Pamantasan ng Lungsod ng Pasig

Alcalde Jose St., Kapasigan, Pasig City

COLLEGE OF NURSING

CASE STUDY:

CEREBROVASCULAR
ACCIDENT INFARCT
Submitted to:
GROUP 2 BSN III Nightingale
CANLAS, Elaine Joy C.
CASTAAS, Arvic Fritz D.R.
CRUZ, Dawn Molly S.
CRUZ, Mylah B.

Submitted by:
Professor Allan David Alcantara

November 2012

INTRODUCTION

A cerebrovascular accident (CVA), also known as a stroke or brain attack, is a

sudden impairment of cerebral circulation in one or more blood vessels. A CVA
interrupts or diminishes oxygen supply, and often causes serious damage or
necrosis in the brain tissues. The sooner the circulation returns to normal after the
CVA, the better chances are for complete recovery. However, about half of patients
who survive a CVA remain permanently disabled and experience a recurrence within
weeks, months, or years.
This case study was all about the CVA infarct/Ischemic in order for us to be
familiar about the disease process, its diagnosis, treatment and etc.
An ischemic stroke is death of an area of brain tissue (cerebral infarction)
resulting from an inadequate supply of blood and oxygen to the brain due to
blockage of an artery.

Ischemic stroke usually results when an artery to the brain is blocked, often
by a blood clot or a fatty deposit due to atherosclerosis.

Symptoms occur suddenly and may include muscle weakness, paralysis, lost
or abnormal sensation on one side of the body, difficulty speaking, confusion,
problems with vision, dizziness, and loss of balance and coordination.

Diagnosis is usually based on symptoms and results of a physical

examination, imaging tests, and blood tests.

Treatment may include drugs to break up blood clots or to make blood less
likely to clot and surgery, followed by rehabilitation.

About one third of people recover all or most of normal function after an
ischemic stroke.

ANATOMY AND PHYSIOLOGY

The Central Nervous System is made up of the brain and spinal cord. The
spinal cord transports sensory and motor information from other parts of the body
to the brain. With the spinal cord, the brain monitors and regulates many
unconscious bodily processes such as heart rate and breathing, and coordinates
most voluntary movements. Most important, it is the site of consciousness and of all
the intellectual functions that allow humans to think and create.
This information is carried through impulses from a neuron. Neuron is consists
of a nucleus situated in the cell body, where outgrowths called processes originate
from. The main one of these processes is the axon, which is responsible for carrying
outgoing messages from the cell. This axon can originate from the central nervous
system (CNS) and extend all the way to the body's extremities, providing an
efficient highway for messages.

Dendrites are smaller secondary processes that

grow from the cell body and axon. On the end of these dendrites lie the axon
terminals, which plug into a cell where the electrical signal from a nerve cell to the
target cell can be made. This 'plug' (the axon terminal) connects into a receptor on
the target cell and can transmit information between cells.
The brain can be subdivided into several distinct regions: The cerebral
hemispheres form the largest part of the brain, occupying the anterior and middle
cranial fossae in the skull and extending backwards over the tentorium cerebelli.
They are made up of the cerebral cortex, the basal ganglia, tracts of synaptic
connections, and the ventricles containing CSF. The Diencephalon includes the
thalamus, hyopthalamus, epithalamus and subthalamus, and forms the central core
of the brain. It is surrounded by the cerebral hemispheres. The Midbrain is located
at the junction of the middle and posterior cranial fossae. The Pons sits in the
anterior part of the posterior cranial fossa- the fibres within the structure connect
one cerebral hemisphere with its opposite cerebellar hemisphere.

The Medulla Oblongata is continuous with the spinal cord, and is responsible
for automatic control of the respiratory and cardiovascular systems. The Cerebellum
overlies the pons and medulla, extending beneath the tentorium cerebelli and

occupying most of the posterior cranial fossa. It is mainly concerned with motor
functions that regulate muscle tone, coordination, and posture.
Brain regulates many of our activities. The impulses generated and carried by
it is an example of the chemical level of organization of the body. This nerve
impulses then regulate the functioning of tissues, organ and organ system, which
permits us to perceive and respond to the world around us and the changes within
us.

NURSING HEALTH HISTORY

BIOGRAPHIC DATA

Patients Name: Patient X

Age: 47 y/o
Gender: Male
Address: Pasig City
Race: Filipino
Marital Status: Married
Occupation: Policeman
Religion: Born Again Christian
Source of Health Care Financing: Wifes small business
Chief Complaint
Mga limang araw bago siya dinala sa ospital, napansin ko lagi na lang siyang
nasasamid habang kumakain, at pautal utal ang kanyang sinasabi as verbalized by
the clients wife.
HEALTH HISTORY
A. History of Present Illness
Patient had CVA 4 years ago with right-sided weakness, maintained with
Amlodipine. One day prior to admission, when his wife arrived home, she noticed
that her husband had a right sided upper extremity weakness and a slurred speech.
He was given Nifedipine by his daughter.
B. History of Past Illness
According to the patients daughter, he had a TB during his childhood. He
also had a gunshot wound on his left thigh when he was about 30 years old. He was
also involved in a bus accident at year 2002, which caused him to have a temporary
loss of memory or amnesia. He also had a surgery on his left leg due to the
accident. Currently, he has a pneumonia and hypertension according to his wife.
C. Family History of Illness
The clients wife and daughter are currently in a good state of health.
According to the clients daughter, his parents died of heart diseases and were also
hypertensive like him.

PAIN ASSESSMENT
The client wasnt able to say anything about his pain, but he has guarding
behaviors when his swollen lower extremities were being touched.

FUNCTIONAL HEALTH PATTERN

Health Perception/Health Management Pattern

The client wasnt able to state anything about his perception of his general
health, but he was crying every time his daughter was being asked about something
that he can do before but cannot do now. According to his daughter, the client used
to consult a doctor every time he was having problems with his health. Also, it was
said that he was smoking and drinking alcohol during his teenage life, but was able
to get out of it when he was married with his wife.

Nutrition/Metabolic Pattern
According to the clients daughter and wife, the client was fond of eating
about 3 cups of rice each meal and drinking more than 1500 ml of water a day
before he was hospitalized. He also eats pork and vegetables sometimes. They also
mentioned that his favorite drink was Sprite. Now, he was in a general liquid diet,
including jelly ace, soup and etc.
Elimination Pattern
According to the clients daughter, the client urinates frequently and
defecates usually twice a day before he was hospitalized. Now, the client voids less
frequently and defecates about three times a day.
Activity-Exercise Pattern
Before, the client was using a walker, and used to exercise with it for some
time. According to them, he doesnt want to exercise much because he was afraid of
getting fatigued, and then become hypertensive. He also used to watch television
and read a dictionary. Now, he just used to listen to a music and sleep.
Feeding - 3
Dressing - 3

Bathing - 2
Grooming - 3

Toileting - 3
Bed mobility - 3
General mobility - 3

Note:
Level
Level
Level
Level
Level

0:
1:
2:
3:
4:

Full Self-Care
Requires use of equipment or device
Requires assistance/supervision from another person
Require assistance/supervision from another person/device
Is dependent and does not participate

Sleep-Rest Pattern
According to his daughter, his sleeps about eight hours every night and takes
short naps before he was hospitalized. He also has no problems sleeping then. Now,
he had longer time for sleep since he lies on bed almost all the time, but was being
interrupted from time to time.

Cognitive Pattern
The client easily responds to people he knows but does not respond to
strangers. In Glascow-Coma Scale, his eye response was scored as 4; verbal
response was 3; and his motor response was 2. Thus, he was in GCS-9. The client
looks uncomfortable when strangers talk to him.
Self-Perception/Self-Concept Pattern
The client wasnt able to express much of his own perception subjectively,
but it was obvious to the client that he was not feeling good about himself because
he cries whenever some changes about his abilities are being mentioned.
Role/Relationship Pattern
The client was the breadwinner of his family before, with his job as a
policeman. Now, his wife runs a small business and takes care of him. They had a
good relationship since then.
Sexuality/Reproductive Pattern
According to the clients daughter, her parents are of a long distance
relationship before, and so she was the only daughter of the couple. Therefore, he
was not sexually active before and until now. The client was in Genital Stage
according to Sigmund Freud Psychosexual Theory, because he had physical sexual
changes that reawaken his repressed needs. Also, he had direct sexual feelings
towards other that lead to sexual gratification.
Coping-Stress Tolerance Pattern
According to his daughter, he used to pray every time he encounters a
problem.
Value-Belief Pattern
According to his daughter, the client values his family and religion. He was an
active Born Again Christian before he was hospitalized.

PRE PHYSICAL EXAMINATION

(November 07, 2010)
Name: Mr. Felix Agoncillo, Jr
Age: 46 y/o
Gender: Male
Married
Address: #9913 Aguinaldo St., Nagpayong 2, Pasig City
Vital Signs: T 36.5C P 87 R 26 BP 180/100

Status:

1. General Survey
weak looking
conscious and coherent
GCS=15
2. Skin
(+) pallor
(+) dryness
3. Head
Symmetric face
Normal hair, and fine distribution
(-)alopecia
4. Eyes
anicteric sclera
lids symmetrical
pink palpebral conjunctiva
5. Ears
Pinnae symmetrical
(+) hearing on both sides
6. Nose
Symmetrical
Septum in midline (-) perforation
Both nares patent
Pinkish mucosa

7. Mouth
(-)dentures
Slurring of speech
(-) lesions
Tongue in midline
(+) caries

Gums pinkish
Uvula in midline
Tonsils not inflamed
dry buccal mucosa

8. Neck
Trachea in midline
Non-palpable thyroids
Non-palpable cervical
lymphnodes
(-) neck enlargement
Normal ROM
9. Breast and Axillae
Equal size, symmetrical
(-) discharge, nipple masses
(-) edema, tenderness
10.

Chest and Lungs

Symmetrical chest expansion
(-) wheezes
(-) dullness
(-) retraction
Clear breath sounds

11. Abdomen
(-) lesions
(-) rashes
(-) striae
Umbilicus is not bulging
Flat abdomen
No tenderness
12. Back and Extremities
Peripheral pulses is symmetrical
Pale nail beds
(-) clubbing
Tone normal
Spine is in the midline

POST PHYSICAL EXAMINATION

(November 29, 2010)
Name: Mr. Felix Agoncillo, Jr
Age: 46 y/o
Gender: Male
Married
Address: #9913 Aguinaldo St., Nagpayong 2, Pasig City

Status:

Vital Signs: T 36.6C P 84 R 26 BP 130/90

1. General Survey
Awake

conscious and coherent

On supine position

GCS=8

2. Skin
Poor skin turgor
Hooked IVF: PNSS 1L x 16
(-) dryness
3. Head
Symmetric face
Normal hair, and fine distribution
(-)alopecia
4. Eyes
anicteric sclera
Lids symmetrical
Eyes symmetrical
pink palpebral conjunctiva
5. Ears
Pinnae symmetrical
(+) hearing on both sides
6. Nose
Symmetrical
Septum in midline (-) perforation
Both nares patent
Pinkish mucosa

7. Mouth
(-)dentures
(-) lesions
Tongue in midline
(+) caries
Gums pinkish
Uvula in midline
Tonsils not inflamed
dry buccal mucosa
8. Neck
Trachea in midline
Non-palpable thyroids

Non-palpable cervical
lymphnodes
(-) neck enlargement
Normal ROM

9. Breast and Axillae

Equal size, symmetrical
(-) discharge, nipple masses
(-) edema, tenderness
10.

Chest and Lungs

Symmetrical chest expansion
(+) wheezes
(-) dullness
(-) retraction
(-) murmur

11.

Abdomen
(-) lesions
(-) rashes
(-) striae
Umbilicus is not bulging
Flat abdomen
No tenderness

12.

Back and Extremities

Pale nail beds
Peripheral pulses is symmetrical
(-) clubbing
Tone normal
Spine is in the midline
(-) edema
Swelling of both lower extremities
With wound at left foot
Right sided paralysis
Dry toe
With metal inside the thigh and
legs

LABORATORY FINDINGS

Date
11-0710

Laboratory
Tests

Normal
Values

Results

Interpretati
on

Indications

BUN

3.2-7.1
mmol/L

2.3
mmol/L

decreased

Severe
Hepatic
Damage,
Malnutrition

Serum
potassium

3.6-5.0
mmol/L

3.6
mmol/L

normal

NA

Prothrombin
Time

10-14
sec.

11.4 sec.

normal

NA

Activated
partial
Thrombopla
stin time

27.7034.10
sec.

28.9 sec.

normal

NA

Hemoglobin

135-160
g/L

145 g/L

normal

NA

Hematocrit

0.400.54 g/L

0.45 g/L

normal

NA

Platelet
Count

150400x109
/L

ADEQUAT
E

normal

NA

WBC count

4.5011.00x1
09/L

6.8x109/L

normal

NA

Neutrophil

0.350.65

0.79

increased

Infection,
ischemic
neurosis

Lymphocyte

0.200.40

0.17

decreased

Affection of
immune
system

0.04

normal

NA

Monocyte

0.020.08

11-1010

11-1710

11-2210

Prothrombin
Time

10.0014.00se
c

11.4sec

normal

NA

Activated
Partial
Thrombopla
stin Time

27.7034.10se
c

28.9sec

normal

NA

Serum Total
Cholesterol

0.0-5.2
mmol/L

6.3
mmol/L

increased

Coronary
Artery
Disease

Serum HDL
Cholesterol

1.0-1.6
mmol/L

0.8
mmol/L

decreased

hypertriglycer
idemia

Serum LDL
Cholesterol

0.003.36
mmol/L

4.97
mmol/L

increased

Coronary
Artery
Disease

Hemoglobin

135-160
g/L

149

normal

NA

Hematocrit

0.400.54 g/L

0.44

normal

NA

Platelet
Count

150400x109
/L

ADEQUAT
E

normal

NA

WBC Count

4.5011.00x1
09/L

15.5

increased

Infection

Neutrophil

0.350.65

0.89

increased

Infection,
ischemic
neurosis

Lymphocyte

0.350.65

0.11

decreased

Affection of
immune
system

Hemoglobin

135-160
g/L

146.0

normal

NA

Hematocrit

0.400.54 g/L

0.44

normal

NA

Adequate

normal

NA

Platelet
Count

150400x109
/L

11-2710

WBC Count

4.5011.00x1
09/L

Neutrophil

0.350.65

Lymphocyte

increased

Infection

0.87

increased

Infection,
ischemic
neurosis

0.350.65

0.10

decreased

Affection of
immune
system

Monocyte

0.020.08

0.03

normal

NA

Hemoglobin

135-160
g/L

149.0

normal

NA

Hematocrit

0.400.54 g/L

0.45

normal

NA

Platelet
Count

150400x109
/L

Adequate

normal

NA

WBC Count

4.5011.00x1
09/L

13.8

increased

Infection

Neutrophil

0.350.65

0.89

increased

Infection,
ischemic
neurosis

Lymphocyte

0.350.65

0.10

decreased

Affection of
immune
system

Monocyte

0.020.08

0.02

normal

NA

URINE SPECIMEN: 11-10-10

PHYSICAL
Color yellow
Transparency slightly turbid
pH 6.5
DIAGNOSTIC PROCEDURE

13.0

Specific Gravity 1.030

CHEMICAL TEST
Albumin negative
Sugar - negative

11-07-10
CT scan: (IMPRESSION)
Acute to subacute non-hemorrhagic infarct, right cerebellar hemisphere.
Chronic infarct, right subinsular cortex & lentiform nucleus.
Periventricular ischemic white matter changes, both fronto-parietal lobes.
Age-related cerebral volume loss.
Mild atherosclerotic vessel disease.
Small right sphenoid sinus mucous retention cyst.
Congested left nasal turbinate.

11-07-10 X-RAY RESULTS

CHEST PAIAP (ADULT)
The lungs are clear.
The heart is not enlarged.
Hemidiaphragms, sinuses and visualized osseous structures are intact.
IMPRESSION:
- NORMAL CHEST

11-19-10 X-RAY RESULTS

CHEST PAIAP (ADULT)
Supine:
There are suspicious infiltrates in the left apex. Suggest Apicolordotic view.
Heart & great vessels are within normal size & configuration.
Other chest structures are unremarkable.

PATHOPHYSIOLOGY OF CVA (STROKE)

Predisposing Factors

Precipitating Factors

Smoking, Overweight, Hypertension, High

Cholesterol Level, Excessive Alcohol
Consumption,Sedentary Life Style.

Age, Family History of

CVA, Sex (Men), Race

Destruction of alpha and

beta cells of the pancreas

Failure to produce insulin

Inc. serum glucose level

Glycoprotein cell
wall deposits
Impaired immune
function
(decrease level
of morphonuclear
leukocytes)
Infection

Neutrophil 0.79

Levofloxaci

Production of
excess glucagon
Production of
glucose from protein
and fat stores
Wasting of lean
body mass

Small vessel
disease

Delayed wound
healing

Wt. from 80kg to

Average BP:

Symmetri
cal loss
of
protectiv
Numbness
and tingling
in the
extremities

Weight loss

Accelerated
atherosclerosis

Neuropath

Fatigue

Hypertension
Increase LDL levels -

Furosemide
Irbesarta

4.97 mmol/L

Autonomic
neuropath

Dry cracked skin

Thrombus
Emboli

CEREBROVASCULA
R ACCIDENT

Decreased Tissue
perfusion (brain)

Occludes a blood
vessel in the brain
Hemiparesis (right side)
Loss of speech
Hemisensory loss

Impaired tissue

Cerebral Hypoxia

Results to blockage of blood

vessel impeding blood flow
Continuous build p of
pressure

Results to increased
intracranial pressure

Cerebral ischemia
Confusionn

Citicoline

Altered

Mannitol
Short term
Ischemia
(<1015mins)
Temporary
Deficit

No
permanent
damage

MID CEREBRAL
ARTERY

Hemiparesis (right side)

Aphasi
Hemiplegia (left side)

ANTERIOR
CEREBRAL A.

POSTERIOR
CEREBRAL A.

Ataxia
Hemisensory loss
Incontinence

VERTEBROBASILA
R ARTERY

Dysphagi

Dysarthia

DRUG STUDY
Generic Name: Clindamycin
Classification: Anti-infectives, lincosamines
Indication / Action

Dosage & frequency

rate

Treatment of various
respiratory, skin, sinus,
and maxillary infection.

60 mg TIV every 8 hours

Date started: Dec. 20-27

Contraindication

Should not be used

against:

Allergy
Diarrhea

Adverse Reaction

This medication may

cause:

Discontinued by: Dec.

28

Abdominal
Cramping
Anorexia
Diarrhea
Vomiting
Confusions
Uncontrollable
Emotions

Nursing Consideration

Check culture and

sensitivity test to see if this
the drug of choice
Ensure that full course is
given to help prevent
emergence of strain.
Provide small frequent
meals to ensure adequate
nutrition due to GI upset

Generic Name: Citicholine

Classification: neurotonics
Indication / Action

-CVD in acute & recovery

phase, symptoms &
signs of cerebral
insufficiency (dizziness,
memory loss, poor
concentration,
disorientation, recent
cranial trauma)

Dosage & frequency

rate

1gm IV q 12
Date started: Dec. 7-20
Shifted to tablet by Dec.
20-29

Contraindication

-Parasympathetic
-hypertonia

Adverse Reaction

This medication may

cause:
-shocks, hypersensitivity,
hypotension, insomnia,
excitement.

Nursing Consideration

- Somazine must not be

administered along with
medicaments containing
meclophenoxate

Generic Name: Levofloxacin

Classification: Anti-infectives, quinolones
Indication / Action
Dosage & frequency
rate

Infections caused by
susceptible strains of
microorganisms in acute
maxillary sinusitis, acute
bacterial exacerbation of
chronic bronchitis.
ACTION:

500mg tab OD

Contraindication

IM, intrathecal,
intraperitoneal, or SC
administration.

Teatment of edema associated

with congwstive hearrt failiure
(CHF), hepatic cirrhosis, and renal
disease, hypertension.

his medication may

cause:

Interferes with
DNA gyrase and
topoisomerase IV. DNA
gyrase is an enzyme
needed for replication,
transcription, and repair
of bacterial DNA.

Generic Name: Furosemide

Classification: Diuretics
Indication / Action

Adverse Reaction

Dosage & frequency

rate

40mg tad BID x 3days

Date started: Dec.

17-29

Contraindication

Should not be used

against:

Hypersensitivity
to drug
Anuria

Headache
Dizziness
Insomnia
Nausea and
Vomiting
Diarrhea

Adverse Reaction

This medication may

cause:
Jaundice
Hearing
impairement
Tinnitus

Nursing Consideration

Obtain baseline assessment

Assess patient for previous
sensitivity reaction
Monitor for possible drug
induced adverse reaction

Nursing Consideration

Do not confuse Lasix

with Lanoxin (a
cardiac glycoside).
Monitor Vital signs
especially BP
Monitor I&O

ACTION:

Inhibits the reabsorption of

sodium and dichloride in the
proximal and distal tuconstibules
as well as the ascending loop of
Henle; this results in the excretion
of sodium,

Hypotension
Pancreatitis
Abdominal pain
Dizziness
Anemia

chloride, and, to a lesser degree,

potassium and bicarbonate ions.

Generic Name: Lactulose

Classification: Laxative
Indication / Action

Constipation, salmonellosis.
Treatment of hepatic
encephalopathy.
ACTION:
Causes an influx of fluid in the
intestinal tract by increasing the
osmotic pressure within the
intestinal lumen.

Dosage & frequency

rate

30cc OD

Date started: Dec.

21-23

Contraindication

Adverse Reaction

-Patients who require a

low lactose diet.

This medication may

cause:

-Galactosaemia or
disaccharide deficiency.

-Intestinal obstruction.

Abdominal
discomfort
Diarrhea
Nausea and
vomiting
Flatulence

Nursing Consideration

Monitor for possible

adverse GI reaction
Monitor fluid and
electrolyte status

Generic Name: Acetylcysteine

Classification: Expectorant
Indication / Action

Dosage & frequency

rate

Treatment for respiratory

affections characterized
by thick and viscous
hypersecretion: acute and
chronic bronchitis and its
exacerbation, pulmonary
emphysema and
bronchiectasis.

600mg

Date started: Dec. 20-28

Contraindication

Should not be used

against:

Hypersensitivity
phenylketonuria

This medication may

cause:

Decrease viscosity of
respiratory tract
secretions

Generic Name: Salbutamol

Classification: Sympathomimetics
Indication / Action
Dosage & frequency
rate

Adverse Reaction

Contraindication

nausea and
vomiting
GI symptoms
Generalized
urticaria
accompanied by
mild fever
Hypotension
Wheezing
Dyspnea
stomatitis

Adverse Reaction

Nursing Consideration

Assess patients
underlying condition, cough:
type, frequency, character
Assess patients
respiration and pulmonary
secretions, axarcise caution
on patients with respiratory
insufficiency and history of
bronchospasm.

Nursing Consideration

Bronchospasms chronic
bronchitis, emphysema

Nebulizer every 8hours

Date started: Dec.

18,22-25

Should not be used

against:

Cardiac Disease
Vascular Disease
Diabetes
Hyperthyroidism
Pregnancy and
Lactation

This medication may

cause:

Teach the client about the

proper use of prescribe
delivery system.

CNS Stimulation
GI Upset
Hypertension
Bronchospasm
Sweating Pallor
Flushing

Generic Name: Clarithromycin

Classification: Anti-infectives, Macroplides
Indication / Action

Dosage & frequency

rate

Treatment of various
respiratory, skin, sinus,
and maxillary infection.

500mg / tab BID

Interfere with protein

synthesis and altering
them in bacteria

Date started: Dec. 19-20

Discontinued by:
29( 8am)

Contraindication
Should not be used
against:

Allergy

to fungal, viral
infection

diarrhea

concomitant use
with any of the ff:
-Cysapride
-Pimozide
-Terfenadine

Adverse Reaction
This medication may
cause:

Abdominal
Cramping

Anorexia

Diarrhea

Vomiting

Confusions

Uncontrollable
Emotions

Nursing Consideration

Check culture and

sensitivity test to see if this
the drug of choice
Monitor renal function
decrease dose as needed
Ensure that full course is
given to help prevent
emergence of strain.
Provide small frequent
meals to ensure adequate
nutrition due to GI upset

Generic Name: Mannitol

Classification: Diuretic
Indication / Action

Dosage & frequency

rate

Contraindication

Adverse Reaction

Nursing Consideration

Reduction of elevated
intracranial
pressure,cerebral edema,
or increased intraocular
pressure
Elevates blood
plasma,osmolality,
resulting in enhanced flow
of water from tissues
including the brain and
cerebrospinal fluid, into
interstitial fluid and
plasma.

100cc TIV q 8
Shifted to 75cc

Should not be used

against:

Hypertensive to
drug

Anuria

Severe pulmonary
congestion

Pulmonary edema.

This medication may

cause:

Dizziness

Headache

fever

assess patients blood

ptressure
monitor blood and blood
pressure regularlty
check weight
monitor CNS symptoms and
changes in mental status

Generic Name Ceftriaxone

Classification: Anti-infective Ceophalosporin second generation
Indication / Action

Sepsis, meningitis;
abdominal, Respiratory
tract infection

Dosage & frequency

rate

1g IV q 12

Should not be used

against:

Adverse Reaction

Nursing Consideration

This medication may

cause:

Shifted to Levofloxacin
by Nov.12

For prophylaxis or
infections

Contraindication

Previous
hypersensitivity to
aspirin
Anaphylactic
Shock
Severe renal and
hepatic failure

GI Upsets
Hematological
changes
Skin reactions
Coagulation
Disorders
Phlebitis (IV
administration)
Headache
Dizziness
Renal and
gallbladder
precipitation
Increase In liver
enzyme

Check culture and

sensitivity test to see if this
the drug of choice
Monitor renal function
decrease dose as needed
Ensure that full course is
given to help prevent
emergence of strain.
Provide small frequent
meals to ensure adequate
nutrition due to GI upset

Oliguria
Increase serum
creatinine
Anaphylactoid
reaction
Chill
Cyanosis in
infants

Generic Name: Paracetamol

Classification: Antipyretic
Indication / Action

Dosage & frequency

rate
500mg 1 tab

For fever, mild to severe

pain.

Contraindication

Should not be used

against:

Impaired kidney or
liver
Sensitivity to the
drug

Generic Name: Irbesartan

Classification: Cardiovascular drug, Angiotensin II Antagonist

Adverse Reaction

This medication may

cause:

Skin rashes and

other allergic
reaction.
GI disturbances.

Nursing Consideration

Do not take other drugs

containing acetaminophen
without medical advice over
dosage and chronic use can
cause hepatic damage and
other toxic effect

Indication / Action

Dosage & frequency

rate

Competitively block the

angiotension AT1 receptor
located in vascular
smooth muscle and the
adrenal glands.

500mg 1 tab

TYPE OF
SOLUTION

Should not be used

against:

Continued by: Dec. 20-29

CLASSIFICATION

CONTENT

Contraindication

Hypersensitivity

MECHANISM OF
ACTION

INDICATION

Adverse Reaction

This medication may

cause:

Nursing Consideration

Take only as directed.

Mat take with or without
food

URTI, cough,
fatigue,
dyspepsia/heartburn, diarrhea

CONTRAINDICATIO
N

HOW
SUPPLIE
D

DOSE

NURSING
RESPONSIBILITIES

Plain
Normal
Saline
Solution
(PNSS)
[0.9%
Sodium
Chloride
Solution]

-Isotonic volume
expander
-Electrolyte
replacement

Sodium
154 mmol
Chloride
154 mmol
(NS is 9g
NaCl
dissolved
in 1 liter
water; NS
contains
154 mEq/L
of Na+ and
Cl)

Isotonic solution
expands
intracellular and
extracellular space
equally.
No net fluid shifts
occur between
isotonic solutions
because the
solutions are
equally
concentrated.

>Replacement &
maintenance of
fluid &
electrolytes.
Uses: intravenous
drips (IVs), for
patients who
cannot take fluids
orally and have
developed or are
in danger of
developing
dehydration or
hypovolemia

It has a slightly
higher degree of
osmolarity (i.e.
more solute per
litre) than blood
(hence, though it is
said to be isotonic
with blood in
clinical contexts,
this is a technical
inaccuracy).
Nonetheless, the
osmolarity of
normal saline is a
pretty close
approximation to
the osmolarity of
NaCl in blood.

IV FLUID STUDY

Severe HPN,
Pulmonary
Edema

1000 ml

1L @ 25
gtts/min.
(20cc/kg of
lean body
weight for
hypovolem
ic
hypotensio
n)

>Monitor pt. frequently

for:
a. Signs of infiltration /
sluggish flow
b. Signs of phlebitis /
infection
c. Dwell time of
catheter and need to
be replaced
d. Condition of
catheter dressing
>Check the level of the
IVF.
>Correct solution,
medication and volume.
>Check and regulate
the drop rate.
Change the IVF solution
if needed.

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

EVALUATION

UBJECTIVE:

Impaired physical

Long term:

1. Assess patients ability

Long term:

hindi siya makagalaw

mobility r/t

After 4 days of nursing

to perform ADLs

After 4 days of nursing

simula ng mastoke

neuromuscular

intervention, client will

effectively using

intervention, client was able to

siya as verbalized of

damage involvement

be able to physical

Functional Level

physical mobility

her wife.

as evidence d by

mobility

Classification.

decreased motor
activity

2. Encourage appropriate
Short term:

use of assistive device

Short term:

OBJECTIVE:

After 8 hrs of nursing

such as crutches, walker,

After 8 hrs of nursing

Limited ROM

intervention, client will

and wheelchair to

intervention, client was able to:

Body weakness

be able to:

increase mobility.

1. Participate

Decreased motor

1. Participate

3. Turn and position the

in the interventions

activity

in the interventions

patient every 2 hours to

rendered by the

Inability to perform

rendered by the

promote circulation to all

nurse by being active in every

action as instructed

nurse

tissues and relieves

activities that they have

2. Demonstrate

pressure.

2. Demonstrate

resumption of

4. Perform passive

resumption of

activities

assistive ROM exercises

activities by performing it

3. Maintain skin

to affected extremities to

3. Maintain skin integrity

integrity

promote venous return

4. Maintain or muscle control

4. Maintain or

and maintain muscle

muscle control

strength.

NURSING CARE PLAN

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

EVALUATION

SUBJECTIVE:

Ineffective tissue

Long Term:

1. Perform passive range-

Long Term:

Napansin ko na lagi

perfusion r/t

After 8 hours of nursing

of-motion (ROM) exercises

After 8 hours of nursing

nalang may dinadaing

vasoconstriction of

intervention, the client

to unaffected extremity

intervention, the client will be

na masakit na hindi

blood vessels

will be able to

every 2 to 4 hours to

able to maintains optimal tissue

alam ang dahilan. As

maintains optimal

prevent venous stasis.

perfusion to vital organs, as

verbalized by the

tissue perfusion to vital

2. Elevate head of bed 30-

evidenced by strong peripheral

patients wife.

organs, as evidenced by

45 if increase ICP.

pulses, normal ABGs, alert LOC,

strong peripheral

3. Avoid measures that

and absence of chest pain

pulses, normal ABGs,

may trigger increased ICP

OBJECTIVE:

alert LOC, and absence

such as straining, and

Short-Term:

Confused

of chest pain

strenuous coughing.

After 4 hours of nursing

4. Instructed to exhale

intervention, the client will be

Altered LOC
Lethargic

Short-Term:

through the mouth during

able to :

Increased ICP

After 4 hours of nursing

voiding or defecation to

1. Participate in passive ROM.

(BP: 160/100)

intervention, the client

decrease strain.

2.Recognize regarding some

(+) facial grimace

will be able to :

5. Monitor the respiratory

measures to prevent increase

1. Participate in passive

status.

ICP.

ROM.

3. Exercise breathing pattern

2.Recognize regarding

during defecation and voiding.

some measures to
prevent increase ICP.
3. Exercise breathing
pattern during
defecation and voiding.

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

EVALUATION

SUBJECTIVE:

Impaired verbal

Long Term:

1. Provide alternative

Long-Term:

Napansin ko sa asawa

communication

After 6 hours of

methods of communication,

After 1 hr. of

ko na pautal-utal n

related to loss of

nursing

like pictures or visual cues,

nursing

magsalita at hindi ko na

facial or oral muscle

intervention, the

gestures or demonstration. R:

intervention, the

naiintndihan ang

tone control.

patient will establish

Provide communication

patient was able to

sinasabi as verbalized

method of

needs.

establish method of

by the patients wife.

communication in

2. Talk directly to patient.

communication in

which needs can be

Speaking slowly and

which needs can be

expressed.

directly. Use yes or no

expressed.

OBJECTIVE:

question to begin with. R: It

Difficulty

reduces confusion or anxiety

producing

Short-Term:

3. Anticipate and provide for

Short-Term:

speech.

After 2 hours of

patients needs. R: Helpful in

After 2 hours of nursing

Facial paralysis.

nursing intervention,

decreasing

intervention, the patient was

Muscle and

the patient will be able

frustration

able to:

facial tension.

to:

4. Place important objects

1. Utilized non-verbal cues as a

1. Utilize non-verbal

within reach. R: This

form of communication.

cues as a form of

maximizes patients sense of

2. Reduce anxiety

communication.

independence.

3. Decrease frustrations.

2. Reduce anxiety.

5. Instruct the family

4. Maximize sense of

3. Decrease

members to give ample time

independence.

frustrations.

talking to the patient. R: It is

5. Lessen the feeling of being

4. Maximize sense of

important for family members

isolated.

independence.

to continue talking to the

5. Lessen the feeling of

patient to reduce patients

being isolated.

isolation.

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

Subjective:

Impaired skin

Long-term:

Simula nang maparalize

integrity r/t physical

After 8 hours of

implementation and

After 8 hours of nursing

siya, wala n siyang gnwa

immobilization as

nursing intervention,

posting of a turning

intervention, the client was able

kundi ang humiga ng

evidence by

the client will be able

schedule, restricting time

to display improvement in wound

humiga. As verbalized

hemiparesis, limited

to display

in one position to 2 hours

healing

of the patients wife

ROM and dry skin.

improvement in wound

or less.

healing

1. Encourage

EVALUATION
Long-term:

2. Instructed family to
maintain clean, dry

Short term:

clothes, preferably cotton

After 4 hours of nursing

fabric (any T- shirt).

intervention, the client was able

Objective:

Short term:

-Limited ROM

After 4 hours of

-Dry cracked skin

nursing intervention,

increase fluid intake to

1. Lessen skin breakdown

the client will be able

lessen the skin breakdown.

2. Reduce shearing forces of the

to:

3. Encourage the patient to

4. Encourage the client to

1. Lessen skin

utilize lift sheets to reduce

breakdown.

shearing forces of the skin

2. Reduce shearing
forces of the skin.

to:

skin AEB turning the client side

to side.

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

EVALUATION

Sujective:

Risk for

Long Term:

1. Monitor level of

Long-Term:

Sa tuwing

aspiration r/t

After 8 hours of nursing

consciousness to prevent

After 2 hours of nursing

pinapakain ko na siya

impaired

intervention, the client

risk for aspiration.

intervention the client was

lagi siyang

swallowing

will be able to maintain a

2. Assess gag and cough

able to:

nahihirapan

patent airway and clear

reflex to prevent risk for

Maintain a patent airway and

lumunok. As

lung sounds

aspiration.

clear lung sounds by

3. Encourage patient to

discharge.

verbalized of the
patients wife.

Short term:

chew thoroughly and eat

After 4 hours of nursing

slowly during meals. Instruct

Short term:

Objective:

intervention, the client

patient not to talk while

After 4 hours of nursing

Pt exhibits difficulty

will be able to:

eating.

intervention, the client was

swallowing without

1. prevent from aspiration

4. Provide oral care after

able to:

choking.

2. position properly

meals.

1. prevent from aspiration

during eating

5.

2. position properly during

eating

COURSE IN THE WARD

History of Past Illness
According to the patients daughter, he had a TB during his childhood. He
also had a gunshot wound on his left thigh when he was about 30 years old. He was
also involved in a bus accident at year 2002, which caused him to have a temporary
loss of memory or amnesia. He also had a surgery on his left leg due to the
accident. Currently, he has pneumonia and his wife.
History of Present Illness
Patient had CVA 4 years ago with right sided weakness, maintained with
Amlodipine. One day prior to admission, when his wife arrived home, she noticed
that her husband had a right sided upper extremity weakness and a slurred speech.
He was given Nifedipine by his daughter.

ER (11/07/10)

Patient X was admitted to the ED last November 07, 2010 at 12:25 pm. Chief
complaint was dizziness; slurring of speech. Patient has normocephalic head, pink
palpebral conjunctiva, anicteric sclera, rough,dry skin. Symmetrical lung expansion
was noted along with adynamic precordium. Some part of the extemitites is swelling.
Patient has hypertension in the past. Family also have hypertension. Patient is an
alcohol drinker along smoking. The working diagnosis for him was CVA infarct. Doctor
ordered IVF of PNSS 1L to run for 16 hours, that the patient be admitted to ED, O2 via
NC at 4 lpm. The doctor also ordered for some lab workups like CBG, CXR, UA, Na, K,
BUN, Crea, Main CT scan. The patient was instructed to be on NPO temporarily and on
HBR position. V/S was to be monitored every 1 hour along with his I&O. patient had
the ff. medications: Citicholine 2gm TIV now then 1gm BID, Ranitidine 50mg IV,
Aspirin 80mg 1tab, 1tab to be chewed and swallowed, Ceftriaxone 1gm IV q12 ANST,

Citicholine 1gm IV q 12, Lactulose 30cc q HS, Irbesartan 150g 1 tab OD, Furosemide
40g IV now, Clarithromycin 500mg.
The doctor also ordered that the patient be admitted to the MMW in service of
Dra. Lim/ Dr. Deleon/ Dr. teodocio. Doctor asked that a secured consent to admission
and management. NGT was ordered to be inserted and start OF feeding at 1600 kcal
in 6 divided using nutren optimum at 3:50pm
MMW (11/08/10)
Patient was admitted to the male medicine ward accorging to the doctors order .
he was awake and coherent, on MHBR. Patients family refused NGT insertion with
consent signed and secured. Prescribed medications were followed accordingly. He
was put on clear liquid diet. IVF was maintained and O2 support via NC at 3lpm.
Instructed the client to have LSLF diet as ordered.
(11/09/10 11/29/10)
Care and management is continued to the patient who have ongoing IVF of PNSS
1L to run for 10 hrs.. Follow up of CXR, CT scan was prompted. Client was ordered to
be turned from side to side every 2 hrs. and be placed on MHBR. Client was
instructed to have LSLF diet as ordered, mannitol was ordered to be decreased to
45cc TIV every12 hrs. for 2 doses then discontinue(11/10/10). For relay CXR, CT scan
result and kept rested (11/11/10). Doctor ordered to Shift cefriaxone to levofloxacin 1
tab OD and clindamycin 300mg 1 cap QID (11/12/10). Increase irbesartan to 300mg 1
tab OD (11/13/10).

Nebulization instructed. Similar interventions were carried out

through the days.

NURSING THEORY

This study utilized the Goal Attainment Theory which was first introduced by
Imogene King in the early 1960s. The essence of goal attainment theory is that the
nurse and the patient work together to define and reach goals that they set
together. Through communication, they set goals and agree on how to achieve
those goals (King, 1981). Nursing involves caring for the human being and views the
goal of health as adjusting to the stressors in the internal and external
environments (Boyd, 2005).
First, a definition of the three (3) dynamic interacting systems will be
discussed in order to gain an understanding of what is expected during the hospital
stay. Afterwards nursing activities and goals which are necessary will be integrated
regarding the said interacting system.
Personal System consists of variables that are unique to each person
(nurse, patients, etc.). It includes perception, self, growth and development, body
image, space, learning and time.
In this interacting system, the nurse will be able to communicate with patient
to obtain information regarding self-perception, body image and other relevant
information of all the components of his personal self. In the nursing process, during
assessment, the patient and the nurse must be able to interact and begins in
communicating.
According to the patients wife, before he was hospitalized in Pasig City
General Hospital, he wanted to continue his activities of daily living right after his
recovery. She added that Mr. X wanted to ambulate again for him to help his family
financially and be able to support his only daughter. The nurse must be able to
encourage Mr. X to perform passive ROM to prevent venous stasis. In line with this,
Mr. X goal was to ambulate again. The nurse must encourage utilizing mobility
assistive device such as walker, crutches and etc., to return from previous activities
of daily living. Empowerment to the client must be done in order to reach the goal
of Mr. X.
Interpersonal System includes variables that exist when an interaction
between persons occur (nurse-patient, patient-relative, etc.). Concepts related to
interpersonal systems are interaction, communication, transactions, role and stress.

Upon having communication with the client, interpersonal system will then
exist wherein during the planning, transactions and clients participation are
encouraged in decision making by the means to achieve the goals. If a goal has
been set, a transaction is said to have occurred. This is where the nurse and the
patient also decide on way to work toward the goal that has been decided upon,
and put into action the plan that has been agreed upon. Transaction will occur
during implementation phase; Imogene King believes that the main function of
nursing is to increase or to restore the health of the patient to re-establish the
normal activities of daily living.
In this situation, Mr. X chief complaint was slurring of speech. Both the client
and the nurse had a problem in terms of communication. Although Mr. X can
comprehend the words that the nurse says to him, but he was hard to express on
what he wanted to say or to talk about. So, nurses must be focus on communication
of the patient. The goal here was to communicate with others. The nurse must use
non-verbal cues in order to convey messages to the receiver.
Social System occurs when socially acceptable roles and boundaries are
accepted and followed as a mechanism to regulate interactions. It includes the
organization, authority, power, status, and the decision making.
This is where Mr. X will realize that he is a patient who permitted himself to
be in this institution that has the same goal as what he wants. The patient wants to
get well that is why he is in a caring institution (Pasig City General Hospital) wherein
he has to follow certain rules as well as to communicate his needs to the healthcare
team.

DISCHARGE PLANNING

Medication
Discuss with the patient the need to comply with home medication. This will
help the family and the patient to know the importance and advantage in
complying treatment regimen.

 Explain with them the advantages and disadvantages of strict compliance of

treatment regimen. This will ensure and encourage the patient that taking
medications will help treat and prevent recurrence of the disease and for
faster recovery
Instruct the patient and whether the right time, right medication, right
dosage, and right routes as ordered by the physician. This will avoid
confusion of the proper drugs that would be taken by the patient.
Instruct the patient not to skip taking medications and complete the whole
course of medication. This will help for an effective action and compliance of
the medications and for faster recovery.
Remind the patient about the importance of taking consideration of the foods
and other drugs that is contraindicated while taking the medications. This will
prevent further complications and unnecessary effects to the patient.
Instruct and warn patients and significant other about the possible effects
and adverse reactions that may occur brought about by taking the
medications.
Remind them to take the drugs properly and taking note of the expiration
date before taking the medication. This will ensure good compliance of the
medications to be taken and to prevent accident poisoning.
Instruct the patient and the family to properly store and handle the
medications so as to let children accidentally get hold of it. This will prevent
accidents of drug poisoning.

Exercise/Environment
Encourage the client to exercise ROM.

Treatment
Explain the purpose of treatment and why it is continued at home. This will
help the patient and family to be oriented about the treatment and this will
help him understand about the importance of taking the prescribed drugs for
faster recovery in the disease process. Also, to make them aware that the
treatment is not only done in the hospital but it should be continued at home.
Direct and instruct the patient and the family to give medication or assist the
patient according to the medication regimen. Giving the medication and
assisting the patient accordingly will have good compliance of the
medications and will give sufficient effect to the patients condition.
Emphasize the importance of recognizing any sign of unusuality. To give
appropriate intervention.

Health Teaching/Hygiene
Encourage and advice the patient and family members practice proper
handwashing before and after eating. Proper handwashing will prevent the
spread of infection.
Instruct patient to do activities of daily living if the client is able to do. To
promote good health and prevent infection. It also increases the sense of
wellness, which is very much needed in the therapeutic process.

Out-patient Referral
Encourage the patient and the family to have regular check-up with their
physician. To monitor health status and conditions. This will help recognize
any alterations in the body.
Advice patient and family to follow doctors order comply with the doctors
advice and follow what is stated in the written discharge instruction.
Following the doctors order and complying will help achieve the success of
the treatment coarse and will help for the immediate recovery of the patient.
Encourage the patient and the family to immediately report any unusualities
regarding the patients condition. To immediately give enough attention to
treat the said complaint.

Diet
Encourage the client to be on low salt low fat. To prevent having elevated
blood pressure.

Research Paper help

https://www.homeworkping.com/