration. 5. Prepare the medication as needed. DURING 1. Administer as indicated in the doctors order. 2. Administer medication cautiously and slowly. 3. If IVF clean the insertion point with cotton balls. 4. Gradually inject the drug in to the port. 5. Observed aseptic technique. AFTER 1. Advice patients SO to report any signs of reaction. 2. Wash hands after administration of medication. 3. Observe clients reaction and Document.

Nimodipine PRIOR 1. Check doctors order. 2. Verify the Client. 3. Wash hands before handling the medication. 4. Assess patient V/S prior to administration. 5. Prepare the medication as needed. DURING 1. Administer as indicated in the doctors order. 2. Administer medication cautiously and slowly. 3. If IVF clean the insertion point with cotton balls. 4. Gradually inject the drug in to the port. 5. Observed aseptic technique. AFTER 1. Advice patients SO to report any signs of reaction.

2. Wash hands after administration of medication. 3. Observe clients reaction and Document.

Losartan PRIOR 1. Check doctors order. 2. Verify the Client. 3. Perform skin test. 4. Wash hands before handling the medication. 5. Assess patient V/S prior to administration. 6. Prepare the medication as needed. DURING 1. Administer as indicated in the doctors order. 2. Administer medication cautiously and slowly. 3. If IVF clean the insertion point with cotton balls. 4. Gradually inject the drug in to the port. 5. Observed aseptic technique. AFTER 1. Advice patients SO to report any signs of reaction. 2. Wash hands after administration of medication. 3. Observe clients reaction and Document.

Amlodipine PRIOR 1. Check doctors order. 2. Verify the Client. 3. Wash hands before handling the medication. 4. Assess patient V/S prior to administration. 5. Prepare the medication as needed. DURING 1. 2. 3. 4. 5. Administer as indicated in the doctors order. Administer medication cautiously and slowly. If IVF clean the insertion point with cotton balls. Gradually inject the drug in to the port. Observed aseptic technique.

AFTER 1. Advice patients SO to report any signs of reaction. 2. Wash hands after administration of medication. 3. Observe clients reaction and Document. c. Diet Clients reaction and/or response to the diet The client was able to comply with the diet regimen as prescribed by the physician as evidenced by absence of difficulty in breathing.

Type of Diet

Date Ordered Date Started Date Changed

General description

Indications or Purposes

Specific food taken

NPO

NPO diet is a Date Ordered: type of diet 06-25-11 wherein the patient is not Date Discontinued: allowed to eat any fluids or 06-26-11 food.

To have a patent airway and prevent aspirations of secretions.

NONE

Small Feeding with Strict aspiration precaution SFF with SAP

This diet is indicated to the client in order to regain energy Date Ordered: and prevent 06-27-11 dehydration, the Date foods and Performed: liquids are to be 06-27-11 administered in small amounts to prevent aspirations.

The client was able to comply with the diet To regain regimen as energy and prescribed by maintain Breast feeding the physician hydration and to as evidenced prevent by absence of aspirations. difficulty in breathing.

Nursing Responsibilities: 1. 2. 3. 4. Check for the doctor's order. Explain the purpose or reason. Advice to serve and take diet as required. Advice to increase fluid intake.

D. Activity/Exercise Clients reaction and/or response to the activity / exercise

Type of Exercise

Date Ordered Date Started Date Changed

General description

Indications or Purposes

Complete bed rest

Date ordered: 06-25-11 to 0626-11 Date Started: 06-25-11 to 0626-11

Complete bed rest can help the patient to lessen the use of energy and limit the occurrence of fatigue.

In order to lessen The patient able fatigue and to to tolerate the conserve energy. type of exercise.

May sit on the bed

Date ordered: 06-27-11 to 0628-11 Date Started: 06-27-11 to 0628-11

In order to promote It increases the mobilization or muscle strength by resumption of giving passive and activities within active range of tolerance. motion exercises

The patient was able to tolerate such type of exercise.