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PONTINE BLEEDING

(HEMORRHAGIC STROKE)
Prepared by:
BSN IV
Leader:
Dela Cruz, Jeffrey S.
Members:
Ariffuddin, Arifah-Nangco L.
Corpuz, Mariane Bianca O.
Uba, Leslie Ann B.

INTRODUCTION

Also called pontine hemorrhage or hemorrhagic stroke, it


is a form of intracranial hemorrhage
Accounts for -.5% (range 5-10%) and has an incidence of
-3 per 100,000 people
Present with sudden and precipitous neurological deficits

Introduction

Manifestations

Decreased level of consciousness (most common)


Long track signs including tetraparesis
Cranial nerve palsies
Seizures
Cheyne-Stokes respiration.

Introduction

Has poor prognosis, with large bleeds being almost


universally fatal.
Open surgical evacuation of the clot is usually not
performed, although stereotactic clot aspiration has been
advocated by some.
In smaller hemorrhages, medical management and
treatment of hydrocephalus with extraventricular drains
may be life-saving, however, often with significant
residual neurological deficits.
Overall mortality ranges between 30% and 90%, with the
overall volume of the bleed and initial GCS being related
to outcome

Introduction

Risk Factors
Non-modifiable risk factors
1. Old age
2. Previous CVA patients
3. Gender, mostly male
4. Race, including Asian-Pacific
5. Family history of CVA
6. Diabetes
Modifiable risk Factors
7. High blood pressure
8. High cholesterol level
9. Smoking
10. Management on heart disease/diabetes

Introduction

AnatomyandPhysiology

Introduction

PONS
The pons is part of the brainstem
Lies between the midbrain (above) and the medulla oblongata
(below) and in front of the cerebellum.
Also called the pons Varolii ("bridge of Varolius").
This region of the brainstem includes neural pathways or tracts
that conduct signals from the brain down to the cerebellum and
medulla, and tracts that carry the sensory signals up into the
thalamus.
Measures about 2.5 centimetres (0.98 in) in length.
Most of it appears as a broad anterior bulge rostral to the
medulla. Posteriorly, it consists mainly of two pairs of thick
stalks called cerebellar peduncles. They connect the cerebellum
to the pons and midbrain.

Introduction

Functions (CN V-VIII)


sleep,
respiration (inhalation and exhalation
swallowing
bladder control
hearing
equilibrium
taste
eye movement
facial expressions
facial sensation
posture
dream generator

Introduction

RationaleforChoosingtheCase
We chose this case study particular because my clinical
instructor assigned this to us. I was given the opportunity
to handle this patient for this will be my first case of GCS 5
(E1V1M3). The particulars of this case are to explore every
facet of the pathophysiology of the diagnosed condition, its
anatomy and physiology, nursing care management and
summary discharge planning.

Introduction

SignificanceoftheStudy
The significance of the study is to focus on the cases health
promotion, early detection and illness prevention. Through
this, it will serve as a guide for us to learn more about the
disease, its procedure, as well as its medical and nursing
management.

Introduction

ScopeandLimitation
The scope of the plan of care for patient WB is focused on
the morning shift from 6 AM up to 2 PM. The case
presentation covered only for the Intensive Care Unit (ICU)
and for the duration of my duty, which are on the following
dates: September 21-23, September 28-30 and October 5-7,
every Wednesday to Friday of the given dates.

Introduction

PATIENTS HEALTH HISTORY

GeneralData
Name:WB
Age: 65 years old
Birthdate:April 17, 1951
Birthplace: Negros
Sex: Female
Religion: Roman Catholic
Civil Status: Married
Address: 75 San Guillermo St., Bayanan, Muntinlupa
Date/Time Admitted: September 18, 2016, 1:50 AM

Patients Health History

ChiefComplaint
WB was referred to Medical Center Paranaque with a
chief complaint of loss of consciousness accompanied by
her son.
HistoryofPresentIllness
4 minutes prior to complaint, WB had sudden episode of
loss of consciousness, rushed to the nearby hospital and
referred to Medical Center Paranaque.

Patients Health History

PastMedicalHistory
WB had a medical history of hypertension. Had her
first check up last 2010 and was diagnosed with
hypertension. On 2011, she was diagnosed with Acute
Kidney Failure near her barangay health center.
FamilialHistory
WBs father side had history of hypertension. Patients
brother had a history of mild CVA.

Patients Health History

GORDONs11functionalhealthpattern
HealthPerceptionandHealthManagementPattern
BEFORE HOSPITALIZATION:
Ang nanay ko kung tutuusin, maalaga yan. Hindi siya nagkukulang ng
pagpapaalala sa amin tungkol sa kahalagahan ng kalusugan. Habang
nagtatrabaho si tatay, si nanay naman ang umaasikaso sa lahat ng gawaing
bahay at pag-aalaga sa amin. Nalaman lamang naming na highblood siya
noong 40 years old pa lang siya habang nagpacheck siya ng BP sa health
center. Sa pamilya namin, ang sa fatherside naming ay may history rin ng
highblood at sa kapatid ko na inatake ng mild stroke. Di naman siya palainom
ng vitamins although di naman siya naninigarilyo o umiinom ng alak. Ako
bale ang gumagastos sa pagpapaospital ni nanay gamit credit card ko habang
nilalakad ko ang PhilHealth at PCSO para makamenos sa gastos, as
verbalized by the patients son.

Patients Health History

DURING HOSPITALIZATION:
The patient is currently on comatose with GCS 3-4 (E1V1M1-2), pupils of 2
mm RTL. Transfused with 2 units of packed RBC, BP range of 140/90 mmHg,
PR 70-80, RR on mechanical ventilator settings, (-) spontaneous breathing and
(-) corneal reflex. She was on a mechanical ventilator with settings: RR of 18
cpm, O2 sat of 98%, TV of 500, AC mode and FiO2 of 40%. Cardio
medications given are the following: Amlopidine, Coaprovel, Terasozin,
Coralan and Atorvastatin.
Nutritional-MetabolicPattern
BEFORE HOSPITALIZATION:
Noong nasabihan siya na high blood si nanay, madalang na lang ito kumain ng
karne. Gulay, prutas at isda ang kinakain nito madalas. Si nanay ang tagaluto ng
kinakain nila ni tatay. Sa pag-inom ng tubig, since noong nag-asawa na ako,
hindi na ako nakasubaybay kung regular man umiinom ng tubig si nanay. So
far, walang naming inirereklamo si nanay sa akin, as verbalized by the
patients son.

Patients Health History

DURING HOSPITALIZATION:
She has been hooked up with continuous IVF of PNSS 1L to run for 12 hours
and 50 ml. Mannitol via IVF. Currently has a NGT insertion with OF of 1,500
kcal/day divided into 6 equal feedings
EliminationPattern
BEFORE HOSPITALIZATION:
Wala naman kaming napagkukuwentuhan tungkol sa problema nya either sa
pagdumi o pag-ihi, as verbalized by the patients son.
DURING HOSPITALIZATION:
The patient was has an IJ insertion as she had AKI oliguric phase, while hooked
on IVF TF PNSS 1 L x KVO to IVF PNSS x KVO, increased UFR at 2.5 L,
consumed bicarbonate drip, on hemodialysis with a duration of 4 hours, UFR
set for 2 L, heparin free, with bicarb bath, QB: 250, QD: 500. Currently with a
foley catheter and monitored on hourly intake and output.

Patients Health History

ActivityandExercisePattern
BEFORE HOSPITALIZATION:
Libangan ni nanay? Mahilig sa facebook yun at palanood ng TV pag wala
siyang ginagawa. Palaabang ng teleserye at balita, as verbalized by the patients
son.
DURING HOSPITALIZATION:
The patient was on vegetative state with GCS of 3-5 (E1V1M1-3).
Cognitive-PerceptualPattern
BEFORE HOSPITALIZATION:
Wala naman akong natatandaan na nagkaproblema sa mata o tenga si nanay.
Mabilis ang pick-up nito sa mga bagay-bagay, kung tutuusin, siya pa nga ang
nagtuturo sa akin sa mga assignment ko noong kabataan ko, as verbalized by
the patients son.

Patients Health History

DURING HOSPITALIZATION:
The doctor ordered CBC, U/A, Crea, Na, K, 12 Lead ECG, Chest X-ray,
Cranial CT Scan (the following were done outside the hospital premises), BUN,
Lipid Profile, CBG, AST, ALT, PT and PTT. Ordered vital signs and GCS every
hour. Ordered a 10 mg. Nicardipine drip in 90 cc. D5W to maintain SBP < 150
mmHg. Ordered suction secretion as needed. Done NGT and notified the AP on
the admission and patients status. Set mechanical ventilator at: TV 300, FiO2
100%, AC mode, RR 18. To update AP once in a while regarding patients
status
SleepandRestPattern
BEFORE HOSPITALIZATION:
10 PM lagi natutulog si nanay at nagigising ng 5 ng madaling araw. Madalas
ito nakakapagsiyesta. Pampatulog nito ang pasilip silip nito sa smartphone para
ito makapag-FB. Wala naman siyang nairereklamong problema na kahit ano sa
paggising nito sa umaga, as verbalized by the patients son.

Patients Health History

DURING HOSPITALIZATION:
Patients GCS dropped to 3-4 (E1V1M1-2), pupils 2 mm RTL, BP range 100120/70-80. Son was updated on the poor prognosis of the patient. Best case
scenario was persisted in vegetative state.
SelfPerceptionPattern
BEFORE HOSPITALIZATION:
Sa kabila ng nangyari kay nanay, hindi pa rin kami nawawalan ng pag-asa. Sa
pagkakakilala ko kay nanay, alam kong lumalaban siya hanggang sa huli nitong
hininga. Si nanay pa, iba ang pagpapalaki nya sa amin, as verbalized by the
patients son.

Patients Health History

Role-RelationshipPattern
BEFORE HOSPITALIZATION:
Noong humiwalay kaming 4 na magkakapatid sa aming mga magulang, sila na
lang ni tatay ang magkasama sa bahay. Pinalaki kami nila nanay at tatay sa
pagmamahal at takot sa Diyos. Maliban sa aming kinabibilangang sekta sa
simbahan, wala na akong alam na iba pa nitong ginagawa pa, as verbalized by
the patients son.
SexualityandReproductivePattern
DURING HOSPITALIZATION:
Wala po akong maisasagot po dyan, as verbalized by the patients son.

Patients Health History

CopingandStressTolerancePattern
BEFORE HOSPITALIZATION:
Sa tuwing may problema si nanay, tatawag yan sa amin para
makipagkwentuhan o kung wala sa amin makasagot sa telepono,
makikipagkwentuhan siya kahit kanino. Sa aming lahat, ako ang
pinakanilalapitan ni nanay since ako ang pinakapaborito nito. Hanggat may
oras ako, makikipag-usap ako sa kanya siyempre, as verbalized by the
patients son.
ValuesandBeliefPattern
DURING HOSPITALIZATION:
Para sa amin, lalo kay nanay, mahalaga ang aming pananalig sa Diyos. Siya
ang aming inspirasyon at pinagkukunan ng lakas ng loob. Anumang ang
kahinatnan nito, mananatili ang aming tiwala at pananalig sa kanya dahil
naniniwala kami na may dahilan ang lahat kaya ito nangyayari. Kung dumating
man ang takdang panahon sa aming lahat, mahirap man ito matanggap ay
magpapatuloy pa rin kami sa aming ginagawa, as verbalized by the patients
son

Patients Health History

PHYSICAL AND NEUROGICAL


EXAMINATION

VITAL SIGNS:

Temperature : 36C
PR : 62 bpm
RR
: on mechanical ventilator
BP : 180/140 mmHg
GENERAL SURVEY:

Current weight unidentified, no fever, no chills,


known hypertensive with poor maintenance, GCS 3
(E1V1M1).

Physical and neurogical examination

SKIN/EENT
With scars on lower extremities, with pallor on lower extremities, cold and
clammy skin, poor capillary reflex, white hair (uneven distribution), presence
of blisters in the feet, desquamation in the inguinal area, clean and short nails
With pinpoint pupils 2mm RTL.
Air conduction unassessed, no tragal tenderness, no tinnitus, no aural
discharge
With colds, no epistaxis, with few nasal discharge
No bleeding gums, no sores, no fissures, with oral white secretions (saliva),
with two loose teeth on upper left canine and lower right molar, no tongue
movement
No tonsillitis, no gum bleeding, no mouth sores, no sore throat
PULMONARY
No cough, no hemoptysis, on mechanical ventilator with O2 sat of 97%, TV 500,
Fio2 OF 40%, SCE CBS, (-) murmur.

Physical and neurogical examination

CARDIOVASCULAR
No chest pain, no palpitation, no PND, no orthopnea, no easy fatigability, no
syncope, hypertensive (180/140)
No phlebitis, no varicosities, no claudification
GASTROINTESTINAL
No abdominal pain, no vomiting, no diarrhea, no melena, no hematochezia,
without constipation
GENITO-URINARY
No incontinence, no urgency, no frequency, no dysuria, no nocturia, no flank
pain, on diaper
MUSCULOSKELETAL
Musculoskeletal unassessed
ENDOCRINE
No heat and cold tolerance

Physical and neurogical examination

HEMATOPOEITIC
No bruising, no bleeding tendencies, no anemia.
NEUROLOGIC
GCS 3 (E1V1M1), Cranial Nerves

CN I: not assessed
CN II: pinpointed pupils 2 mm ERTL
CN III, IV, VI: not assessed
CN V: intact
CN VII: not assessed
CN VIII: not assessed
CN IX, X: not assessed
CN XI: not assessed
CN XII: not assessed
Motor: 1/5 on RUE and RLE, 1/5 on LUE and LLE
Sensory: not assessed
DTRS: + on RUE and RLE, + on LUE and LLE
Pathological Reflexes: not assessed
Meningeal signs: not assessed

Physical and neurogical examination

PATHOPHYSIOLOGY

ModifiableRiskFactors
Stress
Lifestyle
Exercise
Hypertension
Obesity

Nonmodifiable
Age
Sex
Family history of
stroke
Race

Continuity of risk
factors

Pathophysiology

Increased vasoconstriction

Formation of fatty
plaque deposits

Increased blood
perfusion

Thrombus
formation

Hardening and
narrowing of arteries
Occlusion of major
vessels

Pathophysiology

Increased blood
coagulation

Plaque ruptures the pons

Pontine bleeding

GFR

renal
perfusion
Beta receptor
activation

oxygenated blood to
the brain

oxygenation in
kidneys
blood flow to
the organs

Pathophysiology

Hypertension

Changes in arteriolar
bed systemic vascular
resistance

afterload

water
reabsorption
Renin

plasma volume
(ECF)
sodium
reabsorption
blood
pressure

aldosterone

peripheral
resistance

Arteriolar
vasoconstriction

Pathophysiology

Angiotensin I
ACE from
lungs

Angiotensinogen

Angiotensin II

DIAGNOSTICS

CT SCAN
September 17, 2016
Findings:
Multiple plain CT images of the head were obtained
There is a parenchymal bleed in the pons measures 1.3 x 3.5
x 2.3 cm. with approximate volume of 5.4 cc. The cerebral
and cerebellar parenchyma show normal attenuation with no
evidence of acute or chronic infarcts and bleed noted. No
mass or abscess noted. The gray-white matter interface is
maintained
The sulci and gyri are normal
The midline structures are not displaced
The ventricles are normal in size, shape and location
No extra-axial fluid or bleed noted
Impression:
Pontine bleed

Diagnostics

BLOOD CHEMISTRY
September 17, 2016
PARAMETERS

NORMAL VALUES

ACTUAL
RESULTS

INTERPRETATION

53-97 mmol/L

316

Indicator for impaired


kidney function or kidney
disease.

Creatinine

COMPLETE BLOOD COUNT


September 17,2016
Normal Values

Actual Results

Hemoglobin

140.00-170.00

95

Indicator for anemia

Hematocrit

0.41-0.51

0.28

Same as hemoglobin

RBC count

4.60-5.20

3.26

Same as hemoglobin

WBC count

4.50-11.00

12.11

Indicator for infection

142,000-424,000 U/L

428,000

Platelet count

Diagnostics

Interpretation

Indicator for
thrombocytosis/thrombocythemia

Red Blood Cells Indices


MCV

83.00-101.00 fL

82.1fL

315.00-345.00 g/L

366g/L

39.00-46.00 fL

38.8fL

Indicator for microcytic


anemia
Indicator for macrocytic
anemia
Same as MCHC

Neutrophil

0.55-0.70

0.41

Indicator for neutropenia

Lymphocyte

0.20-0.35

0.51

Indicator for infection

MCHC
RDW
Differential Count

Diagnostics

CT SCAN
September 18,2016
Findings:
Hemorrhagic foci are again seen in the pontine region with a
combined computed volume of 5.5 ml. (previously 5.4 ml.).
Perimetric edema is noted.
The rest of the brain parenchyma appears normal
The ventricles are not dilated. There is no midline shift.
The paranasal sinuses, orbits and bony calvarium are intact
Impression:
Pontine hemorrhage, stable since the previous study
No new focus of hemorrhage or infarction identified
No hydrocephalus detected at this time

Diagnostics

ABG
September 18, 2016
FiO2: 80%
Parameters

Normal Values

Actual Results

7.35-7.45

7.37

35-45

35

PO2

80-100 mmHg

218

HCO3

22-26 mEq/L

20.2

BE/BD

(+/-)2-2 mEq/L

-4.4

O2 Sat

95-98%

100%

pH
PCO2

Interpretation:

Fullycompensatedmetabolicacidosis

Diagnostics

BLOOD CHEMISTRY
September 18,2016
Parameters

Normal Values

Actual Results

Urea Nitrogen

2.85-7.20 mmol/L

12.59

Sodium

136-145 mmol/L

134

53-97 mmol/L

272.49

Creatinine

Interpretation
Indicator for heart failure
Indicator for hyponatremia
Indicator for impaired kidney
function or kidney disease.

LIPID PROFILE
September 18, 2016
Normal Values

Actual Results

Interpretation

Fasting Glucose
(FBG)
Total Cholesterol

70-115 mg/dL

152.73mg/dL

Indicator for diabetes

< 200 mg/dL

213.85mg/dL

Triglycerides

50.00-150.00
mg/dL
25.77-62.69
mg/dL
65.40-130.00
mg/dL

175.45mg/dL

High risk for heart


diseases
High risk for heart
diseases
High risk for heart
diseases
High risk for heart
diseases

HDL cholesterol

Diagnostics

LDL cholesterol

22.31mg/dL
157.69mg/dL

COMPLTETE BLOOD COUNT


September 18,2016
ProthrombineTime
Control

13.4 seconds
Normal Values

Actual Results

Patient

12.00-15.00 sec

14.2 sec

Activity

70.00-120.00 sec

93.1 sec

INR

1.05

ActivatedPartialThromboplastinTime
Control
Patient

Diagnostics

28.3 sec
25.1

CT SCAN
September 19,2016
Findings:
There is no significant interval change in the extent and amount of the
pontine bleed now with a computed volume of 5.6 ml (previously 5.5 ml.).
Same degree of surrounding edematous changes are seen
The rest of the brain parenchyma remains normal
As before, the ventricles remain intact with no dilatation noted. There is no
midline shift
The paranasal sinuses, orbits and bony calvarium remains unremarkable
Impression:
Pontine hemorrhage with no significant change in volume or extent
As before, no new focus of hemorrhage or infarction identified
No ventricular dilatation detected at the time of this examination

Diagnostics

ETA
September 19,2016

Gram Stain Results:

Epithelial cells
:
few
Pus cells
:
>50/hpf
Gram(+) Cocci (Singly/In pairs) :
3+
Gram (-) Bacilli
:
few
No other microorganisms seen

Diagnostics

ABG
September 19, 2016
FiO2: 40%
Temp: 37.8C
Parameters

Normal Values

Actual Results

7.35-7.45

7.38

35-45

32

PO2

80-100 mmHg

74

HCO3

22-26 mEq/L

18.8

BE/BD

(+/-)2-2 mEq/L

-5.2

O2 Sat

95-98%

94%

pH
PCO2

Interpretation:

Fullycompensatedmetabolicacidosis

Diagnostics

ABG
September 20,2016
FiO2: 35%
TV: 400
Parameters

Normal Values

Actual Results

7.35-7.45

7.27

35-45

28

PO2

80-100 mmHg

65

HCO3

22-26 mEq/L

12.9

BE/BD

(+/-)2-2 mEq/L

-12.6

O2 Sat

95-98%

89%

pH
PCO2

Interpretation:

Partiallycompensatedmetabolicacidosis

Diagnostics

BLOOD CHEMISTRY
September 20, 2016
Parameters

Normal Values

Actual Results

Interpretation

Urea Nitrogen

2.85-7.20 mmol/L

17.04

Indicator for heart failure

Sodium

136-145 mmol/L

130.00

Indicator for hyponatremia

Potassium

3.6-5.1 mmol/L

2.90

Indicator for hypokalemia

Creatinine

53-97 mmol/L

570.62

Indicator for impaired kidney


function or kidney disease.

COMPLETE BLOOD COUNT


September 20,2016
Normal Values

Actual Results

Hemoglobin

140.00-170.00

80

Indicator for anemia

Hematocrit

0.41-0.51

0.25

Same as hemoglobin

RBC count

4.60-5.20

2.77

Same as hemoglobin

WBC count

4.50-11.00

24.2

Indicator for infection

Diagnostics

Interpretation

RedBloodCellsIndices
RDW

39.00-46.00 fL

53.9fL

Indicator for macrocytic anemia

Segmenters

0.55-0.65

0.93

Indicator for infection

Lymphocytes

0.25-0.35

0.07

Indicator for infection

Differential Count

CT SCAN
September 21, 2016
Impression/Findings:
There is a stability in the area of the formerly seen pontine hemorrhage. No
progression noted.
Ventricles are not dilated. No intraventricular hemorrhagic extension detected
Cerebral atrophy is demonstrated
The internal carotid arteries are segmentally calcified
No midline shift
The orbits, paranasal sinuses, mastoids and sella turcica are intact
NGT is partially visualized

Diagnostics

CHEST X-RAY
September 21, 2016
Roentgenological Findings:
Dense hilar shadows
Enlarged cardiac outline
Sclerotic thoracic aorta
The left sulcus is not well defined
IJ catheter is seen
NGT is partially visualized
EDT tip is about 2-3 cm from the carina
Impression:
Hilar congestive changes
Cardiomegaly
Atheromatous aorta
Minimal pleural effusion, left is not ruled out

Diagnostics

BLOOD CHEMISTRY
September 23, 2016
Parameters
Urea Nitrogen
Creatinine

Normal Values

Actual Results

Interpretation

2.85-7.20 mmol/L

10.50

Indicator for heart failure

53-97 mmol/L

305.09

Indicator for impaired


kidney function or kidney
disease.

COMPLETE BLOOD COUNT


September 23, 2016
Normal Values

Actual Results

Hemoglobin

140.00-170.00

106

Indicator for anemia

Hematocrit

0.41-0.51

0.33

Same as hemoglobin

RBC count

4.60-5.20

3.65

Same as hemoglobin

WBC count

4.50-11.00

18.2

Indicator for infection

Diagnostics

Interpretation

Red Blood Cells Indices


RDW
39.00-46.00 fL

55.4fL

Indicator for macrocytic


anemia

Differential Count
Segmenters

0.55-0.65

0.85

Indicator for infection

Lymphocytes

0.25-0.35

0.12

Indicator for infection

Diagnostics

COURSE IN THE WARD

September18,2016
At 1:50 AM, patient arrived unconscious in the ER. Vital signs were the
following: BP 180/140, PR: 62, RR was mechanical ventilator assisted
and with a temperature of 36C. Patient was admitted to ICU under the
care of Dr. Pena. Secured consent for admission and management. On
NPO diet.
At 2:35 AM, patient was hooked with PNSS 1 L x 12. The doctor
ordered CBC, U/A, Crea, Na, K, 12 Lead ECG, Chest X-ray, Cranial CT
Scan (the following were done outside the hospital premises), BUN,
Lipid Profile, CBG, AST, ALT, PT and PTT. Ordered medications:
Citicoline, Mannitol, Omeprazole and Atorvastatin. Ordered vital signs
and GCS every hour. Ordered a 10 mg. Nicardipine drip in 90 cc. D5W
to maintain SBP < 150 mmHg. Ordered suction secretion as needed.
Done NGT and notified the AP on the admission and patients status. Set
mechanical ventilator at: TV 300, FiO2 100%, AC mode, RR 18. To
update AP once in a while regarding patients status

Course in the ward

At 4:10 AM, patients drip revised to 90 cc. PNSS + 10 mg.


Nicardipine x 5 ugtts/min to maintain SBP < 150 mmHg, also to
follow PNSS 1 L x 12.
At 8 AM, patients BP dropped from 200/100 to 160/100 @
Nicardipine 11 mg/hr (110 cc/hr). Referred to cardiologist.
At 8:10 AM, two cardiologists were referred but both not available
At 8:15 AM, patients BP 160/100 @ Nicardipine 11 mg/hr (110
cc/hr) with GCS 6 (E1V1M4). Given Coaprovel and Amlodipine for
hypertension.
At 8:20 AM, AP was informed of orders from cardiologist Dr. delos
Reyes to maintain BP @ 150-160/90-100 mmHg

Course in the ward

At 10:45 AM, patients relatives were updated on status and decided to


do all medical and surgical management to the patient. Referred to
neurosurgeon for consult and ordered increase of Mannitol to 100 cc q 2
At 10:50 AM, neurosurgeon cant be reached through landline and
cellphone and referred next on deck via SMS
At 11:20 AM, neurosurgeon Dr. Colasito was informed and aware of
referral for neurosurgeon consult via phone call.
At 11:40 AM, patients temperature rose to 38. 4C. Given Paracetamol
via IV q 4
At 11:50 AM, CVD hemorrhage, pontine observed via CT scan done last
September 17, 2016. Another CT scan was ordered by Dr. Colasito

Course in the ward

At 12:10 PM, patients relatives were advised and explained patients


current condition. Ordered PNSS 1 L x 12.
At 2:00 PM, patient seen with (+) pontine bleed, with GCS 6 (E1V1M4)
and lateral wall ischemia. Relatives were aggressive in management.
History reviewed and entries noted. Under Nicardipine drip. Given
Coaprovel drip with BD after 30 minutes. With BP 160/100 mmHg and HR
104 bpm. Ordered to continue Coaprovel and Amlodipine as ordered. Plan
2-D Echo and Color Doppler. Impression seen: s/p CVA, hypertension Stage
2 t/c hypertensive nephrosclerosis t/c diabetes nephropathy
At 2:15 PM, patient has creatinine (310), with GCS 5 (E1V1M3), pupils 2
mm. RTL. Relatives were updated on condition. Ordered Cranial CT Scan
for confirm brain stem hemorrhage. Neurology ordered labs: Na, K, BUN,
Crea. Referred to pulmonologist for co-management. Also ordered ABG,
NPO except for medication (Ketosteril 600 mg. TID). Inserted separate
heplock for Cerebrolysin infusion, lactulose and CBG monitoring q 8

Course in the ward

At 2:50 PM, ABG results were relayed and informed referral for
pulmonologist. Increased TV to 500, decreased FiO2 by 10 q 30
minutes until 40% is reached to maintain O2 sat at 98% and above.
Scheduled for ETA GS/CS. Started on nebulization (Pulmodual) q 6
At 11:45 PM, patient has GCS 6 (E1V1M4). Advised to watch out
for further deterioration. Ordered to repeat Cranial CT scan
tomorrow PM. Anticipated for the possibility of external ventricular
draining (EVD) and explained to patient and follow up.

Course in the ward

September19,2016
At 10 AM, patient had GCS 5 (E1V1M3) with O2 sat of 97% at 40%
FiO2. Ordered to repeat ABG.
At 12 PM, vital signs were noted and given PNSS 1 L x 12 for 2 cycles
At 12:55 PM, patients O2 sat was at 98% @ 48% FiO2. Ordered to
decrease FiO2 at 35%
At 3:45 PM, patients pupil were at 2mm RTL with GCS 6 (E1V1M4)
with no spontaneous breathing. Condition unchanged from yesterday
and updated relative.
At 3:50 PM, CT scan were relayed. No significant progression and no
hydrocephalus. Carried on with the present management.

Course in the ward

At 4 PM, ETA GS indicated: epithelial cells few, pus cells - >50 hpf,
gram(+) cocci 3+, gram(-) bacilli few and (+) yellowish secretion
per ET. Ordered Piperacillin+Tazobactam (Vigocid) IV qid
At 5:40 PM, patient started with Terazosin 5 mg. tab q 8 PM daily.
At 5:50 PM upon admission to ER, patient arrived unconscious. Vital
sign was BP 100/90. Patients medication were given as ordered: 10
mgs. Amlodipine, 300/25 mg. Coaprovel and 10-20 gtts/min
Nicardipine drip. Gave 2 mg. Terasozin NGT OD every 8 PM duty.
Started 5 mg. Ivabradine (Coralan) NGT OD
At 6:57 PM, CBG results relayed at 121 mg/dL. Started OF of 1,500
kcal/day divided into 6 equal feedings. Discontinued CBG monitoring
upon starting on OF.

Course in the ward

September20,2016
At 2:45 PM, patients O2 sat around 96-97% @ 35% FiO2. Given Fluimucil 60
mg. to dissolve in 50 cc water bid. Reduced dosage Vigocid to 2.25 mg. IV q 8
At 3:48 PM, patients GCS 5 (E1V1M3), pupils at 3 mm. RTL, I/O 4667/2260
and with (+) spontaneous shallow breathing. Ordered for repeat CBC, Na, K,
BUN and Crea. Shifted Omeprazole IV to Omeprazole 40 mg/cap OD.
Referred to nephrology for evaluation and management. Also to repeat Cranial
CT scan tomorrow morning.
At 4:10 PM, contacted 3 nephrologists but all were not available and updated
Dr. Pena. Increased Ketosteril to 2 tabs tid.
At 5:05 PM, Nephrologist Dr. Guce answered back and aware of the referral.
Suggested to decreased TV to 100

Course in the ward

At 5:25 PM, Dr. Alcantara updated the orders via phone.


At 9 PM, Dr. Alcantara ordered to increase TV to 400 and to repeat
ABG after 2 hours.
At 9:20 PM, potassium was observed and started the patient with
K-Lyte 2 tabs tid
At 9:30 PM, Dr. Guce from nephrology viewed and examined
patient. Findings showed that patient had chronic kidney failure and
done the following instructions: advised to continue ketosteril,
transfusion of 2 u PRBC properly typed and crossmatched once
available, hemodialysis with attached consent, IJ insertion with
consent, gave NaHCO3 with 250 D5W x 12 x2 cycles, increased TV
to 500 as recommended by Dr. Alcantara

Course in the ward

September21,2016
At 1:55 AM, advised to vigocid 2.25 g. q 12. Scheduled for HBsAg, antiHBS,anti-HCV with consent. Prescribed dialysis were as followed: duration 4
hours, UFR: 0.5 L, no heparin, dialyzer F7 or equivalent, QB: 250, QD: 500,
with bicarbonate bat, dialysate temp: 36, dialysate sodium: 140, dialysate
potassium: 2.0 and with PNSS 1 L x 12
At 7 AM, patient consented on the IJ catheter insertion and hemodialysis.
Referred to TCVS for IJ catheter creation.
At 8 AM, patients relatives were been aware on the referral to TCVS and
anesthesiologist
At 8:20 AM, patients relative was aware of referral, noted history and
reassessed patients GCS 6 (E1V1M4) and intubated. Scheduled for IJ insertion
at 11 AM. Referred to anesthesiologist and OR. Secured consent with no pre-op
meds.

Course in the ward

At 8:30 AM, four anesthesiologists were contacted and Dr. Dizon was the
only available one on deck who was aware of the patients status. Asked
Dr. Desquitado to reschedule patient at 10 AM
At 9 AM, Dr. Alcantara and Dr. Pena were aware of the above orders via
phone call. Updated other APs through SMS. Cranial CT scan was done
and results were sent via Viber
At 9:45 AM, informed on the order and rescheduled OR at 10 AM by Dr.
Desquitado
At 10 AM, patient was sent back to ICU and connect ventilator with the
same settings. Monitor v/s q 15 minutes until stable. Scheduled for x-ray,
continued OF, regulated IVT at 60 cc/hr and continued all previous
medications.

Course in the ward

At 11 AM, s/p IJ insertion, patient had AKI, oliguric phase, hooked on IVF
TF PNSS 1 L x KVO to IVF PNSS x KVO, increased UFR at 2.5 L,
consumed bicarbonate drip, rescheduled for hemodialysis for tomorrow,
duration = 4 hours, UFR: 2 L, heparin free, with bicarb bath, QB: 250, QD:
500. Dr. Marcial was OOC and covered by Dra. Marcial.
At 1 PM, ICU inquired regarding on pre-BT drugs. Informed re: blood
(leukoreduce). Dr. Guce gave Paracetamol for pre-BT and also approved
for leukoreduce blood on BT.
At 1:30 PM, patient was for HD. Doctor approved to increase FiO2 to
100% while on HD
At 2:10 PM, patients v/s: BP 80/40 mmHg, O2 sat 99%, Spent 30 min on
HD.

Course in the ward

At 4:30 PM, cardio meds were given: Amlodipine, Coaprovel,


Terazosin, Coralan and Atorvastatin.
At 4:40 PM, Dr. Pena reduced Mannitol to 50 ml. q 6
At 10:30 PM, Dr. Pena prescribed 2 u PRBC to run for 4-6 hours.
For reassessment after transfusion c/o ROD.
September22,2016
At 8:30 AM, patients GCS 5 (E1V1M3), SCE CBS, transfused 2 nd unit
PRBC.
At 10:00 AM, patients GCS dropped to 3-4 (E1V1M1-2), pupils 2 mm
RTL, BP range 100-120/70-80. Put all anti-hypertensive drugs on hold.
Relatives were updated on the poor prognosis of the patient. Best case
scenario was persisted in vegetative state.

Course in the ward

At 1 PM, talked to Dr. Marcial through phone call regarding


referrals.
At 2:30 PM, Dr. Pena and Dr. Guce were informed on Dr.
Marcials decision regarding referral through phone call and SMS
respectively.
At 3:20 PM, patient was seen and examined by Dr. Alcantara with
NND.
At 8:20 PM, done with HD and BT 2 u PRBC. Vital signs: BP
140/90, PR 70-80, RR 18, O2 Sat 98%, (-) spontaneous breathing,
(-) corneal reflex. Ordered for repeat CBC, Na, K, BUN, Crea 12
hours post BT.

Course in the ward

DRUGS STUDY

ATORVASTATIN
Lipitor
Anti-lipidemic

80mg/tab ODHS
Indication:
A revolutionary medication that is used to both treat hypertension, angina, and prevent further
circulatory, and heart conditions.
Mechanism of action:
Is in a group of drugs called HMG CoA reductase inhibitors or statins. Reduces the level of bad
cholesterol and triglycerides in the blood, while increasing levels of good cholesterol.
Adverse effect:
Difficulty breathing; swelling of your face, lips, tongue, or throat.
Unexplained muscle pain, tenderness, or weakness; fever, unusual tiredness, and dark colored urine;
severe drowsiness,, pounding heartbeats, chest pains, diarrhea, mild nausea, stomach pain, joint pain and
flushing
Nursing consideration:
Watch out for allergic reaction.
Before taking this medication, consult your doctor, if you have a history of any of the following
medical conditions: heart disease, diabetes, kidney disease, liver problems, thyroid disorder, or if you
have an alcohol dependency.

Drug study

AMLODIPINE
Calciumchannelblocker

10mg/tab OD
Indication:
Is slowly and almost completely absorbed from the gastrointestinal tract. Peak plasma
concentrations are reached 6-12 hour following oral administration. Its estimated
bioavailabilty is 64-90%. Absorption is not affected by food.
Mechanism of action:
Decreases arterial smooth muscle contractility and subsequent vasoconstriction by
inhibiting the influx of calcium ions. Entering the cell through these channels bind to
calmodulin. A long-acting CCB essential for hypertension and exertion-related angina.
Adverse effects:
Difficulty breathing; swelling of your face, lips, tongue, or throat.
Unexplained muscle pain, tenderness, or weakness; fever, unusual tiredness, and dark
colored urine; severe drowsiness,, pounding heartbeats, chest pains, diarrhea, mild nausea,
stomach pain, joint pain and flushing
Nursing consideration:
Watch out for allergic reaction.

Drug study

IRBESARTAN + HCTZ
Co-aprovel
AngiotensinIIreceptorblocker

300mg/125mg/tab OD
Indication:
It works by blocking the action of certain chemicals that tighten the blood vessels, so blood
flows more smoothly.
Mechanism of action:
Keeps blood vessels from narrowing, which lowers blood pressure and improves blood
flow. Used to treat high blood pressure. It is sometimes given together with other blood
pressure medications.
Adverse effect:
Urinating less than usual, drowsiness, confusion, mood changes, increased thirst, loss of
appetite, nausea and vomiting, weight gain, shortness of breath, diarrhea, heartburn, upset
stomach, mild dizziness, or tired feeling.
Nursing consideration:
Do not use potassium supplements or salt substitutes while you are taking this med.
Avoid getting up too fast for you may feel dizzy.
Get up slowly and steady yourself to prevent from a fall.

Drug study

MANNITOL
Lacryvisc
Osmoticdiuretic

100cc IV Q2
Indication:
An osmotic diuretic that is metabolically inert in humans and occurs naturally, as
a sugar or sugar alcohol, in fruits and vegetables. May also be used for the
promotion of diuresis before irreversible renal failure becomes established.
Mechanism of action:
Chemically, mannitol is an alcohol and a sugar, or a polyol; it is similar xylitol
or sortibol. However, mannitol has a tendency to lose hydrogen ion in aqueous
solutions, which causes the solution to become acidic.
Adverse effect:
Pulmonary congestion, Fluid and electrolyte imbalance, acidosis, dryness of the
mouth, thirst.
Nursing consideration:
Monitor vital signs hourly: urine output, CVP and Pulmonary artery pressures.

Drug study

CEREBROLYSIN INFUSION
3 amp in 70cc PNS ODx2
Indication:
Organic, metabolic and neurodegenerative disorders of the brain especially
senile dementia of Alzheimer's type; postapoplectic complications;
craniocerebral trauma; postoperative trauma, cerebral contusion or concussion.
Adverse effect:
Aggression, confusion, insomnia, hyperventilation, hypertension, hypotension,
tiredness, tremors, depression, apathy, dizziness and symptoms of influenza.
Nursing consideration:
Single use only.
It has to be rinsed before and after the application with physiological sodium
chloride solution.

Drug study

LACTULOSE
Duphalac
Laxative

30ml ODHS
Indication:
Aims to restore healthy bowel movement for people who suffer from
constipation. May also be used to treat liver disorders.
Mechanism of action:
A colonic acidifier that softens stool in order to stimulate bowel movements.
Adverse effect:
Allergic reactions to lactose, stomach ache, bloating, belching, nausea and
vomiting, irregular heartbeat, muscle cramps, seizure, diarrhea, and irregular
mood swings.
Nursing consideration:
Watch out for allergic reactions to lactulose.
Rare problem called galactosemia.

Drug study

TERASOZIN
Hytrin
AlphaI-adrenergicreceptorantagonist

5mg/tab tab OD
Indication:
Relaxes veins and dilates blood vessels resulting in lowered blood pressure. It is used to
treat hypertension.
Mechanism of action:
This drug relaxes your veins and arteries so that blood can easily pass through them. It also
relaxes your muscles in the prostate and bladder neck, making it easier to urinate. It can be
also used to treat hypertension.
Adverse effect:
Decrease sexual ability, easy bleeding or bruising, irregular or unusually fast heartbeat,
dizziness, drowsiness, headache, constipation, loss of appetite, fatigue, nasal congestion or
dry eyes.
Nursing consideration:
Use caution in performing tasks requiring alertness.
To avoid dizziness or fainting, get up slowly from a lying or seated position.
Limit your intake of alcohol.

Drug study

ACETYLCYSTEINE
Fluimicil
Mucolytic

600mg/tab BD dilution in 50cc H2O


Indication:
It is used as a mucolytic agent to reduce the viscosity of mucous secretions. It
has also been shown to have antiviral effects in patients with HIV due to
inhibition of viral stimulation by reactive oxygen intermediates.
Mechanism of action:
May act by reducing the metabolite to the parent compound and/or by providing
sulfhydryl for coagulation of the metabolite.
Adverse effect:
N & V, generalized urticaria accompanied by mild fever, hypotension, wheezing,
dyspnea and stomatitis
Nursing consideration:
Assess for fluid and electrolyte status

Drug study

OMEPRAZOLE
Losec
Protonpumpinhibitor

40mg/cap OD
Indication:
Used to treat ulcers, heartburn, gastroesophageal reflux, or Zollinger-Ellison syndrome. It
works by blocking acid production in the stomach.
Mechanism of action:
The onset of the anti-secretory effect of omeprazole occurs within one hour and maximum
effect occurring within 2 hours. A proton pump inhibitor that suppresses gastric acid
secretion by specific inhibition of HK it blocks the final step in acid production, thus
reducing gastric acidity.
Adverse effect:
Dizziness, confusion, jerking muscle movement, diarrhea, cough, choking feeling, or
seizure.
Nursing consideration:
May cause diarrhea, which may be a sign of a new infection.
Stop omeprazole if diarrhea occurs.

Drug study

PARACETAMOL
Aeknil
Analgesic

1 amp IV Q4 PRN
Indication:
Is a generic pain reliever that is used to relieve a variety of mild aches and pain.
Commonly known to treat headaches, but can also be used for muscles aches,
colds, fever, backaches, tooth aches, and even arthritis.
Mechanism of action:
Works as both analgesic and antipyretic to treat aches, pains and reduce fevers.
Adverse effect:
Allergic reactions, nausea, loss of appetite, stomach pains, discolored stool,
jaundice, and vomiting.
Nursing consideration:
Watch out for allergic reactions.
Before taking paracetamol, consult the doctor of any history of liver disease
and alcohol abuse.

Drug study

CITICOLINE
Somazine
CNSStimulant

1gram IV Q12
Indication:
is used for Alzheimer's disease and other types of dementia, head trauma, cerebrovascular disease such
as stroke, age-related memory loss, Parkinson's disease, attention deficit-hyperactive disorder
(ADHD), and glaucoma.
Mechanism of action:
It increase a brain chemical called phosphatidylcholine. This brain chemical is important for brain
function. Citicoline might also decrease brain tissue damage when the brain is injured.
Adverse effect:
trouble sleeping (insomnia), headache, diarrhea, low or high blood pressure, nausea, blurred vision,
chest pains, and others.
Nursing consideration:
Monitor v/s
Caution that large doses of the medication could aggravate increase in cerebral blood flow in
episodes of persistent intracranial hemorrhage.
POSSIBLY SAFE when taken by mouth short-term (up to 90 days). The safety of long-term use is
not known. Most people who take citicoline don't experience problematic side effects.

Drug study

IVABRADINE
Coralan
Cyclicnucleotide-gatedchannelblocker.

5mg/tab OD
Indication:
It is used in certain patients with heart failure to lower the chance of having to go to the hospital for
worsening heart failure.
A cyclic nucleotide-gated channel blocker. It works by helping to regulate heart rate.
Adverse effect:
Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of
the mouth, face, lips, or tongue); chest pain or pressure; dizziness or fainting; irregular heartbeat;
severe or persistent headache; shortness of breath; slow heartbeat; tiredness or weakness; vision
changes.
Nursing consideration:
Tell your doctor or dentist that you take ivabradine before you receive any medical or dental care,
emergency care, or surgery.
Do not eat grapefruit or drink grapefruit juice while you use ivabradine.
Check blood pressure and heart rate as the doctor has told you.
You will need to have your heart checked before starting this drug and while taking it. This
includes an electrocardiogram (ECG). Discuss any questions or concerns with your doctor.

Drug study

PIPERACILLIN+ TAZOBACTAM
Vigous
Antibiotic

2.25grams IV Q5 (-) ANST


Indication:
Treating moderate to severe infections caused by certain bacteria.
An antibacterial agent. It works by blocking the bacteria's cell wall growth, which kills the bacteria.
Mechanism of action:
Medication is given by injection into a vein as directed by your doctor, usually every 6 hours. It should be
injected slowly over at least 30 minutes. The dosage is based on your medical condition and response to
treatment. For children, the dosage is also based on age and weight.
Adverse effect:
Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the
mouth, face, lips, or tongue); bloody stools; chest pain; decreased urination; fainting; fast, slow, or
irregular heartbeat; fever, chills, or sore throat; inflammation at the injection site; red, swollen, blistered,
or peeling skin; seizures; severe diarrhea,
Nursing consideration:
Piperacillin/tazobactam may cause dizziness. This effect may be worse if you take it with alcohol or
certain medicines. Use piperacillin/tazobactam with caution. Do not drive or perform other possibly
unsafe tasks until you know how you react to it.
Piperacillin/tazobactam may reduce the number of clot-forming cells (platelets) in your blood. Avoid
activities that may cause bruising or injury. Tell your doctor if you have unusual bruising or bleeding.
Tell your doctor if you have dark, tarry, or bloody stools.

Drug study

KETOANALOGICS
Ketosteril

2 tabs TID
Indication:
Protein energy malnutrition. Prevention and treatment of conditions caused by
modified or insufficient protein metabolism in chronic renal failure.
Mechanism of action:
Normalizes metabolic process, promotes recycling product exchange. Reduces
ion concentration of potassium, magnesium and phosphate.
Adverse effect:
Hypercalcemia may develop.
Nursing consideration:
Evaluate for any contraindications
Take drug as prescribed
Warn the patient about possible side effects and how to recognize them
Give with food if GI upset occurs
Frequently assess for hypercalcemia

Drug study

KCL
K-lyte

2 tabs TID
Indication:
Preventing or treating low blood potassium levels when the amount of potassium in the diet
is inadequate. It may also be used to treat low potassium levels caused by some diseases,
severe or prolonged episodes of vomiting or diarrhea, or by certain medicines, such as
diuretics.
Adverse effect:
Diarrhea; nausea; stomach discomfort; vomiting.
Nursing consideration:
Check with your doctor before you use a salt substitute or a product that has potassium
in it.
Lab tests, including blood potassium, kidney function, and electrocardiogram (ECG),
may be performed while you use K-Lyte/Cl 25. These tests may be used to monitor your
condition or check for side effects. Be sure to keep all doctor and lab appointments.
Use K-Lyte/Cl 25 with caution in the ELDERLY; they may be more sensitive to its
effects.

Drug study

NURSING CARE PLAN

ACTUAL
Nursing Care Plan

IneffectiveTissuePerfusionmayberelatedtopontine
hemorrhagepossiblyevidencedbyalteredlevelof
consciousness
ASSESSMENT:
Subjective:
none

Objective:
GCS 3-4 (E1V1M1-2)
BP: 140/90
ABG: Fully compensated metabolic acidosis
On mechanical ventilator
(-) spontaneous breathing
(-) corneal reflex

PLANNING:
Short Term Goal:
After an hour of nursing intervention, the patient will demonstrate stable vital signs

Nursing Care Plan

INTERVENTION

RATIONALE

Closely assess and monitor


neurological status frequently and
compare with baseline.

Assesses trends in level of


consciousness (LOC) and potential for
increased ICP and is useful in
determining location, extent, and
progression of damage.

Position with head slightly elevated


and in neutral position.

Reduces arterial pressure by promoting


venous drainage and may improve
cerebral perfusion.

EVALUATION:
After an hour of nursing intervention, the patient demonstrates
stable vital signs.
Goal met.

Nursing Care Plan

Impairedphysicalmobilityrelatedtoocclusion
ofmajorcerebralarteries.
ASSESSMENT:
Subjective:
none
Objective:
No ROM
Decreased muscle strength
PLANNING:
Short Term Goal:
At the end of the, the patient will be able to maintain skin integrity by absence
of decubitus.

Nursing Care Plan

INTERVENTION

RATIONALE

Positioned patient
comfortably on
bed.

Promotes relaxation

Provided cool & quiet


environment.

For comfortability

Elevate head of the bed.

To promote blood circulation

EVALUATION:
After the shift, the patient will be able to maintain skin integrity
by absence of decubitus.
Goal met.

Nursing Care Plan

IneffectiveThermoregulationrelatedtopontinebleeding
ASSESSMENT:
Subjective:
None

Objective:
Temp: 38.4 C
Intermittent fever
Hot to touch

PLANNING:
Short term goal:
After an hour of nursing intervention, the patient will maintain body temperature within
normal limits.

INTERVENTION

RATIONALE

Administer fluids, electrolytes and


medications as indicated

To restore or maintain body/organ function

Apply tepid sponge bath

To help lower the body temperature

EVALUATION:
After an hour of nursing intervention, the patient maintains body temperature within normal
limits
Goalmet.

Nursing Care Plan

POTENTIAL

Nursing Care Plan

Riskforinfectionrelatedtoinadequate
primaryandsecondarydefenses
ASSESSMENT:
Subjective:
none

Objective:
IJ insertion seen
Lymphocytes: 0.93
Segmenters:
WBC: 24.2
RDW: 53.9 fL

PLANNING:
Short term goal:
At the end of the shift, the patients intensive care will be regulated

Nursing Care Plan

INTERVENTION

RATIONALE

Monitor visitors / caregivers

To prevent exposure of client

Provide regular catheter care

To reduce the risk of UTI

Provide regular morning care

To reduce the proliferation of


infection.

EVALUATION:
After the end of shift, the patients intensive care will be
regulated
Goalmet.

Nursing Care Plan

RiskforImpairedSkinIntegrity
relatedtophysicalimmobility
ASSESSMENT:
Subjective:
none

Objective:
Age: 65 years old
GCS 3-4 (E1V1M1-2)
anasarca
On mechanical ventilator

PLANNING:
Short term goal:
At the end of the shift, the nurse on duty will ensure the patients skin is taken
care of.

Nursing Care Plan

INTERVENTION

RATIONALE

Change patients position every 2


hours

To reduce likelihood of progression to


skin breakdown

Provide regular morning care

To reduce the proliferation of infection.

Apply strict skin care

To prevent skin breakdown

Provide protection

To promote comfortability

Keep clothes dry and keep bed free of To eliminate excessive tissue pressure
wrinkles and crumbs
Massage bony prominences gently

To avoid friction

EVALUATION:
At the end of the shift, the nurse on duty ensures the patients skin is taken care
of.
Goalmet.

Nursing Care Plan

DISCHARGE PLANNING

Medication
Instruct the patient to comply with the prescribed take home
medication and the importance of it.
Atorvastatin, 80 mg/tab OD at bedtime
Irbesartan, 300 mg/25 mg/tab OD
Terasozin, tab OD
Ivabradine, 5 mg/tab OD
Amlodipine, 10 mg/tab OD with BP precaution 90/60
(do not give)

Discharge planning

Exercise

Perform mild exercise


Stretching exercise
Swallowing exercise
Speech exercise

Treatment
Refer to rehab for speech and physical therapy

Discharge planning

Health Teaching
Always observed for proper diet (limit fat sources foods)

Outpatient follow-up
Follow up check up to OPD two weeks after discharge

Discharge planning

Diet
Low salt, low fat diet

Spiritual
Encouraged patient/relatives to participate in
rehabilitation sessions so they can learn functional
assistance techniques

Discharge planning

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